835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
ST Transaction Set Header M
Autogenerated by Translator ST01 Transaction Set Identifier Code M 3 3 ID Automatically set to 835
Autogenerated by Translator ST02 Transaction Set Control Number M 4 9 AN Automatically generated.
BPR Financial Information M
TRANS_HNDL_CD BPR01 Transaction Handling Code M 1 2 ID C - Payment Accompanies Remittance
Advice
D - Make Payment Only
H - Notification Only
I - Remittance Information Only
P - Prenotification of Future Transfers
U - Split Payment and Remittance
X - Handling Party's Option to Split Payment
and Remittance
MED_PMT
MED_PMT TTL_PROV_PMT_AMT BPR02 Monetary Amount M 1 18 R Total Actual Provider Payment Amount
TRANS_TYPE_CD BPR03 Credit/Debit Flag Code M 1 1 ID C - Credit
D - Debit - NOT ADVISED TO USE THIS
MED_PMT ONE
PMT_MTHD_CD BPR04 Payment Method Code M 3 3 ID ACH - Automated Clearing House (ACH)
BOP - Financial Institution Option
CHK - Check
FWT - Federal Reserve Funds/Wire
Transfer - Nonrepetitive
MED_PMT NON - Non-Payment Data
PMT_FRMT_CD BPR05 Payment Format Code S 1 10 ID CCP - Cash Concentration/Disbursement
plus Addenda (CCD+)(ACH)
MED_PMT CTX - Corporate Trade Exchange
(CTX)(ACH)
Hardcode "01" BPR06 (DFI) ID Number Qualifier S 2 2 ID 01 - ABA Transit Routing Number Including
Check Digits
04 - Canadian Bank Branch and Institution
Number
PRSN_ORG TRANSIT_RTE_NUM BPR07 (DFI) Identification Number S 3 12 AN Sender DFI Identifier
PRSN_ORG BANK_ACCT_TYPE_CD BPR08 Account Number Qualifier S 1 3 ID DA - Demand Deposit
PRSN_ORG BANK_ACCT_NUM BPR09 Account Number S 1 35 AN Sender Bank Account Number
PRSN_ORG PRIM_ID BPR10 Originating Company Identifier S 10 10 AN Payer Identifier
BPR11 Originating Company Supplemental S 9 9 AN Used to further identify the payer by division or region, must match TRN03 is
Code used.
Hardcode "01" BPR12 (DFI) ID Number Qualifier S 2 2 ID 01 - ABA Transit Routing Number Including
Check Digits
04 - Canadian Bank Branch and Institution
Number
PRSN_ORG TRANSIT_RTE_NUM BPR13 (DFI) Identification Number S 3 12 AN Receiver or Provider Bank Number
BANK_ACCT_TYPE_CD BPR14 Account Number Qualifier S 1 3 ID DA - Demand Deposit
PRSN_ORG SA - Savings
PRSN_ORG BANK_ACCT_NUM BPR15 Account Number S 1 35 AN Receiver or Provider Account Number
MED_PMT CHK_ISS_DTE BPR16 Date M 8 8 DT Expressed in CCYYMMDD Check Issue or EFT Effective Date
TRN Reassociation Trace Number M
Hardcode "1" TRN01 Trace Type Code M 1 2 ID 1 - Current Transaction Trace Numbers
MED_PMT PMT_TRCE_NUM TRN02 Reference Identification M 1 30 AN Check or EFT Trace Number
PRIM_ID TRN03 Originating Company Identifier M 10 10 AN Payer Identifier must contain the Federal Tax ID Number, preceded by a "1" or
PRSN_ORG is must be identical to BPR10.
TRN04 Reference Identification S 1 30 AN Originating Company Supplemental Code - If used must be identical to BPR11.
CUR Foreign Currency Information S Used to specify the currency and exchange rate when the payment is
made in different currency from that of the original claim.
CUR01 Entity Identifier Code M 2 3 ID PR - Payer
CUR02 Currency Code M 3 3 ID
CUR03 Exchange Rate S 4 10 R
REF Receiver Identification S Required when the receiver of the transaction is other than the payee.
PRSN_ORG PRIM_ID_TYPE_CD REF01 Reference Identification Qualifier M 2 3 ID EV - Receiver Identification Number
12/6/2011 Page: 1
835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
PRSN_ORG PRIM_ID REF02 Reference Identification M 1 30 AN Receiver Identifier
REF Version Identification S Provide version number when this information is Required by the payer in
order to resolve customer service questions from the payee.
REF01 Reference Identification Qualifier M 2 3 ID F2 - Version Code - Local
REF02 Reference Identification M 1 30 AN Version Identification Code
DTM Production Date S Required when the cutoff date of the adjudication system is different from
the date of the 835.
Hardcode "405" DTM01 Date/Time Qualifier M 3 3 ID 405 - Production
MED_PMT ADJUD_DTE DTM02 Date M 8 8 DT Production Date - Expressed in CCYYMMDD
1000A N1 Payer Identification M
PRSN_ORG prsn_org_typ_cd N101 Entity Identifier Code M 2 3 ID PR - Payer
PRSN_ORG ORG_NME N102 Name S 1 60 AN Payer Name
N103 Identification Code Qualifier S 1 2 ID XV - Health Care Financing Administration
National PlanID
N104 Identification Code S 2 80 AN Payer Identifier
1000A N3 Payer Address M
PRSN_ORG_ADDR ADDR_1_TXT N301 Address Information M 1 55 AN Payer Address Line
PRSN_ORG_ADDR ADDR_2_TXT N302 Address Information S 1 55 AN Payer Address Line
1000A N4 Payer City, State, Zip Code M
PRSN_ORG_ADDR CITY_NME N401 City Name M 2 30 AN Payer City Name
PRSN_ORG_ADDR ST_CD N402 State of Province Code M 2 2 ID Payer State Code
PRSN_ORG_ADDR ZIP_CD N403 Postal Code M 3 15 ID Payer Postal Code
1000A REF Additional Payer Identification S Used whenever additional payer identification numbers are required.
REF01 Reference Identification Qualifier M 2 3 ID 2U - Payer Identification Number
EO - Submitter Identification Number
HI - Health Industry Number (HIN)
NF - National Association of Insurance
Commissioners (NAIC) Code
REF02 Reference Identification M 1 30 AN Additional Payer Identifier
1000A PER Payer Contact Information S Used when the Payee can not reasonably know how to contact the Payer
about this remittance advice.
Hardcode "CX" PER01 Contact Function Code M 1 2 ID CX - Payers Claim Office
PRSN_ORG ORG_NME PER02 Name S 1 60 AN Payer Contact Name
cntct_num_type_cd PER03 Communications Number Qualifier S 2 2 ID EM - Electronic Mail
FX - Facsimile
CNTCT_NUM TE - Telephone
CNTCT_NUM CNTCT_NUM PER04 Communications Number S 1 80 AN
cntct_num_type_cd PER05 Communications Number Qualifier S 2 2 ID EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
CNTCT_NUM TE - Telephone
CNTCT_NUM CNTCT_NUM PER06 Communications Number S 1 80 AN
PER07 Communications Number Qualifier S 2 2 ID EX - Telephone Extension
PER08 Communications Number S 1 80 AN
1000B N1 Payee Identification M
PRSN_ORG prsn_org_typ_cd N101 Entity Identifier Code M 2 3 ID PE - Payee
PRSN_ORG ORG_NME N102 Name S 1 60 AN Payee Name
PRIM_ID_TYPE_CD N103 Identification Code Qualifier M 1 2 ID FI - Federal Taxpayer's Identification
Number
XX - Health Care Financing Administration
National Provider Identifier
PRSN_ORG
PRSN_ORG PRIM_ID N104 Identification Code M 2 80 AN Payee Identifier
1000B N3 Payee Address S
PRSN_ORG_ADDR ADDR_1_TXT N301 Address Information M 1 55 AN Payee Address Line
PRSN_ORG_ADDR ADDR_2_TXT N302 Address Information S 1 55 AN Payee Address Line
1000B N4 Payee City, State, Zip Code S
PRSN_ORG_ADDR CITY_NME N401 City Name M 2 30 AN Payee City Name
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835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
PRSN_ORG_ADDR ST_CD N402 State of Province Code M 2 2 ID Payee State Code
PRSN_ORG_ADDR ZIP_CD N403 Postal Code M 3 15 ID Payee Postal Code
N404 Country Code S 2 3 ID Required if country is other than USA.
1000B REF Payee Additional Identification S Used whenever additional payee identification numbers are required.
SCNDRY_ID_TYPE_CD REF01 Reference Identification Qualifier M 2 3 ID 0B - State License Number
1A - Blue Cross Provider Number (Not
Advised)
1B - Blue Shield Provider Number (Not
Advised)
1C - Medicare Provider Number (Not
Advised)
1D - Medicaid Provider Number (Not
Advised)
1E - Dentist License Number (Not Advised)
1F - Anesthesia License Number (Not
Advised)
1G - Provider UPIN Number
1H - CHAMPUS Identification Number (Not
Advised)
D3 - National Association of Boards of
Pharmacy Number
G2 - Provider Commercial Number (Not
Advised)
N5 - Provider Plan Network Identification
Number (Not Advised)
PQ - Payee Identification
TJ - Federal Taxpayer's Identification
Number
SCNDRY_ID
SCNDRY_ID SCNDRY_ID REF02 Reference Identification M 1 30 AN Additional Payer Identifier
2000 LX Header Number S Required whenever any information in the LX loop is included in the
transaction.
Incrementing line counter LX01 Assigned Number M 1 6 N0
2000 TS3 Provider Summary Information S Payers and payees outside the Medicare Part A community may need to
use this segment to identify provider subsidiaries whose remittance
information is contained in the 835 transaction transmitted to a single
provider entity.
TS301 Reference Identification M 1 30 AN Provider Identifier
TS302 Facility Code Values M 1 2 AN Facility Type Code
TS303 Date M 8 8 DT Fiscal Period Date - Expressed in CCYYMMDD
TS304 Quantity M 1 15 R Total Claim Count
TS305 Monetary Amount M 1 18 R Total Claim Charge Amount
TS306 Monetary Amount S 1 18 R Total Covered Charge Amount
TS307 Monetary Amount S 1 18 R Total Noncovered Charge Amount
TS308 Monetary Amount S 1 18 R Total Denied Charge Amount
TS309 Monetary Amount S 1 18 R Total Provider Payment Amount
TS310 Monetary Amount S 1 18 R Total Interest Amount
TS311 Monetary Amount S 1 18 R Total Contractual Adjustment Amount
TS312 Monetary Amount S 1 18 R Total Gramm-Rudman Reduction Amount
TS313 Monetary Amount S 1 18 R Total MSP Payer Amount
TS314 Monetary Amount S 1 18 R Total Blood Deductible Amount
TS315 Monetary Amount S 1 18 R Total Non-Lab Charge Amount
TS316 Monetary Amount S 1 18 R Total Coinsurance Amount
TS317 Monetary Amount S 1 18 R Total HCPCS Reported Charge Amount
TS318 Monetary Amount S 1 18 R Total HCPCS Payable Amount
TS319 Monetary Amount S 1 18 R Total Deductible Amount
TS320 Monetary Amount S 1 18 R Total Professional Component Amount
TS321 Monetary Amount S 1 18 R Total MSP Patient Liability Met Amount
TS322 Monetary Amount S 1 18 R Total Patient Reimbursement Amount
TS323 Quantity S 1 15 R Total PIP Claim Count
TS324 Monetary Amount S 1 18 R Total PIP Adjustment Amount
2000 TS2 Provider Supplemental Summary S Used after the TS3. To be used for Medicare Part A Claims.
Information
TS201 Monetary Amount S 1 18 R Total DRG Amount
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835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
TS202 Monetary Amount S 1 18 R Total Federal Specific Amount
TS203 Monetary Amount S 1 18 R Total Hospital Specific Amount
TS204 Monetary Amount S 1 18 R Total Disproportionate Share Amount
TS205 Monetary Amount S 1 18 R Total Capital Amount
TS206 Monetary Amount S 1 18 R Total Indirect Medical Education Amount
TS207 Quantity S 1 15 R Total Outlier Day Count
TS208 Monetary Amount S 1 18 R Total Day Outlier Amount
TS209 Monetary Amount S 1 18 R Total Cost Outlier Amount
TS210 Quantity S 1 15 R Average DRG Length of Stay
TS211 Quantity S 1 15 R Total Discharge Count
TS212 Quantity S 1 15 R Total Cost Report Day Count
TS213 Quantity S 1 15 R Total Covered Day Count
TS214 Quantity S 1 15 R Total Noncovered Day Count
TS215 Monetary Amount S 1 18 R Total MSP Pass-Through Amount
TS216 Quantity S 1 15 R Average DRG Weight
TS217 Monetary Amount S 1 18 R Total PPS Capital FSP DRG Amount
TS218 Monetary Amount S 1 18 R Total PPS Capital HSP DRG Amount
TS219 Monetary Amount S 1 18 R Total PPS DSH DRG Amount
2100 CLP Claim Payment Information M
MED_CLM PAT_ACCT_NUM CLP01 Claim Submitter's Identification M 1 38 AN Patient Control Number
CLM_REMIT_STAT_CD CLP02 Claim Status Code M 1 2 ID 1 - Processed as Primary
2 - Processed as Secondary
3 - Processed as Tertiary
4 - Denied
5 - Pending
10 - Received but not in process
13 - Suspended
15 - Suspended - investigation with field
16 - Suspended - return with material
17 - Suspended - pending review
19 - Processed as Primary, Forwared to
Additional Payers
20 - Processed as Secondary, Forwared to
Additional Payers
21 - Processed as Teriarty, Forwarded to
Additional Payers
22 - Reversal of Previous Payment
23 - Not Our Claim, Forwared to Additional
Payers
25 - Predetermination Pricing Only, No
Payment
27 - Reviewed
REMIT_CLM
MED_CLM TTL_CLM_CHRG_AMT CLP03 Monetary Amount M 1 18 R Total Claim Charge Amount
MED_CLM CLM_PMT_AMT CLP04 Monetary Amount M 1 18 R Claim Payment Amount
MED_CLM PAT_RSPBLTY_AMT CLP05 Monetary Amount S 1 18 R Patient Responsibility Amount
12/6/2011 Page: 4
835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
CLM_FILE_CD CLP06 Claim Filing Indicator Code M 1 2 ID 12 - Preferred Provider Organization
13 - Point of Service
14 - Exclusive Provider Organization
15 - Indemnity Insurance
16 -Health Maintenance Organization
Medicare Risk
AM - Automobile Medical
CH - CHAMPUS
DS - Disability
HM - Health Maintenance Organization
LM - Liability Medical
MA - Medicare Part A
MB - Medicare Part B
MC - Medicaid
OF - Other Federal Program - Use for Black
Lung Program
TV - Title V
VA - Veteran Administration
WC - Worker's Compensation Health Claim
REMIT_CLM
MED_CLM CLM_CNTL_NUM CLP07 Reference Identification S 1 30 AN Payer Claim Control Number
INST_CLM FAC_TYPE_CD CLP08 Facility Code Value S 1 2 AN Facility Type Code
MED_CLM CLM_FREQ_CD CLP09 Claim Frequency Type Code S 1 1 AN Claim Frequency Code
DRG_CD CLP11 Diagnosis Related Group (DRG) S 1 4 AN
INST_CLM Code
INST_CLM DRG_WEIGHT CLP12 Quantity S 1 15 R Diagnosis Related Group Weight
INST_CLM DSCHG_PCT CLP13 Percent S 1 10 R Discharge Fraction
2100 CAS Claim Adjustment S Used to report claim level adjustments that cause the amount paid to
differ from the amount originally charged.
ADJ_GRP_CD CAS01 Claim Adjustment Group Code M 1 2 ID CO - Contractual Obligations
CR - Correction and Reversals
OA - Other Adjustments
PI - Payor Initiated Reductions
REMIT_CLM_ADJ PR - Patient Responsibility
REMIT_CLM_ADJ ADJ_RSN_CD CAS02 Claim Adjustment Reason Code M 1 5 ID Adjustment Reason Code
REMIT_CLM_ADJ ADJ_AMT CAS03 Monetary Amount M 1 18 R Adjustment Amount
REMIT_CLM_ADJ ADJ_QTY CAS04 Quantity S 1 15 R Adjustment Quantity
REMIT_CLM_ADJ ADJ_RSN_CD CAS05 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_CLM_ADJ ADJ_AMT CAS06 Monetary Amount S 1 18 R Adjustment Amount
REMIT_CLM_ADJ ADJ_QTY CAS07 Quantity S 1 15 R Adjustment Quantity
REMIT_CLM_ADJ ADJ_RSN_CD CAS08 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_CLM_ADJ ADJ_AMT CAS09 Monetary Amount S 1 18 R Adjustment Amount
REMIT_CLM_ADJ ADJ_QTY CAS10 Quantity S 1 15 R Adjustment Quantity
REMIT_CLM_ADJ ADJ_RSN_CD CAS11 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_CLM_ADJ ADJ_AMT CAS12 Monetary Amount S 1 18 R Adjustment Amount
REMIT_CLM_ADJ ADJ_QTY CAS13 Quantity S 1 15 R Adjustment Quantity
REMIT_CLM_ADJ ADJ_RSN_CD CAS14 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_CLM_ADJ ADJ_AMT CAS15 Monetary Amount S 1 18 R Adjustment Amount
REMIT_CLM_ADJ ADJ_QTY CAS16 Quantity S 1 15 R Adjustment Quantity
REMIT_CLM_ADJ ADJ_RSN_CD CAS17 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_CLM_ADJ ADJ_AMT CAS18 Monetary Amount S 1 18 R Adjustment Amount
REMIT_CLM_ADJ ADJ_QTY CAS19 Quantity S 1 15 R Adjustment Quantity
2100 NM1 Patient Name M
PRSN_ORG prsn_org_typ_cd NM101 Entity Identifier Code M 2 3 ID QC - Patient
org_id NM102 Entity Type Qualifier M 1 1 ID 1 - Person
PRSN_ORG 2 - Non-Person Entity
PRSN_ORG LST_NME NM103 Name Last of Organization M 1 35 AN Patient Last Name
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835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
PRSN_ORG FRST_NME NM104 Name First M 1 25 AN Patient First Name
PRSN_ORG MID_NME NM105 Name Middle S 1 25 AN Patient Middle Name
PRSN_ORG NME_SFX NM107 Name Suffix S 1 10 AN Patient Name Suffix
PRIM_ID_TYPE_CD NM108 Identification Code Qualifier M 1 2 ID 34 - Social Security Number
HN - Health Insurance Claim Number
II - United States National Individual
Identifier
MI - Member Identification Number
MR - Medicaid Recipient Identification
PRSN_ORG Number
PRSN_ORG PRIM_ID NM109 Identification Code M 2 80 AN Patient Identifier
2100 NM1 Insured Name S
NM101 Entity Identifier Code M 2 3 ID IL - Insured or Subscriber
NM102 Entity Type Qualifier M 1 1 ID 1 - Person
NM103 Name Last of Organization S 1 35 AN Subscriber Last Name
NM104 Name First S 1 25 AN Subscriber First Name
NM105 Name Middle S 1 25 AN Subscriber Middle Name
NM107 Name Suffix S 1 10 AN Subscriber Name Suffix
NM108 Identification Code Qualifier S 1 2 ID 34 - Social Security Number
HN - Health Insurance Claim Number
MI - Member Identification Number
NM109 Identification Code S 2 80 AN Subscriber Identifier
2100 NM1 Corrected Patient/Insured Name S Used to provide corrected information.
PRSN_ORG prsn_org_typ_cd NM101 Entity Identifier Code M 2 3 ID 74 - Corrected Insured
org_id NM102 Entity Type Qualifier M 1 1 ID 1 - Person
PRSN_ORG 2 - Non-Person Entity
PRSN_ORG CORR_LST_NME NM103 Name Last of Organization S 1 35 AN Corrected Patient/Insured Last Name
PRSN_ORG CORR_FRST_NME NM104 Name First S 1 25 AN Corrected Patient/Insured First Name
PRSN_ORG CORR_MID_NME NM105 Name Middle S 1 25 AN Corrected Patient/Insured Middle Name
PRSN_ORG CORR_NME_SFX NM107 Name Suffix S 1 10 AN Corrected Patient/Insured Name Suffix
Hardcode "C" NM108 Identification Code Qualifier S 1 2 ID C - Insured's Changed Unique Identification
Number
PRSN_ORG CORR_PRIM_ID NM109 Identification Code S 2 80 AN Corrected Patient/Insured Identifier
2100 NM1 Service Provider Name S Provide information abou the rendering provider.
PRSN_ORG prsn_org_typ_cd NM101 Entity Identifier Code M 2 3 ID 82 - Rendering Provider
org_id NM102 Entity Type Qualifier M 1 1 ID 1 - Person
PRSN_ORG 2 - Non-Person Entity
PRSN_ORG LST_NME NM103 Name Last of Organization S 1 35 AN Rendering Provider Last Name
PRSN_ORG FRST_NME NM104 Name First S 1 25 AN Rendering Provider First Name
PRSN_ORG MID_NME NM105 Name Middle S 1 25 AN Rendering Provider Middle Name
PRSN_ORG NME_SFX NM107 Name Suffix S 1 10 AN Rendering Provider Name Suffix
PRIM_ID_TYPE_CD NM108 Identification Code Qualifier M 1 2 ID BD - Blue Cross Provider Number
BS - Blue Shield Provider Number
FI - Federal Taxpayer's Identification
Number
MC - Medicaid Provider Number
PC - Provider Commercial Number
SL - State License Number
UP - Unique Physician Identification Number
XX - Health Care Financing Administration
PRSN_ORG National Provider Identifier
PRSN_ORG PRIM_ID NM109 Identification Code M 2 80 AN Rendering Provider Identifier
2100 NM1 Crossover Carrier Name S Provide information abou the crossover carrier.
NM101 Entity Identifier Code M 2 3 ID TT - Transfer To
NM102 Entity Type Qualifier M 1 1 ID 2 - Non-Person Entity
NM103 Name Last of Organization S 1 35 AN COB Carrier Name
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835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
NM108 Identification Code Qualifier M 1 2 ID AD - Blue Cross Blue Shield Association
Plan Code
FI - Federal Taxpayer's Identification
Number
NI - National Association of Insurance
Commissioners Identification
PI - Payor Identification
PP - Pharmacy Processor Number
XV - Health Care Financing Administration
National PlanID
NM109 Identification Code M 2 80 AN COB Carrier Identifier
2100 NM1 Corrected Priority Payer Name S Required when the current payer believes that another payer has priority
for making a payment.
Hardcode "PR" NM101 Entity Identifier Code M 2 3 ID PR - Payer
Hardcode "2" NM102 Entity Type Qualifier M 1 1 ID 2 - Non-Person Entity
PRSN_ORG ORG_NME NM103 Name Last of Organization S 1 35 AN Corrected Priority Payer Name
PRIM_ID_TYPE_CD NM108 Identification Code Qualifier M 1 2 ID AD - Blue Cross Blue Shield Association
Plan Code
FI - Federal Taxpayer's Identification
Number
NI - National Association of Insurance
Commissioners Identification
PI - Payor Identification
PP - Pharmacy Processor Number
XV - Health Care Financing Administration
PRSN_ORG National PlanID
PRSN_ORG PRIM_ID NM109 Identification Code M 2 80 AN Corrected Priority Payer Identification Number
2100 MIA Inpatient Adjudication Information S Generated by Medicare intermediaries.
Hardcode "0" MIA01 Quantity M 1 15 R Covered Days or Visits Count
INST_CLM OUTLIER_PMT_AMT MIA02 Quantity S 1 15 R PPS Operating Outlier Amount
MIA03 Quantity S 1 15 R Lifetime Psychiatric Days Count
INST_CLM DRG_AMT MIA04 Monetary Amount S 1 18 R Claim DRG Amount
REMIT_CLM_RMRK RMRK_CD MIA05 Reference Identification S 1 30 AN Remark Code
MIA06 Monetary Amount S 1 18 R Claim Disproportionate Share Amount
MIA07 Monetary Amount S 1 18 R Claim MSP Pass-through Amount
MIA08 Monetary Amount S 1 18 R Claim PPS Capital Amount
MIA09 Monetary Amount S 1 18 R PPS-Capital FSP DRG Amount
MIA10 Monetary Amount S 1 18 R PPS-Capital HPS DRG Amount
MIA11 Monetary Amount S 1 18 R PPS-Capital DSH DRG Amount
MIA12 Monetary Amount S 1 18 R Old Capital Amount
MIA13 Monetary Amount S 1 18 R PPS-Capital IME Amount
MIA14 Monetary Amount S 1 18 R PPS-Operating Hospital Specific DRG Amount
MIA15 Quantity S 1 15 R Cost Report Day Count
MIA16 Monetary Amount S 1 18 R PPS-Operating Federal Specific DRG Amount
MIA17 Monetary Amount S 1 18 R Claim PPS Capital Outlier Amount
MIA18 Monetary Amount S 1 18 R Claim Indirect Teaching Amount
MIA19 Monetary Amount S 1 18 R Nonpayable Professional Component Amount
REMIT_CLM_RMRK RMRK_CD MIA20 Reference Identification S 1 30 AN Remark Code
REMIT_CLM_RMRK RMRK_CD MIA21 Reference Identification S 1 30 AN Remark Code
REMIT_CLM_RMRK RMRK_CD MIA22 Reference Identification S 1 30 AN Remark Code
REMIT_CLM_RMRK RMRK_CD MIA23 Reference Identification S 1 30 AN Remark Code
MIA24 Monetary Amount S 1 18 R PPS-Capital Exception Amount
2100 MOA Outpatient Adjudication S Generated by Medicare carriers or intermediaries.
Information
MOA01 Percent S 1 10 R Reimbursement Rate
MOA02 Monetary Amount S 1 18 R Claim HCPCS Payable Amount
MOA03 Reference Identification S 1 30 AN Remark Code
MOA04 Reference Identification S 1 30 AN Remark Code
MOA05 Reference Identification S 1 30 AN Remark Code
MOA06 Reference Identification S 1 30 AN Remark Code
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835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
MOA07 Reference Identification S 1 30 AN Remark Code
MOA08 Monetary Amount S 1 18 R Claim ESRD Payment Amount
MOA09 Monetary Amount S 1 18 R Nonpayable Professional Component Amount
2100 REF Other Claim Related Identification S Used for reference numbers specific to the claim identified in the CLP.
Hardcode "G1" REF01 Reference Identification Qualifier M 2 3 ID 1L - Group or Policy Number
1W - Member Identification Number
9A - Repriced Claim Reference Number
9C - Adjusted Repriced Claim Reference
Number
A6 - Employee Identification Number
BB - Authorization Number
CE - Class of Contract Code
EA - Medical Record Identification Number
F8 - Original Reference Number
G1 - Prior Authorization Number
G3 - Predetermination of Benefits
Identification Number
IG - Insurance Policy Number
SY - Social Security Number
INST_CLM PRIOR_AUTH_NUM REF02 Reference Identification M 1 30 AN Other Claim Related Information
2100 REF Rendering Provider Information S Used to identify provider reference numbers that are not already identified
in NM1 segments.
REF01 Reference Identification Qualifier M 2 3 ID 1A - Blue Cross Provider Number
1B - Blue Shield Provider Number
1C - Medicare Provider Number
1D - Medicaid Provider Number
1G - Provider UPIN Number
1H - CHAMPUS Identification Number
D3 - National Association of Boards of
Pharmacy Number
G2 - Provider Commercial Number
REF02 Reference Identification M 1 30 AN Rendering Provider Secondary Identifier
2100 DTM Claim Date S When claim dates are not provided, service dates are required for every
service line.
Hardcode "050" DTM01 Date/Time Qualifier M 3 3 ID 036 - Expiration
Hardcode "232" 050 - Received
Hardcode "233" 232 - Claim Statement Period Start
233 - Claim Statement Period End
CLM_RCV_DTE DTM02 Date M 8 8 DT Claim Date - Expressed in CCYYMMDD
CLM_SVC_BEG_DTE
MED_CLM CLM_SVC_END_DTE
2100 PER Claim Contact Information S Required when there is a claim specific communications contact
instruction
PER01 Contact Function Code M 1 2 ID CX - Payers Claim Office
PER02 Name S 1 60 AN Payer Contact Name
PER03 Communications Number Qualifier S 2 2 ID EM - Electronic Mail
FX - Facsimile
TE - Telephone
PER04 Communications Number S 1 80 AN
PER05 Communications Number Qualifier S 2 2 ID EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
TE - Telephone
PER06 Communications Number S 1 80 AN
PER07 Communications Number Qualifier S 2 2 ID EX - Telephone Extension
PER08 Communications Number S 1 80 AN
2100 AMT Claim Supplemental Information S Informational Only
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835 - 4010 - Outbound - 000 State Nebraska MMIS
Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
Hardcode "AU" AMT01 Amount Qualifier Code M 1 3 ID AU - Coverage Amount
Hardcode "DY" DB - Discount Amount
DY - Per Day Limit
F5 - Patient Amount Paid
I - Interest
NL - Negative Ledger Balance
T - Tax
T2 - Total Claim Before Taxes
ZK - Federal Medicare or Medicaid Payment
Mandate - Category 1
ZL - Federal Medicare or Medicaid Payment
Mandate - Category 2
ZM - Federal Medicare or Medicaid Payment
Mandate - Category 3
ZN - Federal Medicare or Medicaid Payment
Mandate - Category 4
ZO - Federal Medicare or Medicaid Payment
Mandate - Category 5
ZZ - Mutually Defined
INST_CLM DAY_LMT_AMT AMT02 Monetary Amount M 1 18 R Claim Supplemental Information Amount
2100 QTY Claim Supplemental Information S Informational Only
Quantity
Hardcode "CA" QTY01 Quantity Qualifier M 2 2 ID CA - Covered - Actual
Hardcode "NA" CD - Co-insured - Actual
LA - Life-time Reserve - Actual
LE - Life-time Reserve - Estimated
NA - Number of Non-covered Days
NE - Non-covered - Estimated
NR - Not Replaced Blood Units
OU - Outlier Days
PS - Prescription
VS - Visits
ZK - Federal Medicare or Medicaid Payment
Mandate - Category 1
ZL - Federal Medicare or Medicaid Payment
Mandate - Category 2
ZM - Federal Medicare or Medicaid Payment
Mandate - Category 3
ZN - Federal Medicare or Medicaid Payment
Mandate - Category 4
ZO - Federal Medicare or Medicaid Payment
Mandate - Category 5
COVD_DAYS_ACTL_QTY QTY02 Quantity M 1 15 R Claim Supplemental Information Quantity
NONCOVD_DAYS_ACTL_QT
INST_CLM Y
2110 SVC Service Payment Information S Required when the actual payment has been reduced due to service line
specific adjustments
SVC01 Composite Field M
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Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
PROC_TYPE_CD SVC01-1 Product/Service ID Qualifier M 2 2 ID AD - American Dental Association Codes
ER - Jurisdiction Specific Procedure and
Supply Codes
HC - Health Care Financing Administration
Common Procedural Coding System Codes
ID - International Classification of Diseases
Clinical
IV - Home Infusion EDI Coalition
Product/Service Code
N4 - National Drug Code - 5-4-2 Format
NU - National Uniform Billing Committee
UB92 Codes
RB - National Uniform Billing Committee
UB82 Codes
ZZ - Mutually Defined
CLM_SVC
CLM_SVC PROC_CD SVC01-2 Product/Service ID M 1 48 AN Procedure Code
CLM_SVC PROC_MDFR_1_CD SCV01-3 Procedure Modifier S 2 2 AN
CLM_SVC PROC_MDFR_2_CD SCV01-4 Procedure Modifier S 2 2 AN
CLM_SVC PROC_MDFR_3_CD SCV01-5 Procedure Modifier S 2 2 AN
CLM_SVC PROC_MDFR_4_CD SCV01-6 Procedure Modifier S 2 2 AN
SCV01-7 Description S 1 80 AN Procedure Code Description
CLM_SVC LN_ITEM_CHG_AMT SCV02 Monetary Amount M 1 18 R Line Item Charge Amount
CLM_SVC LN_ITEM_PROV_PMT_AMT SCV03 Monetary Amount M 1 18 R Line Item Provider Payment Account
INST_SVC REV_CD SVC04 Product/Service ID S 1 48 AN National Uniform Billing Committee Revenue Code
CLM_SVC UNIT_SVC_QTY SVC05 Quantity S 1 15 R Units of Service Paid Count
SVC06 Composite Field S Required when the adjudicated procedure code provided in SVC01 is different
from the submitted procedure code from the original claim.
SUB_PROC_TYPE_CD SVC06-1 Product/Service ID Qualifier M 2 2 ID AD - American Dental Association Codes
ER - Jurisdiction Specific Procedure and
Supply Codes
HC - Health Care Financing Administration
Common Procedural Coding System Codes
ID - International Classification of Diseases
Clinical
IV - Home Infusion EDI Coalition
Product/Service Code
N4 - National Drug Code - 5-4-2 Format
NU - National Uniform Billing Committee
UB92 Codes
RB - National Uniform Billing Committee
UB82 Codes
ZZ - Mutually Defined
CLM_SVC
CLM_SVC SUB_PROC_CD SVC06-2 Product/Service ID M 1 48 AN Procedure Code
CLM_SVC SUB_PROC_MDFR_1_CD SVC06-3 Procedure Modifier S 2 2 AN
CLM_SVC SUB_PROC_MDFR_2_CD SVC06-4 Procedure Modifier S 2 2 AN
CLM_SVC SUB_PROC_MDFR_3_CD SVC06-5 Procedure Modifier S 2 2 AN
CLM_SVC SUB_PROC_MDFR_4_CD SVC06-6 Procedure Modifier S 2 2 AN
SVC06-7 Description S 1 80 AN Procedure Code Description
CLM_SVC SUB_UNIT_SVC_QTY SVC07 Quantity S 1 15 R Original Units of Service Count
2110 DTM Service Date S Required if no claim date provided.
Hardcode "150" DTM01 Date/Time Qualifier M 3 3 ID 150 - Service Period Start
Hardcode "151" 151 - Service Period End
472 - Service
SVC_BEG_DTE DTM02 Date M 8 8 DT Service Date - Expressed in CCYYMMDD
CLM_SVC SVC_END_DTE
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Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
2110 CAS Service Adjustment S Used to report service level adjustments that cause the amount paid to
differ from the amount originally charged.
ADJ_GRP_CD CAS01 Claim Adjustment Group Code M 1 2 ID CO - Contractual Obligations
CR - Correction and Reversals
OA - Other Adjustments
PI - Payor Initiated Reductions
REMIT_SVC_ADJ PR - Patient Responsibility
REMIT_SVC_ADJ ADJ_RSN_CD CAS02 Claim Adjustment Reason Code M 1 5 ID Adjustment Reason Code
REMIT_SVC_ADJ ADJ_AMT CAS03 Monetary Amount M 1 18 R Adjustment Amount
REMIT_SVC_ADJ ADJ_QTY CAS04 Quantity S 1 15 R Adjustment Quantity
REMIT_SVC_ADJ ADJ_RSN_CD CAS05 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_SVC_ADJ ADJ_AMT CAS06 Monetary Amount S 1 18 R Adjustment Amount
REMIT_SVC_ADJ ADJ_QTY CAS07 Quantity S 1 15 R Adjustment Quantity
REMIT_SVC_ADJ ADJ_RSN_CD CAS08 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_SVC_ADJ ADJ_AMT CAS09 Monetary Amount S 1 18 R Adjustment Amount
REMIT_SVC_ADJ ADJ_QTY CAS10 Quantity S 1 15 R Adjustment Quantity
REMIT_SVC_ADJ ADJ_RSN_CD CAS11 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_SVC_ADJ ADJ_AMT CAS12 Monetary Amount S 1 18 R Adjustment Amount
REMIT_SVC_ADJ ADJ_QTY CAS13 Quantity S 1 15 R Adjustment Quantity
REMIT_SVC_ADJ ADJ_RSN_CD CAS14 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_SVC_ADJ ADJ_AMT CAS15 Monetary Amount S 1 18 R Adjustment Amount
REMIT_SVC_ADJ ADJ_QTY CAS16 Quantity S 1 15 R Adjustment Quantity
REMIT_SVC_ADJ ADJ_RSN_CD CAS17 Claim Adjustment Reason Code S 1 5 ID Adjustment Reason Code
REMIT_SVC_ADJ ADJ_AMT CAS18 Monetary Amount S 1 18 R Adjustment Amount
REMIT_SVC_ADJ ADJ_QTY CAS19 Quantity S 1 15 R Adjustment Quantity
2110 REF Service Identification S Used to provide additional information for processing adjudication
services.
Hardcode "6R" - for Line item REF01 Reference Identification Qualifier M 2 3 ID 1S - Ambulatory Patient Group Number
control number 6R - Provider Control Number
Hardcode "G1" - for prior auth BB - Authorization Number
number E9 - Attachment Code
G1 - Prior Authorization Number
G3 - Predetermination of Benefits
Identification Number
LU - Location Number
RB - Rate Code Number
CLM_SVC LN_ITEM_CNTL_NUM REF02 Reference Identification M 1 30 AN Provider Identifier
DENTAL_SERVICE prior_auth_num
PROF_SERVICE prior_auth_num
2110 REF Rendering Provider Identification S Used for reference numbers specific to the service identified by the SVC
segment.
REF01 Reference Identification Qualifier M 2 3 ID 1A - Blue Cross Provider Number
1B - Blue Shield Provider Number
1C - Medicare Provider Number
1D - Medicaid Provider Number
1G - Provider UPIN Number
1H - CHAMPUS Identification Number
1J - Facility ID Number
HPI - Health Care Financing Administration
National Provider Identifier
SY - Social Security Number
TJ - Federal Taxpayer's Identification
Number
REF02 Reference Identification M 1 30 AN Rendering Provider Identifier
2110 AMT Service Supplemental Amount S Informational Only
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Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
AMT01 Amount Qualifier Code M 1 3 ID B6 - Allowed - Actual
DY - Per Day Limit
KH - Deduction Amount
NE - Net Billed
T - Tax
T2 - Total Claim Before Taxes
ZK - Federal Medicare or Medicaid Payment
Mandate - Category 1
ZL - Federal Medicare or Medicaid Payment
Mandate - Category 2
ZM - Federal Medicare or Medicaid Payment
Mandate - Category 3
ZN - Federal Medicare or Medicaid Payment
Mandate - Category 4
ZO - Federal Medicare or Medicaid Payment
Mandate - Category 5
AMT02 Monetary Amount M 1 18 R Service Supplemental Amount
2110 QTY Service Supplemental Quantity S Informational Only
QTY01 Quantity Qualifier M 2 2 ID NE - Non-covered - Estimated
ZK - Federal Medicare or Medicaid Payment
Mandate - Category 1
ZL - Federal Medicare or Medicaid Payment
Mandate - Category 2
ZM - Federal Medicare or Medicaid Payment
Mandate - Category 3
ZN - Federal Medicare or Medicaid Payment
Mandate - Category 4
ZO - Federal Medicare or Medicaid Payment
Mandate - Category 5
QTY02 Quantity M 1 15 R Service Supplemental Quantity Count
2110 LQ Health Care Remark Codes S Informational Only
rmrk_type_cd LQ01 Code List Qualifier Code M 1 3 ID HE - Claim Payment Remark Codes
RX - National Council for Prescription Drug
REMIT_SVC_RMRK Programs Reject/Payment Codes
REMIT_SVC_RMRK RMRK_CD LQ02 Industry Code M 1 30 AN Remark Code
PLB Provider Adjustment S Used for adjustments that are not specific to a particular claim or service
to the amount of the actual payment.
PRSN_ORG PRIM_ID PLB01 Reference Identification M 1 30 AN Provider Identifier
REMIT_PROV_ADJ FISCAL_PERIOD_DTE PLB02 Date M 8 8 DT Fiscal Period Date - Expressed in CCYYMMDD
PLB03 Composite Field M
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Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
ADJ_RSN_CD PLB03-1 Adjustment Reason Code M 2 2 ID 50 - Late Charge
51 - Interest Penalty Charge
72 - Authorized Return
90 - Early Payment Allowance
AH - Origination Fee
AM - Applied to Borrower's Account
AP - Acceleration of Benefits
B2 - Rebate
B3 - Recovery Allowance
BD - Bad Debit Adjustment
BN - Bonus
C5 - Temporary Allowance
CR - Capitation Interest
CS - Adjustment
CT - Capitation Payment
CV - Capital Passthru
CW - Certified Registered Nurse Anesthetist
Passthru
DM - Direct Medical Education Passthru
E3 - Withholding
FB - Forward Balance
FC - Fund Allocation
GO - Graduate Medical Education Passthru
IP - Incentive Premium Payment
IR - Internal Revenue Service Withholding
IS - Interim Settlement
J1 - Nonreimbursable
L3 - Penalty
L6 - Interest Owed
LE - Levy
REMIT_PROV_ADJ
ADJ_RSN_CD PLB03-1 Adjustment Reason Code Cont. LS - Lump Sum
OA - Organ Acquisition Passthru
OB - Offset for Affiliated Providers
PI - Periodic Interim Payment
PL - Payment Final
RA - Retro-activity Adjustment
RE - Return of Equity
SL - Student Loan Repayment
TL - Third Party Liability
WO - Overpayment Recovery
WU - Unspecified Recovery
ZZ - Mutually Defined
REMIT_PROV_ADJ
PLB03-2 Reference Identification S 1 30 AN Provider Adjustment Identifier
REMIT_PROV_ADJ ADJ_AMT PLB04 Monetary Amount M 1 18 R Provider Adjustment Amount
PLB05 Adjustment Identifier - Composite S Required when additional adjustments apply.
Field
REMIT_PROV_ADJ ADJ_RSN_CD PLB05-1 Adjustment Reason Code M 2 2 ID
PLB05-2 Adjustment Identifier S 1 30 AN Provider Adjustment Identifier
REMIT_PROV_ADJ ADJ_AMT PLB06 Monetary Amount S 1 18 R Provider Adjustment Amount
PLB07 Adjustment Identifier - Composite S Required when additional adjustments apply.
Field
REMIT_PROV_ADJ ADJ_RSN_CD PLB07-1 Adjustment Reason Code M 2 2 ID
PLB07-2 Adjustment Identifier S 1 30 AN Provider Adjustment Identifier
REMIT_PROV_ADJ ADJ_AMT PLB08 Monetary Amount S 1 18 R Provider Adjustment Amount
PLB09 Adjustment Identifier - Composite S Required when additional adjustments apply.
Field
REMIT_PROV_ADJ ADJ_RSN_CD PLB09-1 Adjustment Reason Code M 2 2 ID
PLB09-2 Adjustment Identifier S 1 30 AN Provider Adjustment Identifier
REMIT_PROV_ADJ ADJ_AMT PLB10 Monetary Amount S 1 18 R Provider Adjustment Amount
PLB11 Adjustment Identifier - Composite S Required when additional adjustments apply.
Field
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Mapping Specifications Spreadsheets
Segment/ Mandatory/ Field
Interface Table Name Interface Field Name Loop ID Element Description Min Max Rules Comments
Element Situational Type
REMIT_PROV_ADJ ADJ_RSN_CD PLB11-1 Adjustment Reason Code M 2 2 ID
PLB11-2 Adjustment Identifier S 1 30 AN Provider Adjustment Identifier
REMIT_PROV_ADJ ADJ_AMT PLB12 Monetary Amount S 1 18 R Provider Adjustment Amount
PLB13 Adjustment Identifier - Composite S Required when additional adjustments apply.
Field
REMIT_PROV_ADJ ADJ_RSN_CD PLB13-1 Adjustment Reason Code M 2 2 ID
PLB13-2 Adjustment Identifier S 1 30 AN Provider Adjustment Identifier
REMIT_PROV_ADJ ADJ_AMT PLB14 Monetary Amount S 1 18 R Provider Adjustment Amount
SE Transaction Set Trailer M
Autogenerated by Translator ST01 Number of Included Segment M 1 3 ID Automatically calculated
Autogenerated by Translator ST02 Transaction Set Control Number M 4 9 AN Automatically generated. Has to match
ST02
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EDI Team
Translator Mapping Specifications
Process Task Description
Comments
Number All Reads of X12 segments are automatically performed by the translator. No rules are needed to do this.
Perform a select on the T835_HEADER table with the criteria of EDI_NEWDATAFLG of "Y"
1 Fetch first row in cursor and substring EDI_BASE for the last 11 characters and move that data into the
EDI_TRANSNUM memory variable
2 Write ISA, GS and ST
Perform select on the EDI_UNIQUE_NUMBER table based on the EDI_TRANSNUM that was returned from the first
select of the T835_HEADER table
3
Move ISA, GS and ST System variables to the EDI_UNIQUE_NUMBER table fields - perform update on that row
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
IMServices - MMIS
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