healthcare industry foundation object model · 2019-05-22 · healthcare payer industry and claims...

Pegasystems Inc., Cambridge, MAAll rights reserved.

HCIF Data Classes

X12 Layer

List of classes in Healthcare Industry Framework

Property List in Rulesets: PegaX12, PegaX125010, PegaX124010

PegaHC

Property List in Rulesets: PegaHCLP, PegaHC-PCS-Foundation, PegaHCEDI, PegaHCAGM,

PegaHC, PegaHL7, PegaPCS-Foundation

This document lists the pre-configured class and property rules that support the foundation layer of the Healthcare Industry

Framework. The data is organized in numerous classes and is sorted by Class Name and Property Name.

Healthcare Industry Foundation

Object Model

Copyright 2013

DescriptionWorksheet

PegaHealthCodes Property List in Rulesets: PegaHealthCodeGroups,PegaHealthCodes

Healthcare Payer Industry and Claims Frameworks Object Model

HCIF Data Classes

PegaHC-AG-Data-GrievanceReason Grievance Reasons Y

PegaHC-AG-Data-Service Basic Data structure N

PegaHC-Data-AmbulanceServices Holds ambulance service data N

PegaHC-Data-Attachments Claim attachment information N

PegaHC-Data-Authorization Authorization (referral) information Y

PegaHC-Data-BEAddress Postal Address of a Business Entity N

PegaHC-Data-Benefit Benefit Information N

PegaHC-Data-BenefitGroup Benefit group information N

PegaHC-Data-Claim Claim header information Y

PegaHC-Data-ClaimConditionCodes Claim condition code information N

PegaHC-Data-ClaimDenialCodes Holds denial codes N

PegaHC-Data-ClaimLine Claim line information N

PegaHC-Data-ClaimOccurrenceCodes Claim occurrence code information N

PegaHC-Data-ClaimPendCodes Pend code listing on claim header and line N

PegaHC-Data-ClaimProcedureCodes common demographic information to work parties N

PegaHC-Data-ClaimSpanOccurrenceCodes Claim occurrence span code information N

PegaHC-Data-ClaimStatusCategoryCodes Claim status category code information Y

PegaHC-Data-ClaimStatusCodes Claim status code information Y

PegaHC-Data-ClaimTreatmentCodes Claim treatment code information N

PegaHC-Data-ClaimValueCodes Claim value code information N

PegaHC-Data-CommonMedication Common Medication Y

PegaHC-Data-Contact Holds contact information in claim data object N

PegaHC-Data-DRGCodes DRG code information Y

PegaHC-Data-DrugCodes Drug code information N

PegaHC-Data-EligibilityRequest Eligibility Request Information N

PegaHC-Data-Enrollment Member enrollment information – not likely to be used in claims N

PegaHC-Data-FamilyAccumulators Family Cost Share Accumulator Summary Information Y

PegaHC-Data-FormIdentification Holds form information in claim data model N

PegaHC-Data-IndividualAccumulators Individual Cost Share Accumulator Summary Information Y

PegaHC-Data-InformationCodes Holds HI code information in claim data model N

PegaHC-Data-Issues Issues Information N

PegaHC-Data-LabResults Lab Results N

PegaHC-Data-Languages Language code and description Y

PegaHC-Data-Measurement Measurement Infromation N

DATA CLASSES IN HEALTHCARE INDUSTRY FOUNDATION*

Sample Data

Instances?

Class Repository for:

Pegasystems Inc. Confidential


HCIF Data Classes

PegaHC-Data-MedicalHistory Medical History N

PegaHC-Data-Party Common demographic information to work parties N

PegaHC-Data-Party-Agency Sales Agency information (not likely to be used in claims) N

PegaHC-Data-Party-Broker Sales Broker information (not likely to be used in claims) N

PegaHC-Data-Party-Company Company party information N

PegaHC-Data-Party-InformationReceiver EDI Information Receiver N

PegaHC-Data-Party-InformationSource EDI Information Source N

PegaHC-Data-Party-Member Subscriber / Member / Patient information Y

PegaHC-Data-Party-Payer Healthcare payer (COB) information N

PegaHC-Data-Party-PlanSponsor Employer Group information N

PegaHC-Data-Party-Provider Provider (physician, facility) information Y

PegaHC-Data-Party-Provider-Practitioner NPI Type-1 Provider (Person) N

PegaHC-Data-Party-Provider-ServicingOrg NPI Type-2 Provider (Non-Person) N

PegaHC-Data-Payment Claim and health insurance premium payment information N

PegaHC-Data-Payment-Claim Claim payment information N

PegaHC-Data-Payment-Premium Health insurance premium payment payment information (not likely to be used in claims N

PegaHC-Data-PCPSpecialities Specialties that can be rendered by a Primary Care Physician N

PegaHC-Data-Policy Health insurance Policy information Y

PegaHC-Data-Population Population Information N

PegaHC-Data-Prescription Prescription Information N

PegaHC-Data-Product Benefit Product information (not likely to be used in claims) N

PegaHC-Data-ProductGroup A group of healthcare products N

PegaHC-Data-ProviderAffiliation Relationship between a provider and a business entity N

PegaHC-Data-ProviderContract Contract betwen a business entity and a Healthplan(Payor) N

PegaHC-Data-ProviderSearch Search results for a provider N

PegaHC-Data-ReferralCircle A small circle of providers, to whome a PCP can refer patients N

PegaHC-Data-RemarkCodes Claim Remark Code information Y

PegaHC-Data-Risk Risk Information N

PegaHC-Data-Service Healthcare service related information – Claim, ClaimLine, and Auhtorization inherit from this class since they share many common propertiesN

PegaHC-Data-ToothCodes Tooth codes used in dental claims Y

PegaHC-Data-Trailer Holds trailer information of claim object N

PegaHealth-Codes-Data- Diagnosis-ICD10 ICD-10 diagnosis code set information Y

PegaHealth-Codes-Data-BillType Bill Types Y

PegaHealth-Codes-Data-ClaimAdjustmentReason Claim Adjustment Reason Codes Y

PegaHealth-Codes-Data-ClaimRemark Remittance/Remark Claim Codes Y

PegaHealth-Codes-Data-ClaimStatus Claim Status Codes Y

PegaHealth-Codes-Data-ClaimStatusCategory Claim Status Category Y



HCIF Data Classes

PegaHealth-Codes-Data-CodeSet Holds codesets belong to a given code group (mapped to exploded code group table) N

PegaHealth-Codes-Data-CPT CPT code set information Y

PegaHealth-Codes-Data-Diagnosis-ICD109Map ICD-10 to ICD-9 diagnosis mapping information Y

PegaHealth-Codes-Data-Diagnosis-ICD109MapReimbursement Map ICD10 To ICD9 Diagnosis Reimbursement Y

PegaHealth-Codes-Data-Diagnosis-ICD9 ICD-9 diagnosis code set information Y

PegaHealth-Codes-Data-Diagnosis-ICD910Map ICD-9 to ICD-10 diagnosis mapping information Y

PegaHealth-Codes-Data-DRG DRG Codes N

PegaHealth-Codes-Data-GCN GCN code set information Y

PegaHealth-Codes-Data-HCPCS HCPCS code set information Y

PegaHealth-Codes-Data-Modifier Modifier Codes Y

PegaHealth-Codes-Data-NDC NDC code set information Y

PegaHealth-Codes-Data-POS Place of Service Code Y

PegaHealth-Codes-Data-Procedure-ICD10 ICD-10 procedure code set information Y

PegaHealth-Codes-Data-Procedure-ICD109Map ICD-10 to ICD-9 procedure mapping information Y

PegaHealth-Codes-Data-Procedure-ICD109MapReimbursement Map ICD10 To ICD 9 Procedure Reimbursement Y

PegaHealth-Codes-Data-Procedure-ICD9 ICD-9 procedure code set information Y

PegaHealth-Codes-Data-Procedure-ICD910Map ICD-9 to ICD-10 procedure mapping information Y

PegaHealth-Codes-Data-ProviderTaxonomy Provider Taxonomy Codes Y

PegaHealth-Codes-Data-Revenue Revenue Codes Y

PegaHealth-Codes-Data-ServiceReview Service Review Codes Y

PegaHealth-Codes-Data-ServiceType Service Type Codes Y

PegaHealth-Codes-Data-Specialty Specialty Codes N

* Excludes PegaHC-X12 classes that contain rules that support X12 message segments and data elements.



HCIF Data Classes


Class Name Property Name Description Ruleset Name

@baseclass TreeGridLevel TreeGridLevel PegaHC@baseclass UpdateType UpdateType PegaHC@baseclass DisplayEndDate DisplayEndDate PegaHC@baseclass DisplayName DisplayEffectiveDate PegaHC@baseclass UpdatePurpose UpdateType PegaHC@baseclass TodaysDate Today's Date PegaHC@baseclass DisplayEffectiveDate DisplayEffectiveDate PegaHC@baseclass CurrentDateTime CurrentDateTime PegaHCData- IsMainVersion IsMainVersion PegaHCData-Party pyHomeStreet Home Street Address PegaHCData-Party pyWorkStreet Work Street Address PegaHCData-Portal ContractType ContractType PegaHCData-Portal FirstName FirstName PegaHCData-Portal ActiveStatus ActiveStatus PegaHCData-Portal TIN TIN PegaHCData-Portal LastName LastName PegaHCData-Portal ReferralCircleType ReferralCircleType PegaHCData-Portal DateOfBirth DateOfBirth PegaHCData-Portal BEName NPI PegaHCData-Portal NPI NPI PegaHCEmbed-PegaHC- TaxonomyCode TaxonomyCode PegaHCEmbed-PegaHC- AuthorizationDecision AuthorizationDecision PegaHCEmbed-PegaHC-Address Country Country PegaHCEmbed-PegaHC-Address AddressLine2 AddressLine1 PegaHCEmbed-PegaHC-Address ManagerLastName ManagerLastName PegaHCEmbed-PegaHC-Address PrimaryIndicator PrimaryIndicator PegaHCEmbed-PegaHC-Address ManagerFirstName ManagerFirstName PegaHCEmbed-PegaHC-Address PostalCode PostalCode PegaHCEmbed-PegaHC-Address Email Email PegaHCEmbed-PegaHC-Address AddressLine1 AddressLine1 PegaHCEmbed-PegaHC-Address WheelchairAccess WheelchairAccess PegaHCEmbed-PegaHC-Address AddressType AddressType PegaHCEmbed-PegaHC-Address City city PegaHCEmbed-PegaHC-Address Fax Fax PegaHCEmbed-PegaHC-Address MailingAddress MailingAddress PegaHCEmbed-PegaHC-Address State State PegaHCEmbed-PegaHC-Address PhoneNumber PhoneNumber PegaHCEmbed-PegaHC-Address County County PegaHCEmbed-PegaHC-Address ErrorMessage ErrorMessage PegaHC

Embed-PegaHC-Address RemoveAddress Remove Address PegaHCEmbed-PegaHC-Address Payee Payee PegaHCEmbed-PegaHC-AdjudicatedLine PaidServiceUnitCount PaidServiceUnitCount PegaHCEmbed-PegaHC-AdjudicatedLine OtherPayerPrimaryIdentifier OtherPayerPrimaryIdentifier PegaHCEmbed-PegaHC-AdjudicatedLine ProcedureModifiers ProcedureModifiers PegaHCEmbed-PegaHC-AdjudicatedLine ServiceAdjudicationOrPaymentDate ServiceAdjudicationOrPaymentDate PegaHCEmbed-PegaHC-AdjudicatedLine BundledOrUnbundledLineNumber BundledOrUnbundledLineNumber PegaHCEmbed-PegaHC-AdjudicatedLine Payments Payments PegaHCEmbed-PegaHC-AdjudicatedLine ServiceLinePaidAmount ServiceLinePaidAmount PegaHC

Embed-PegaHC-AdjudicatedLine RemainingPatientLiabilityClaimLineAmount RemainingPatientLiabilityClaimLineAmount PegaHCEmbed-PegaHC-AdjudicatedLine ProductOrServiceIDQualifier ProductOrServiceIDQualifier PegaHCEmbed-PegaHC-AdjudicatedLine ProcedureCodeDescription .ProcedureCodeDescription PegaHCEmbed-PegaHC-AdjudicatedLine ProcedureCode ProcedureCode PegaHCEmbed-PegaHC-Adjustments AdjustmentAmount AdjustmentAmount PegaHCEmbed-PegaHC-Adjustments AdjustmentReasonCode AdjustmentReasonCode PegaHCEmbed-PegaHC-Adjustments AdjustmentQuantitiy AdjustmentQuantitiy PegaHCEmbed-PegaHC-BEAddress IsRemittance IsRemittance PegaHCEmbed-PegaHC-BEAddress IsServicing IsServicing PegaHCEmbed-PegaHC-BEAddress IsProviderCorrespondance IsProviderCorrespondance PegaHCEmbed-PegaHC-BEAddress AddressKey AddressKey PegaHCEmbed-PegaHC-BEAddress ServicingAddendum ServicingAddendum PegaHCEmbed-PegaHC-BEAddress RemittanceAddress RemittanceAddress PegaHCEmbed-PegaHC-BEAddress Address Address PegaHCEmbed-PegaHC-BEAddress IsProviderServicing IsServicing PegaHCEmbed-PegaHC-BEAddress IsFinancial IsFinancial PegaHCEmbed-PegaHC-Campaign ResolvedDateTime ResolvedDateTime PegaHCEmbed-PegaHC-Campaign CampaignID CampaignID PegaHCEmbed-PegaHC-Campaign CampaignName CampaignName PegaHCEmbed-PegaHC-Campaign CreateDateTime CreateDateTime PegaHCEmbed-PegaHC-Certification ExpirationDate ExpirationDate PegaHCEmbed-PegaHC-Certification Certified Certified PegaHCEmbed-PegaHC-Certification TaxonomyCode Taxonomy Code PegaHCEmbed-PegaHC-Certification Board Board PegaHCEmbed-PegaHC-Certification PrimaryCert PrimaryCert PegaHCEmbed-PegaHC-CodeInformation FromDate FromDate PegaHCEmbed-PegaHC-CodeInformation Amount Amount PegaHCEmbed-PegaHC-CodeInformation AdmissionIndicator AdmissionIndicator PegaHCEmbed-PegaHC-CodeInformation ToDate ToDate PegaHCEmbed-PegaHC-CodeInformation DateTimePeriodFormatQualifier DateTimePeriodFormatQualifier PegaHC

Embed-PegaHC-CodeInformation QualifierCode QualifierCode PegaHCEmbed-PegaHC-CodeInformation Code ProcedureCode PegaHCEmbed-PegaHC-CodeInformation Date Date PegaHCEmbed-PegaHC-Condition CodeCategory CodeCategory PegaHCEmbed-PegaHC-Condition CertificationConditionIndicator CertificationConditionIndicator PegaHCEmbed-PegaHC-Condition ConditionCode ConditionCode PegaHCEmbed-PegaHC-ContactInformation Address Address PegaHCEmbed-PegaHC-ContactInformation Name Name PegaHCEmbed-PegaHC-ContactInformation Title Title PegaHCEmbed-PegaHC-Date DateTimeQualifier DateTimeQualifier PegaHCEmbed-PegaHC-Date Date Date PegaHCEmbed-PegaHC-Diagnosis DiagnosisTypeCode Diagnosis Type Code PegaHCEmbed-PegaHC-Diagnosis DiagnosisCategory DiagnosisCategory PegaHCEmbed-PegaHC-Diagnosis DiagnosisCode DiagnosisCode PegaHCEmbed-PegaHC-Diagnosis DiagnosisDescription DiagnosisDescription PegaHCEmbed-PegaHC-Diagnosis DiagnosisDate DiagnosisDate PegaHCEmbed-PegaHC-Disability DisabilityPeriodStartDate DisabilityPeriodStartDate PegaHCEmbed-PegaHC-Disability DisabilityTypeCode DiabilityTypeCode PegaHCEmbed-PegaHC-Disability DisabilityPeriodEndDate DisabilityPeriodStartDate PegaHCEmbed-PegaHC-FileInformation FixedFormatInformation FixedFormatInformation PegaHCEmbed-PegaHC-FormQuestion QuestionNumberOrLetter Question Number Or Letter PegaHCEmbed-PegaHC-FormQuestion QuestionResponse Question Response PegaHCEmbed-PegaHC-FormQuestion QuestionResponseIndex QuestionResponseIndex PegaHCEmbed-PegaHC-Measurement MeasurementQualifier MeasurementQualifier PegaHC

Embed-PegaHC-Measurement MeasurementReferenceIdentificationCode MeasurementReferenceIdentificationCode PegaHCEmbed-PegaHC-Measurement TestResults TestResults PegaHCEmbed-PegaHC-Member EndDate EndDate PegaHCEmbed-PegaHC-Member IndividualRelationshipCode IndividualRelationshipCode PegaHCEmbed-PegaHC-Member PolicyRole IndividualRelationshipCode PegaHCEmbed-PegaHC-Member MemberStatus MemberStatus PegaHCEmbed-PegaHC-Member MemberNumber MemberNumber PegaHCEmbed-PegaHC-Member EffectiveDate EffectiveDate PegaHCEmbed-PegaHC-Network NetworkName NetworkName PegaHCEmbed-PegaHC-Network EndDate EndDate PegaHCEmbed-PegaHC-Network Participating Participating PegaHCEmbed-PegaHC-Network StartDate StartDate PegaHCEmbed-PegaHC-Notes NoteReferenceCode NoteReferenceCode PegaHCEmbed-PegaHC-Notes ClaimNoteText ClaimNoteText PegaHCEmbed-PegaHC-Plans PlanNumber PlanNumber PegaHC

Embed-PegaHC-Plans PlanName PlanName PegaHCEmbed-PegaHC-Plans PlanEffectiveDate PlanEffectiveDate PegaHCEmbed-PegaHC-Plans PlanEndDate PlanEndDate PegaHCEmbed-PegaHC-Policy PolicyStatus PolicyStatus PegaHCEmbed-PegaHC-Policy EffectiveDate Effective Date PegaHCEmbed-PegaHC-Policy PolicyNumber PolicyNumber PegaHCEmbed-PegaHC-Policy IndividualRelationshipCode IndividualRelationshipCode PegaHCEmbed-PegaHC-Policy EndDate End Date PegaHCEmbed-PegaHC-Policy MemberStatus MemberStatus PegaHCEmbed-PegaHC-Procedure ProcedureCode ProcedureCode PegaHCEmbed-PegaHC-Procedure ActionCode Action Code PegaHCEmbed-PegaHC-Procedure ProcedureQuantity Procedure Quantity PegaHCEmbed-PegaHC-Procedure CodeDate CodeDate PegaHCEmbed-PegaHC-Procedure AuthorizedUnitCount Authorized Service Unit Count PegaHCEmbed-PegaHC-Procedure ApprovedUnits ApprovedUnits PegaHCEmbed-PegaHC-Procedure RepricedApprovedServiceUnitCount Repriced Approved Service Unit Count PegaHCEmbed-PegaHC-Procedure ProcedureDescription ProcedureDescription PegaHCEmbed-PegaHC-Procedure Treatment Treatment PegaHCEmbed-PegaHC-Procedure RequestedUnits RequestedUnits PegaHCEmbed-PegaHC-Provider EndDate EndDate PegaHCEmbed-PegaHC-Provider ProviderID GroupID PegaHCEmbed-PegaHC-Provider EffectiveDate EffectiveDate PegaHCEmbed-PegaHC-ProviderAffiliation AffiliationData ProviderAffiliations PegaHCEmbed-PegaHC-ProviderAffiliation ProviderID ProviderID PegaHCEmbed-PegaHC-ProviderAffiliation EffectiveDate EffectiveDate PegaHCEmbed-PegaHC-ProviderAffiliation BusinessEntityID BusinessEntityID PegaHCEmbed-PegaHC-ProviderContractPick LineNumber LineNumber PegaHCEmbed-PegaHC-ProviderContractPick IsProviderActive IsProviderActive PegaHCEmbed-PegaHC-ProviderContractPick IsContractActive IsContractActive PegaHCEmbed-PegaHC-ProviderContractPick IsAffiliationActive IsAffiliationActive PegaHCEmbed-PegaHC-ProviderContractPick AffiliationPickMessage AffiliationPickMessage PegaHCEmbed-PegaHC-ProviderContractPick ProviderPickMessage ProviderPickMessage PegaHCEmbed-PegaHC-ProviderContractPick IsBusinessEntityActive IsBusinessEntityActive PegaHCEmbed-PegaHC-ProviderContractPick BusinessEntityPickMessage BusinessEntityPickMessage PegaHCEmbed-PegaHC-ProviderContractPick ContractPickMessage ContractPickMessage PegaHCEmbed-PegaHC-ProviderGroup EndDate EndDate PegaHCEmbed-PegaHC-ProviderGroup EffectiveDate EffectiveDate PegaHCEmbed-PegaHC-ProviderGroup GroupID GroupID PegaHCEmbed-PegaHC-Reference ReferenceIdentifier ReferenceIdentifier PegaHCEmbed-PegaHC-Reference RefIDQualifier RefIDQualifier PegaHC

Embed-PegaHC-Reference AdditionalRefIDQualifier AdditionalRefIDQualifier for REF04 PegaHCEmbed-PegaHC-Reference AdditionalRefenceIdentifier AdditionalRefenceIdentifier for REF04 PegaHCEmbed-PegaHC-Remittance DBAName DBAName PegaHCEmbed-PegaHC-Remittance BankAccountNumber BankAccountNumber PegaHCEmbed-PegaHC-Remittance BankRoutingNumber BankRoutingNumber PegaHCEmbed-PegaHC-Remittance BankAccountType BankAccountType PegaHCEmbed-PegaHC-ServicingAddendum Fax Fax PegaHCEmbed-PegaHC-ServicingAddendum PhoneNumbers PhoneNumbers PegaHCEmbed-PegaHC-ServicingAddendum OpenTime OpenTime PegaHCEmbed-PegaHC-ServicingAddendum IsFridayWorkingDay IsFridayWorkingDay PegaHCEmbed-PegaHC-ServicingAddendum ServicesOffered Services Offered PegaHCEmbed-PegaHC-ServicingAddendum PhoneNumber PhoneNumber PegaHCEmbed-PegaHC-ServicingAddendum PhoneNumberExtension PhoneNumber Extension PegaHCEmbed-PegaHC-ServicingAddendum CloseTime OpenTime PegaHCEmbed-PegaHC-ServicingAddendum HandicappedAccessible HandicappedAccessible PegaHCEmbed-PegaHC-ServicingAddendum IsMondayWorkingDay IsMondayWorkingDay PegaHCEmbed-PegaHC-ServicingAddendum Email Email PegaHCEmbed-PegaHC-ServicingAddendum IsTuesdayWorkingDay IsTuesdayWorkingDay PegaHCEmbed-PegaHC-ServicingAddendum website website PegaHCEmbed-PegaHC-ServicingAddendum IsSaturdayWorkingDay IsSaturdayWorkingDay PegaHCEmbed-PegaHC-ServicingAddendum IsWednesdayWorkingDay IsWednesdayWorkingDay PegaHCEmbed-PegaHC-ServicingAddendum IsSundayWorkingDay IsSundayWorkingDay PegaHCEmbed-PegaHC-ServicingAddendum IsThursdayWorkingDay IsThursdayWorkingDay PegaHCEmbed-PegaHC-Stringlist EffectiveDate EffectiveDate PegaHCEmbed-PegaHC-Stringlist EndDate EndDate PegaHCEmbed-PegaHC-Stringlist ServicesOffered Services Offered PegaHCEmbed-PegaHC-Stringlist PhoneNumber PhoneNumber PegaHCEmbed-PegaHC-Stringlist Value Value PegaHCEmbed-PegaHC-Stringlist TerminationReason TerminationReason PegaHCHistory-PegaHC-Data-ProductGroup UpdatedMetadata UpdatedMetadata PegaHC

History-PegaHC-Data-ProviderAffiliation UpdatedMetaData UpdatedMetaData PegaHCHistory-PegaHC-Data-ReferralCircle UpdatedMetadata UpdatedMetadata PegaHCPegaHC AuthorizationDecision AuthorizationDecision PegaHCPegaHC-Data- ProductOrServiceIDQualifier Product Or Service ID Qualifier PegaHCPegaHC-Data- SpecialtyMatched SpecialtyMatched PegaHCPegaHC-Data- UpdateFlag UpdateFlag PegaHCPegaHC-Data- Versions Versions PegaHCPegaHC-Data- IsActive IsActive PegaHCPegaHC-Data- ProviderContractPick ProviderContractPick PegaHC

PegaHC-Data- County County PegaHCPegaHC-Data- DisplayName DisplayEffectiveDate PegaHCPegaHC-Data- IsApproved IsApproved PegaHCPegaHC-Data- Latitude Latitude PegaHCPegaHC-Data- MasterEndDate MasterEndDate PegaHCPegaHC-Data- DateTimePeriodFormatQualifier DateTimePeriodFormatQualifier PegaHCPegaHC-Data- GapEndDate GapStartDate PegaHCPegaHC-Data- InformationSource Information Source PegaHCPegaHC-Data- InformationReceiver Information Receiver PegaHCPegaHC-Data- LocationMatched LocationMatched PegaHCPegaHC-Data- OnHold OnHold PegaHCPegaHC-Data- LISTING_PREFIX LISTING_PREFIX PegaHCPegaHC-Data- RejectReasonCode Reject Reason Code PegaHCPegaHC-Data- Source Source PegaHCPegaHC-Data- Code Code PegaHCPegaHC-Data- FollowupActionCode Followup Action Code PegaHCPegaHC-Data- TaxonomyCode TaxonomyCode PegaHCPegaHC-Data- DisplayEndDate DisplayEndDate PegaHCPegaHC-Data- NewVersionNote NewVersionNote PegaHCPegaHC-Data- GapStartDate GapStartDate PegaHCPegaHC-Data- ProductKey ProductNumber PegaHCPegaHC-Data- DateTimeQualifier DateTimeQualifier PegaHCPegaHC-Data- EndDate EndDate PegaHCPegaHC-Data- Longitude Longitude PegaHCPegaHC-Data- Description Description PegaHCPegaHC-Data- DisplayEffectiveDate DisplayEffectiveDate PegaHCPegaHC-Data- EffectiveDate EffectiveDate PegaHCPegaHC-Data- RelativeEffectiveDate RelativeEffectiveDate PegaHCPegaHC-Data- Gap2StartDate GapStartDate PegaHCPegaHC-Data- LISTING_SEQ_NO LISTING_SEQ_NO PegaHCPegaHC-Data- PatientID PatientID PegaHCPegaHC-Data- Gap2EndDate GapStartDate PegaHCPegaHC-Data- MasterEffectiveDate MasterEffectiveDate PegaHCPegaHC-Data- RelativeEndDate RelativeEndDate PegaHCPegaHC-Data- TraceTypeCode Trace Type Code PegaHCPegaHC-Data- AmountQualifierCode Amount Qualifier Code PegaHCPegaHC-Data-AmbulanceServices ServiceCountryCode ServiceCountryCode PegaHCPegaHC-Data-AmbulanceServices ServiceCountry ServiceCountry PegaHCPegaHC-Data-AmbulanceServices ServiceLocation ServiceLocation PegaHCPegaHC-Data-AmbulanceServices ServiceAddressLine2 ServiceAddressLine2 PegaHC

PegaHC-Data-Attachments AttachmentControlNumber Attachment Control Number PegaHCPegaHC-Data-Attachments AttachmentDescription Attachment Description PegaHCPegaHC-Data-Attachments AttachmentTransmissionCode Attachment Transmission Code PegaHCPegaHC-Data-Attachments AttachmentReportTypeCode Attachment Report Type Code PegaHCPegaHC-Data-Authorization ProcedureCodeList ProcedureCodeList PegaHCPegaHC-Data-Authorization Attachments Attachments PegaHCPegaHC-Data-Authorization NursingHomeResidentialStatusCode Nursing Home Residential Status Code PegaHCPegaHC-Data-Authorization SourceFileID Source File ID PegaHCPegaHC-Data-Authorization ValidMember ValidMember PegaHCPegaHC-Data-Authorization HomeHealthCertificationPeriod Home Health Certification Period PegaHCPegaHC-Data-Authorization Member Member PegaHCPegaHC-Data-Authorization PolicyNumber PolicyNumber PegaHCPegaHC-Data-Authorization ProposedOrActualServiceDate Proposed Or Actual Service Date PegaHCPegaHC-Data-Authorization RespiratoryTherapistOrderText Respiratory Therapist Order Text PegaHCPegaHC-Data-Authorization SecondSurgicalOpinionIndicator Second Surgical Opinion Indicator PegaHCPegaHC-Data-Authorization SkilledNursingFacilityIndicator Skilled Nursing Facility Indicator PegaHCPegaHC-Data-Authorization StateCode State Code PegaHCPegaHC-Data-Authorization CertificationExpirationDate Certification Expiration Date PegaHCPegaHC-Data-Authorization CertificationIssueDate Certification Issue Date PegaHCPegaHC-Data-Authorization CertificationTypeCode Certification Type Code PegaHCPegaHC-Data-Authorization DelayReasonCode Delay Reason Code PegaHCPegaHC-Data-Authorization MedicareCoverageIndicator Medicare Coverage Indicator PegaHCPegaHC-Data-Authorization MemberID MemberID PegaHCPegaHC-Data-Authorization PhysicianContactDate Physician Contact Date PegaHCPegaHC-Data-Authorization PrognosisCode Prognosis Code PegaHCPegaHC-Data-Authorization ValidRequestIndicator Valid Request Indicator PegaHCPegaHC-Data-Authorization ValidRequestor ValidRequestor PegaHCPegaHC-Data-Authorization ValidServiceProvider ValidServiceProvider PegaHCPegaHC-Data-Authorization ReferringProviderID ReferringProviderID PegaHCPegaHC-Data-Authorization RequestDate RequestDate PegaHCPegaHC-Data-Authorization Requester Requester PegaHCPegaHC-Data-Authorization TraceAssigningEntityAdditionalIdentifier TraceAssigningEntityPrimaryIdentifier PegaHCPegaHC-Data-Authorization CertificationNumber Certification Number PegaHCPegaHC-Data-Authorization LOB Requested LOB PegaHCPegaHC-Data-Authorization PeriodCount Period Count PegaHCPegaHC-Data-Authorization PhysicianOrderDate Physician Order Date PegaHCPegaHC-Data-Authorization PortableOxygenSystemFlowRate Portable Oxygen System Flow Rate PegaHCPegaHC-Data-Authorization Procedure Procedure PegaHCPegaHC-Data-Authorization ProposedOrActualDischargeDate Proposed Or Actual Discharge Date PegaHCPegaHC-Data-Authorization ProposedOrActualSurgeryDate Proposed Or Actual Surgery Date PegaHC

PegaHC-Data-Authorization ReferringProvider Referring Provider PegaHCPegaHC-Data-Authorization ReleaseofInformationCode Release of Information Code PegaHCPegaHC-Data-Authorization TimePeriodQualifier Time Period Qualifier PegaHCPegaHC-Data-Authorization ActionCode Action Code PegaHCPegaHC-Data-Authorization OxygenDeliverySystemCode Oxygen Delivery System Code PegaHCPegaHC-Data-Authorization RequestCategoryCode Request Category Code PegaHCPegaHC-Data-Authorization Submitter Submitter PegaHCPegaHC-Data-Authorization Subscriber Subscriber PegaHCPegaHC-Data-Authorization CodeCategory Code Category PegaHCPegaHC-Data-Authorization EquipmentReasonDescription Equipment Reason Description PegaHCPegaHC-Data-Authorization FacilityCodeQualifier Facility Code Qualifier PegaHCPegaHC-Data-Authorization LastAdmissionPeriod Last Admission Period PegaHCPegaHC-Data-Authorization LevelOfServiceCode Level Of Service Code PegaHCPegaHC-Data-Authorization MemberValid MemberValid PegaHCPegaHC-Data-Authorization AuthList AuthList PegaHCPegaHC-Data-Authorization AuthType Action Code PegaHCPegaHC-Data-Authorization EstimatedBirthDate Estimated Birth Date PegaHCPegaHC-Data-Authorization LastMenstrualPeriodDate Last Menstrual Period Date PegaHCPegaHC-Data-Authorization LastVisitDate Last Visit Date PegaHCPegaHC-Data-Authorization OxygenEquipmentTypeCode Oxygen Equipment Type Code PegaHCPegaHC-Data-Authorization PreviousCertificationIdentifier Previous Certification Identifier PegaHCPegaHC-Data-Authorization ProposedOrActualAdmissionDate Proposed Or Actual Admission Date PegaHCPegaHC-Data-Authorization ServiceTraceNumber ServiceTraceNumber PegaHCPegaHC-Data-Authorization ProviderValid ProviderValid PegaHCPegaHC-Data-Authorization ServiceProvider Service Provider PegaHCPegaHC-Data-Authorization ServiceProviderID ServiceProviderID PegaHCPegaHC-Data-Authorization TraceAssigningEntityIdentifier TraceAssigningEntityIdentifier PegaHCPegaHC-Data-Authorization UMO UMO PegaHCPegaHC-Data-Authorization ValidSubscriber ValidSubscriber PegaHCPegaHC-Data-Authorization CertificationEffectiveDate Certification Effective Date PegaHCPegaHC-Data-Authorization OnsetDate Onset Date PegaHCPegaHC-Data-Authorization OxygenUsePeriodHourCount Oxygen Use Period Hour Count PegaHCPegaHC-Data-BEAddress Addresskey AddressKey PegaHCPegaHC-Data-BEAddress BusinessEntityID BusinessEntityID PegaHCPegaHC-Data-BEAddress CoreAddress CoreAddress PegaHCPegaHC-Data-Benefit NonNetworkCoInsurance NonNetworkCoInsurance PegaHCPegaHC-Data-Benefit ValueStatement ValueStatement PegaHCPegaHC-Data-Benefit NonNetWorkCoPay NonNetWorkCoPay PegaHCPegaHC-Data-Benefit NetworkCoInsurance NetworkCoInsurance PegaHCPegaHC-Data-Benefit ApplyOOPMax ApplyOOPMax PegaHC

PegaHC-Data-Benefit ShortDescription ShortDescription PegaHCPegaHC-Data-Benefit NetworkCoPay NetworkCoPay PegaHCPegaHC-Data-Benefit CoverageDescription Plan Coverage Description PegaHCPegaHC-Data-Benefit ApplyDeductible ApplyDeductible PegaHCPegaHC-Data-Benefit ClaimCostPMPM ClaimCostPMPM PegaHCPegaHC-Data-BenefitGroup Benefit Benefit PegaHCPegaHC-Data-Claim AssumedOrRelinquishedCareDate AssumedOrRelinquishedCareDate PegaHCPegaHC-Data-Claim OtherDiagnosisInformation OtherDiagnosisInformation PegaHCPegaHC-Data-Claim PACDateOfFirstContact PACDateOfFirstContact PegaHCPegaHC-Data-Claim ReferringProviderList ReferringProviderList PegaHCPegaHC-Data-Claim Trailer Trailer PegaHCPegaHC-Data-Claim Prescriber Prescriber PegaHCPegaHC-Data-Claim ReceivedDate Date Claim was received PegaHCPegaHC-Data-Claim SpecialProgramIndicator Special Program Indicator PegaHCPegaHC-Data-Claim StatementToDate Statement To Date PegaHCPegaHC-Data-Claim StatusInformationEffectiveDate StatusInformationEffectiveDate PegaHCPegaHC-Data-Claim AttendingPhysician Attending Physician PegaHC

PegaHC-Data-Claim BenAssignCertIndicator Benefits Assignment Certification Indicator PegaHCPegaHC-Data-Claim BillingProviderID BillingProviderID PegaHCPegaHC-Data-Claim ClaimStatusCode Claim Status Code PegaHCPegaHC-Data-Claim DisabilityFromDate Disability From Date PegaHCPegaHC-Data-Claim LastWorkedDate Last Worked Date PegaHC

PegaHC-Data-Claim OriginatorApplicationTransactionIdentifier Originator Application Transaction Identifier PegaHCPegaHC-Data-Claim OrthodonticBandingDate Orthodontic Banding Date PegaHCPegaHC-Data-Claim PatientDischargeFacilityTypeCode FacilityTypeCode PegaHCPegaHC-Data-Claim PredeterminationOfBenefitsIdentifier Predetermination Of Benefits Identifier PegaHCPegaHC-Data-Claim SupervisingProvider Supervising Provider PegaHCPegaHC-Data-Claim SurgicalProcedureCode Surgical Procedure Code PegaHCPegaHC-Data-Claim Attachments Attachments PegaHCPegaHC-Data-Claim AutoAccidentStateCode Auto Accident State Code PegaHC

PegaHC-Data-Claim BenefitAssignmentCertificationIndicator Benefit Assignment Certification Indicator PegaHCPegaHC-Data-Claim ClaimDaysCount Claim Days Count PegaHCPegaHC-Data-Claim ClaimStatusCategoryCode Claim Status Category Code PegaHCPegaHC-Data-Claim ContractPercentage Contract Percentage PegaHCPegaHC-Data-Claim DelayReasonCode Delay Reason Code PegaHCPegaHC-Data-Claim DischargeHour Discharge Hour PegaHCPegaHC-Data-Claim DRGCode Diagnosis Related Group (DRG) Code PegaHC

PegaHC-Data-Claim InvestigationalDeviceExemptionAmplifier Investigational Device Exemption Amplifier PegaHCPegaHC-Data-Claim LifetimePsychiatricDaysCount Lifetime Psychiatric Days Count PegaHCPegaHC-Data-Claim MedicalRecordNumber Medical Record Number PegaHCPegaHC-Data-Claim Member Member PegaHCPegaHC-Data-Claim OriginalReferenceNumber OriginalReferenceNumber PegaHCPegaHC-Data-Claim OrthodonticTreatmentMonthsCount Orthodontic Treatment Months Count PegaHCPegaHC-Data-Claim OtherDiagnosis Other Diagnosis PegaHCPegaHC-Data-Claim Patient Patient PegaHCPegaHC-Data-Claim PatientSignatureSourceCode Patient Signature Source Code PegaHCPegaHC-Data-Claim PeerReviewAuthorizationNumber Peer Review Authorization Number PegaHCPegaHC-Data-Claim PropertyCasualtyClaimNumber Property Casualty Claim Number PegaHCPegaHC-Data-Claim ProviderAcceptAssignmentCode Provider Accept Assignment Code PegaHCPegaHC-Data-Claim RepricerReceivedDate Repricer Received Date PegaHCPegaHC-Data-Claim SubmitterNumber SubmitterNumber PegaHC

PegaHC-Data-Claim TotalVisitsProjectedThisCertificationCount Total Visits Projected This Certification Count PegaHCPegaHC-Data-Claim TreatmentCode Treatment Code PegaHCPegaHC-Data-Claim TreatmentCodes TreatmentCodes PegaHCPegaHC-Data-Claim WorkReturnDate Work Return Date PegaHCPegaHC-Data-Claim XRayAvailabilityIndicator XRay Availability Indicator PegaHCPegaHC-Data-Claim AdmittingDiagnosis AdmittingDiagnosis PegaHCPegaHC-Data-Claim DisabilityDateFormatQualifier DisabilityDateFormatQualifier PegaHCPegaHC-Data-Claim ICDType ICDType PegaHCPegaHC-Data-Claim OccurrenceInformation OccurrenceInformation PegaHCPegaHC-Data-Claim PatientVisionCondition PatientVisionCondition PegaHCPegaHC-Data-Claim PrincipalDiagnosisInfo PrincipalDiagnosisInfo PegaHCPegaHC-Data-Claim ValueAddedNetworkTrace Value Added Network Trace Number PegaHCPegaHC-Data-Claim AmbulanceCertification AmbulanceCertification PegaHCPegaHC-Data-Claim DRGInformation DRGInformation PegaHCPegaHC-Data-Claim ReasonForVisit ReasonForVisit PegaHCPegaHC-Data-Claim TransactionSetPurposeCode TransactionSetPurposeCode PegaHCPegaHC-Data-Claim ValueInformation ValueInformation PegaHC

PegaHC-Data-Claim AdjRepricedClaimRefNumber Adjusted Repriced Claim Reference Number PegaHCPegaHC-Data-Claim AdjustmentReasonCode Adjustment Reason Code PegaHCPegaHC-Data-Claim ClaimAdjustmentGroupCode ClaimAdjustmentGroupCode PegaHCPegaHC-Data-Claim FacilityCodeQualifier Facility Code Qualifier PegaHCPegaHC-Data-Claim HomeboundIndicator HomeboundIndicator PegaHCPegaHC-Data-Claim HomeHealthCertificationPeriod Home Health Certification Period PegaHC

PegaHC-Data-Claim InvestigationalDeviceExemptionID Investigational Device Exemption Identifier PegaHCPegaHC-Data-Claim MedicareSection4081Indicator Medicare Section 4081 Indicator PegaHCPegaHC-Data-Claim OccurrenceCode Occurrence Code PegaHCPegaHC-Data-Claim Payer Payer PegaHCPegaHC-Data-Claim PayToProvider Pay To Provider PegaHCPegaHC-Data-Claim PolicyNumber PolicyNumber PegaHCPegaHC-Data-Claim PriorIncorrectInsured Prior Incorrect Insured PegaHCPegaHC-Data-Claim BillingProvider BillingProvider PegaHCPegaHC-Data-Claim BillTypeIdentifier Bill Type Identifier PegaHCPegaHC-Data-Claim ClaimFilingIndicatorCode Claim Filing Indicator Code PegaHCPegaHC-Data-Claim ClaimFrequencyCode Claim Frequency Code PegaHCPegaHC-Data-Claim ProviderOrSupplierSignatureIndicator Provider Or Supplier Signature Indicator PegaHCPegaHC-Data-Claim ReimbursementRate Reimbursement Rate PegaHCPegaHC-Data-Claim RelatedHospitalizationDischargeDate Related Hospitalization Discharge Date PegaHCPegaHC-Data-Claim ServiceFacility ServiceFacility PegaHCPegaHC-Data-Claim TermsDiscountPercentage Terms Discount Percentage PegaHCPegaHC-Data-Claim TotalVisitsRenderedCount Total Visits Rendered Count PegaHCPegaHC-Data-Claim ValueCode Value Code PegaHCPegaHC-Data-Claim RevenueCode RevenueCode PegaHCPegaHC-Data-Claim ClaimID ClaimID PegaHCPegaHC-Data-Claim ClaimStatus ClaimStatus PegaHCPegaHC-Data-Claim ContractType Contract Type PegaHCPegaHC-Data-Claim DisabilityToDate Disability To Date PegaHCPegaHC-Data-Claim MedicareCoverageIndicator Medicare Coverage Indicator PegaHCPegaHC-Data-Claim NoteReferenceCode Note Reference Code PegaHCPegaHC-Data-Claim PayToPlan Pay To Plan PegaHCPegaHC-Data-Claim PregnancyIndicator Pregnancy Indicator PegaHCPegaHC-Data-Claim PurchasedServiceProvider Purchased Service Provider PegaHCPegaHC-Data-Claim ReferralDate Referral Date PegaHCPegaHC-Data-Claim ReleaseofInformationCode Release of Information Code PegaHCPegaHC-Data-Claim RepricedApprovedDRGCode Repriced Approved DRG Code PegaHCPegaHC-Data-Claim RepricedClaimReferenceNumber Repriced Claim Reference Number PegaHCPegaHC-Data-Claim StatementFromDate Statement From Date PegaHCPegaHC-Data-Claim ValueAddedNetworkTraceNumber Value Added Network Trace Number PegaHCPegaHC-Data-Claim ConditionInformation ConditionInformation PegaHCPegaHC-Data-Claim DeviceExemption DeviceExemption PegaHCPegaHC-Data-Claim HealthConditionCodes HealthConditionCodes PegaHCPegaHC-Data-Claim IsSubscriberAPatient IsSubscriberAPatient PegaHCPegaHC-Data-Claim OtherProcedureInformation OtherProcedureInformation PegaHC

PegaHC-Data-Claim TreatmentCodeInfo TreatmentCodeInfo PegaHCPegaHC-Data-Claim MammographyCertificationNumber Mammography Certification Number PegaHCPegaHC-Data-Claim MedicareAssignmentCode Medicare Assignment Code PegaHCPegaHC-Data-Claim MentalStatusCode MentalStatusCode PegaHCPegaHC-Data-Claim OtherInsured Other Insured PegaHCPegaHC-Data-Claim PayerClaimControlNumber Payer Claim Control Number PegaHCPegaHC-Data-Claim PolicyName Policy Name PegaHCPegaHC-Data-Claim PricingMethodology Pricing Methodology PegaHCPegaHC-Data-Claim PriorAuthorizationOrReferralNumber Prior Authorization Or Referral Number PegaHCPegaHC-Data-Claim ProcedureCodes ProcedureCodes PegaHCPegaHC-Data-Claim RepricedApprovedAPGGroupCode RepricedApprovedAPGGroupCode PegaHCPegaHC-Data-Claim AdjudOrPaymentDate Adjudication Or Payment Date PegaHCPegaHC-Data-Claim ClaimLine ClaimLine PegaHCPegaHC-Data-Claim ClaimOrEncounterIdentifier Claim Or Encounter Identifier PegaHCPegaHC-Data-Claim ClearinghouseTraceNumber Clearinghouse Trace Number PegaHCPegaHC-Data-Claim COBCode Coordination Of Benefits (COB) Code PegaHCPegaHC-Data-Claim ContractCode ContractCode PegaHCPegaHC-Data-Claim CostReportDayCount Cost Report Day Count PegaHCPegaHC-Data-Claim EstimatedBirthDate Estimated Birth Date PegaHCPegaHC-Data-Claim FunctionalLimitationCode Functional Limitation Code PegaHCPegaHC-Data-Claim IndustryCode Industry Code PegaHCPegaHC-Data-Claim SurgeryDate Surgery Date PegaHCPegaHC-Data-Claim TotalClaimChargeAmount Total Claim Charge Amount PegaHCPegaHC-Data-Claim Type Type PegaHCPegaHC-Data-Claim ValueCodes Value Codes PegaHCPegaHC-Data-Claim SimilarIllnessOrSymptomDate Similar Illness Or Symptom Date PegaHCPegaHC-Data-Claim ClaimList ClaimList PegaHCPegaHC-Data-Claim COB Coordination Of Benefits (COB) PegaHCPegaHC-Data-Claim CodeCategory Code Category PegaHCPegaHC-Data-Claim DateClaimPaid Date Claim Paid PegaHCPegaHC-Data-Claim DocumentControlIdentifier Document Control Identifier PegaHCPegaHC-Data-Claim FixedFormatInformation Fixed Format Information PegaHCPegaHC-Data-Claim LastSeenDate Last Seen Date PegaHCPegaHC-Data-Claim LastVisitDate Last Visit Date PegaHCPegaHC-Data-Claim OccurrenceCodes OccurrenceCodes PegaHC

PegaHC-Data-Claim

OrthodonticTreatmentMonthsRemainingCo

unt

Orthodontic Treatment Months Remaining

Count PegaHCPegaHC-Data-Claim ParticipationAgreement Participation Agreement PegaHCPegaHC-Data-Claim PatientPaidAmount Patient Paid Amount PegaHCPegaHC-Data-Claim PhysicianOrderDate Physician Order Date PegaHC

PegaHC-Data-Claim Policy Policy PegaHCPegaHC-Data-Claim PrincipalProcedureCode Principal Procedure Code PegaHCPegaHC-Data-Claim PriorAuthorizationNumber Prior Authorization Number PegaHCPegaHC-Data-Claim PrognosisCode Prognosis Code PegaHCPegaHC-Data-Claim DisabilityDateQualifier DisabilityDateQualifier PegaHCPegaHC-Data-Claim OccurrenceSpanInformation OccurrenceSpanInformation PegaHCPegaHC-Data-Claim TransactionSetCreationTime TransactionSetCreationTime PegaHCPegaHC-Data-Claim ExceptionCode Exception Code PegaHCPegaHC-Data-Claim LaboratoryOrFacility Laboratory Or Facility PegaHCPegaHC-Data-Claim NetBilledAmount Net Billed Amount PegaHCPegaHC-Data-Claim OccurrenceAssociatedDate Occurrence Associated Date PegaHCPegaHC-Data-Claim OccurrenceSpanCode Occurrence Span Code PegaHCPegaHC-Data-Claim OperatingPhysician Operating Physician PegaHCPegaHC-Data-Claim PhysicianContactDate Physician Contact Date PegaHCPegaHC-Data-Claim PolicyComplianceCode Policy Compliance Code PegaHCPegaHC-Data-Claim ReferringProvider Referring Provider PegaHCPegaHC-Data-Claim RelatedHospitalizationAdmissionDate Related Hospitalization Admission Date PegaHCPegaHC-Data-Claim Receiver Receiver PegaHCPegaHC-Data-Claim ReferralNumber Referral Number PegaHCPegaHC-Data-Claim RepricedApprovedHCPCSCode Repriced Approved HCPCS Code PegaHCPegaHC-Data-Claim RepricingOrganizationIdentifier Repricing Organization Identifier PegaHCPegaHC-Data-Claim SpanOccurrenceCodes SpanOccurrenceCodes PegaHCPegaHC-Data-Claim ToothStatusCode Tooth Status Code PegaHCPegaHC-Data-Claim VisitsPriorToRecertificationDateCount Visits Prior To Recertification Date Count PegaHCPegaHC-Data-Claim BillingNoteText Billing Note Text PegaHCPegaHC-Data-Claim CarePlanOversightNumber Care Plan Oversight Number PegaHCPegaHC-Data-Claim ClaimOriginalReferenceNumber Claim Original Reference Number PegaHCPegaHC-Data-Claim ClaimSubmissionReasonCode Claim Submission Reason Code PegaHCPegaHC-Data-Claim ConditionCodes ConditionCodes PegaHCPegaHC-Data-Claim ContractVersion Contract Version PegaHCPegaHC-Data-Claim DemonstrationProjectIdentifier Demonstration Project Identifier PegaHCPegaHC-Data-Claim DischargeOrEndOfCareDate Discharge Or End Of Care Date PegaHCPegaHC-Data-Claim RemarkCode Remark Code PegaHCPegaHC-Data-Claim RenderingProvider RenderingProvider PegaHCPegaHC-Data-Claim ServiceFromDate ServiceFromDate PegaHCPegaHC-Data-Claim ServiceToDate ServiceToDate PegaHCPegaHC-Data-Claim ToothNumber Tooth Number PegaHCPegaHC-Data-Claim TotalCoinsuranceAmount Total Coinsurance Amount PegaHCPegaHC-Data-Claim ValueCodeAssociatedAmount Value Code Associated Amount PegaHCPegaHC-Data-Claim Visits Visits PegaHC

PegaHC-Data-Claim AssumedOrRelinquishedCareDateQualifier AssumedOrRelinquishedCareDateQualifier PegaHCPegaHC-Data-Claim ExternalCauseOfInjury ExternalCauseOfInjury PegaHCPegaHC-Data-Claim PrincipalProcedureInformation PrincipalProcedureInformation PegaHCPegaHC-Data-Claim TransactionSetCreationDate TransactionSetCreationDate PegaHCPegaHC-Data-Claim Header Header PegaHCPegaHC-Data-Claim HierarchicalStructureCode HierarchicalStructureCode PegaHCPegaHC-Data-Claim ImageNumber ImageNumber PegaHCPegaHC-Data-Claim LastMenstrualPeriodDate Last Menstrual Period Date PegaHCPegaHC-Data-Claim LastXRayDate Last XRay Date PegaHCPegaHC-Data-Claim LifetimeReserveDaysCount Lifetime Reserve Days Count PegaHCPegaHC-Data-Claim MemberID MemberID PegaHCPegaHC-Data-Claim OtherProvider Other Provider PegaHC

PegaHC-Data-Claim PayerResponsibilitySequenceNumberCode Payer Responsibility Sequence Number Code PegaHCPegaHC-Data-Claim Payment Payment PegaHCPegaHC-Data-Claim Prescription Prescription PegaHCPegaHC-Data-Claim PrescriptionDate Prescription Date PegaHCPegaHC-Data-Claim RenderingProviderID RenderingProviderID PegaHCPegaHC-Data-Claim RepricedApprovedRevenueCode Repriced Approved Revenue Code PegaHCPegaHC-Data-Claim ResponsibleParty Responsible Party PegaHCPegaHC-Data-Claim ServiceAuthorizationExceptionCode Service Authorization Exception Code PegaHCPegaHC-Data-Claim ServiceDate Service Date PegaHCPegaHC-Data-Claim SkilledNursingFacilityIndicator Skilled Nursing Facility Indicator PegaHCPegaHC-Data-Claim Submitter Submitter PegaHCPegaHC-Data-Claim AdjustmentQuantity Adjustment Quantity PegaHCPegaHC-Data-Claim AmbulatoryPatientGroupNumber Ambulatory Patient Group Number PegaHCPegaHC-Data-Claim Cardholder Cardholder PegaHCPegaHC-Data-Claim DisciplineTypeCode Discipline Type Code PegaHCPegaHC-Data-Claim EOBIndicator Explanation Of Benefits Indicator PegaHCPegaHC-Data-Claim Subscriber Subscriber PegaHCPegaHC-Data-Claim TraceNumber Trace Number PegaHCPegaHC-Data-Claim EPSDTCodeCategory EPSDTCodeCategory PegaHCPegaHC-Data-ClaimConditionCodes Code Code PegaHCPegaHC-Data-ClaimConditionCodes Amount Amount PegaHCPegaHC-Data-ClaimDenialCodes Code Code PegaHCPegaHC-Data-ClaimDenialCodes Description Description PegaHCPegaHC-Data-ClaimLine StatusReason PPEStatusReason PegaHCPegaHC-Data-ClaimLine TermsDiscountPercentage Terms Discount Percentage PegaHCPegaHC-Data-ClaimLine AdjRepricedLineRefNumber AdjRepricedLineRefNumber PegaHC

PegaHC-Data-ClaimLine ClaimStatusCategoryCode Claim Status Category Code PegaHCPegaHC-Data-ClaimLine ClaimStatusCode Claim Status Code PegaHCPegaHC-Data-ClaimLine ContractCode ContractCode PegaHCPegaHC-Data-ClaimLine ContractPercentage Contract Percentage PegaHCPegaHC-Data-ClaimLine AmbulancePatientCount AmbulancePatientCount PegaHCPegaHC-Data-ClaimLine CompositeMedicalProcedureCode CompositeMedicalProcedureCode PegaHCPegaHC-Data-ClaimLine DMEPurchasePrice DMEPurchasePrice PegaHCPegaHC-Data-ClaimLine MedicalProcedureCodeDescription MedicalProcedureCodeDescription PegaHCPegaHC-Data-ClaimLine PurchasedServiceProvider Purchased Service Provider PegaHCPegaHC-Data-ClaimLine ReferralDate Referral Date PegaHCPegaHC-Data-ClaimLine ContractVersion Contract Version PegaHCPegaHC-Data-ClaimLine CoPayStatusCode CoPayStatusCode PegaHCPegaHC-Data-ClaimLine DMEDuration DMEDuration PegaHCPegaHC-Data-ClaimLine EmergencyIndicator EmergencyIndicator PegaHCPegaHC-Data-ClaimLine LaboratoryOrFacility Laboratory Or Facility PegaHCPegaHC-Data-ClaimLine NoteReferenceCode Note Reference Code PegaHCPegaHC-Data-ClaimLine OnsetDate OnsetDate PegaHCPegaHC-Data-ClaimLine PolicyComplianceCode Policy Compliance Code PegaHCPegaHC-Data-ClaimLine OrderingProvider OrderingProvider PegaHCPegaHC-Data-ClaimLine OtherProvider Other Provider PegaHCPegaHC-Data-ClaimLine ProcedureCode ProcedureCode PegaHCPegaHC-Data-ClaimLine RepricingOrganizationIdentifier Repricing Organization Identifier PegaHCPegaHC-Data-ClaimLine Status Status PegaHCPegaHC-Data-ClaimLine ToothCode ToothCode PegaHCPegaHC-Data-ClaimLine HospiceEmployedProviderIndicator HospiceEmployedProviderIndicator PegaHCPegaHC-Data-ClaimLine LastCertificationDate LastCertificationDate PegaHCPegaHC-Data-ClaimLine LineNumber LineNumber PegaHCPegaHC-Data-ClaimLine ServiceAdjudicationOrPaymentDate ServiceAdjudicationOrPaymentDate PegaHCPegaHC-Data-ClaimLine SimilarIllnessOrSymptomDate Similar Illness Or Symptom Date PegaHCPegaHC-Data-ClaimLine TestResults TestResults PegaHCPegaHC-Data-ClaimLine AcuteManifestationDate Acute Manifestation Date PegaHCPegaHC-Data-ClaimLine AdjustmentReasonCode Adjustment Reason Code PegaHCPegaHC-Data-ClaimLine AssignedNumber AssignedNumber PegaHCPegaHC-Data-ClaimLine CertificationRevisionDate CertificationRevisionDate PegaHCPegaHC-Data-ClaimLine ConditionIndicator ConditionIndicator PegaHCPegaHC-Data-ClaimLine FamilyPlanningIndicator FamilyPlanningIndicator PegaHCPegaHC-Data-ClaimLine LineNoteText LineNoteText PegaHC

PegaHC-Data-ClaimLine MeasurementReferenceIdentificationCode MeasurementReferenceIdentificationCode PegaHCPegaHC-Data-ClaimLine ProsthesisCrownOrInlayCode ProsthesisCrownOrInlayCode PegaHC

PegaHC-Data-ClaimLine AttendingPhysician Attending Physician PegaHCPegaHC-Data-ClaimLine EPSDTIndicator EPSDTIndicator PegaHCPegaHC-Data-ClaimLine ExceptionCode Exception Code PegaHCPegaHC-Data-ClaimLine HCPCSCode HCPCSCode PegaHCPegaHC-Data-ClaimLine LastSeenDate Last Seen Date PegaHCPegaHC-Data-ClaimLine LineItemControlNumber LineItemControlNumber PegaHCPegaHC-Data-ClaimLine MEEStatus Status PegaHCPegaHC-Data-ClaimLine PrescriptionNumber PrescriptionNumber PegaHCPegaHC-Data-ClaimLine PricingMethodology Pricing Methodology PegaHCPegaHC-Data-ClaimLine ProcedureCount ProcedureCount PegaHCPegaHC-Data-ClaimLine DatePrescriptionDate DatePrescriptionDate PegaHCPegaHC-Data-ClaimLine NationalDrugUnitCount NationalDrugUnitCount PegaHCPegaHC-Data-ClaimLine QuestionResponse QuestionResponse PegaHCPegaHC-Data-ClaimLine RenderingProvider RenderingProvider PegaHCPegaHC-Data-ClaimLine TestPerformedDate TestPerformedDate PegaHCPegaHC-Data-ClaimLine ToothSurfaceCode ToothSurfaceCode PegaHCPegaHC-Data-ClaimLine UniversalProductNumber UniversalProductNumber PegaHCPegaHC-Data-ClaimLine DMERentalPrice DMERentalPrice PegaHCPegaHC-Data-ClaimLine DRGCode DRGCode PegaHCPegaHC-Data-ClaimLine ReferenceIdentificationQualifier ReferenceIdentificationQualifier PegaHCPegaHC-Data-ClaimLine Weight Weight PegaHC

PegaHC-Data-ClaimLine LineRepricingProductOrServiceIDQualifier LineRepricingProductOrServiceIDQualifier PegaHCPegaHC-Data-ClaimLine MedicalProductOrServiceIDQualifier MedicalProductOrServiceIDQualifier PegaHCPegaHC-Data-ClaimLine SupervisingProvider SupervisingProvider PegaHCPegaHC-Data-ClaimLine PurchasedServiceChargeAmount PurchasedServiceChargeAmount PegaHCPegaHC-Data-ClaimLine ReplacementDate ReplacementDate PegaHCPegaHC-Data-ClaimLine RepricedLineItemReferenceNumber RepricedLineItemReferenceNumber PegaHCPegaHC-Data-ClaimLine StatusDate StatusDate PegaHCPegaHC-Data-ClaimLine XRayAvailabilityIndicator XRay Availability Indicator PegaHCPegaHC-Data-ClaimLine AdjustmentQuantitiy AdjustmentQuantitiy PegaHCPegaHC-Data-ClaimLine AmbulatoryPatientGroupNumber Ambulatory Patient Group Number PegaHCPegaHC-Data-ClaimLine AnesthesiaUnitCount AnesthesiaUnitCount PegaHCPegaHC-Data-ClaimLine ChargeAmount ChargeAmount PegaHCPegaHC-Data-ClaimLine CodeCategory Code Category PegaHCPegaHC-Data-ClaimLine ContractType Contract Type PegaHCPegaHC-Data-ClaimLine FacilityTaxAmount FacilityTaxAmount PegaHCPegaHC-Data-ClaimLine LastXRayDate Last XRay Date PegaHCPegaHC-Data-ClaimLine MammographyCertificationNumber Mammography Certification Number PegaHCPegaHC-Data-ClaimLine NonCoveredReason NonCoveredReason PegaHC

PegaHC-Data-ClaimLine ReferringCLIANumber ReferringCLIANumber PegaHCPegaHC-Data-ClaimLine ShippedDate ShippedDate PegaHCPegaHC-Data-ClaimLine CCIStatus Status PegaHCPegaHC-Data-ClaimLine FixedFormatInformation Fixed Format Information PegaHCPegaHC-Data-ClaimLine FormIdentifier FormIdentifier PegaHCPegaHC-Data-ClaimLine PaidServiceUnitCount PaidServiceUnitCount PegaHCPegaHC-Data-ClaimLine PredeterminationOfBenefitsIdentifier Predetermination Of Benefits Identifier PegaHCPegaHC-Data-ClaimLine ClaimFilingIndicatorCode Claim Filing Indicator Code PegaHC

PegaHC-Data-ClaimLine

CompositeMedicalProductOrServiceIDQualif

ier

CompositeMedicalProductOrServiceIDQualifi

er PegaHCPegaHC-Data-ClaimLine DMEAttachmentTransmissionCode DMEAttachmentTransmissionCode PegaHCPegaHC-Data-ClaimLine PurchasedServiceProviderIdentifier PurchasedServiceProviderIdentifier PegaHCPegaHC-Data-ClaimLine ReferralNumberList ReferralNumberList PegaHCPegaHC-Data-ClaimLine RepricedApprovedAPGGroupCode RepricedApprovedAPGGroupCode PegaHCPegaHC-Data-ClaimLine RentalUnitPriceIndicator RentalUnitPriceIndicator PegaHCPegaHC-Data-ClaimLine QuestionNumberOrLetter QuestionNumberOrLetter PegaHCPegaHC-Data-ClaimLine ReferralNumber Referral Number PegaHCPegaHC-Data-ClaimLine UnitsOfServicePaidCount UnitsOfServicePaidCount PegaHCPegaHC-Data-ClaimLine Visits Visits PegaHCPegaHC-Data-ClaimLine CompositeMedicalProcedure CompositeMedicalProcedure PegaHCPegaHC-Data-ClaimLine ConditionIndicators ConditionIndicators PegaHCPegaHC-Data-ClaimLine DMEUnitorBasisforMeasurementCode DMEUnitorBasisforMeasurementCode PegaHCPegaHC-Data-ClaimLine LineAdjudicationList LineAdjudicationList PegaHCPegaHC-Data-ClaimLine Measurement Measurement PegaHCPegaHC-Data-ClaimLine OperatingPhysician OperatingPhysician PegaHCPegaHC-Data-ClaimLine PriAuthReference PriAuthReference PegaHCPegaHC-Data-ClaimLine ProcedureIdentifiers ProcedureIdentifiers PegaHCPegaHC-Data-ClaimLine ApprovedAmount ApprovedAmount PegaHCPegaHC-Data-ClaimLine BundledOrUnbundledLineNumber BundledOrUnbundledLineNumber PegaHCPegaHC-Data-ClaimLine ClaimAdjustmentGroupCode ClaimAdjustmentGroupCode PegaHCPegaHC-Data-ClaimLine DiagnosisCodePointer Diagnosis Code Pointer PegaHCPegaHC-Data-ClaimLine MeasurementQualifier MeasurementQualifier PegaHCPegaHC-Data-ClaimLine Payment Payment PegaHCPegaHC-Data-ClaimLine PriorAuthorizationOrReferralNumber Prior Authorization Or Referral Number PegaHCPegaHC-Data-ClaimLine PriorPlacementDate PriorPlacementDate PegaHCPegaHC-Data-ClaimLine ProcedureModifier ProcedureModifier PegaHCPegaHC-Data-ClaimLine ConditionCodeAmbulanceList ConditionCodeAmbulanceList PegaHCPegaHC-Data-ClaimLine ServiceFacility ServiceFacility PegaHCPegaHC-Data-ClaimLine AdjudOrPaymentDate Adjudication Or Payment Date PegaHCPegaHC-Data-ClaimLine AnesthesiaModifyingUnits AnesthesiaModifyingUnits PegaHC

PegaHC-Data-ClaimLine Attachments Attachments PegaHCPegaHC-Data-ClaimLine ImmunizationBatchNumber ImmunizationBatchNumber PegaHCPegaHC-Data-ClaimLine MUEStatus Status PegaHCPegaHC-Data-ClaimLine OrthodonticBandingDate Orthodontic Banding Date PegaHCPegaHC-Data-ClaimLine ProcessingStatus ProcessingStatus PegaHCPegaHC-Data-ClaimLine FormIdentificationListList FormIdentificationListList PegaHCPegaHC-Data-ClaimLine CompositeUnitOfMeasurementUnit CompositeUnitOfMeasurementUnit PegaHCPegaHC-Data-ClaimLine LengthOfMedicalNecessity LengthOfMedicalNecessity PegaHCPegaHC-Data-ClaimLine ObstetricAdditionalUnits ObstetricAdditionalUnits PegaHCPegaHC-Data-ClaimLine ProfessionalServiceUnitCode ProfessionalServiceUnitCode PegaHCPegaHC-Data-ClaimLine ThirdPartyOrganizationNotes ThirdPartyOrganizationNotes PegaHCPegaHC-Data-ClaimLine ServiceTaxAmount ServiceTaxAmount PegaHCPegaHC-Data-ClaimOccurrenceCodes Code Occurrence Code PegaHCPegaHC-Data-ClaimOccurrenceCodes Date Date PegaHCPegaHC-Data-ClaimPendCodes Description Description PegaHCPegaHC-Data-ClaimPendCodes Code Code PegaHCPegaHC-Data-ClaimProcedureCodes Code Code PegaHCPegaHC-Data-ClaimProcedureCodes Amount Amount PegaHC

PegaHC-Data-ClaimSpanOccurrenceCodes Amount Amount PegaHC

PegaHC-Data-ClaimSpanOccurrenceCodes Code Code PegaHC

PegaHC-Data-ClaimStatusCategoryCodes Code ID PegaHCPegaHC-Data-ClaimStatusCodes ClaimStatus Claim Status PegaHCPegaHC-Data-ClaimStatusCodes Code ID PegaHCPegaHC-Data-ClaimTreatmentCodes Amount Amount PegaHCPegaHC-Data-ClaimTreatmentCodes Code Code PegaHCPegaHC-Data-ClaimValueCodes Amount Amount PegaHCPegaHC-Data-ClaimValueCodes ValueCode Value Code PegaHCPegaHC-Data-CodeGroup Description Description PegaHCPegaHC-Data-CodeGroup GroupName GroupName PegaHCPegaHC-Data-CodeGroup CodeType CodeType PegaHCPegaHC-Data-CodeGroup CodeList CodeList PegaHCPegaHC-Data-CommonMedication Medication Medication PegaHCPegaHC-Data-CommonMedication Category Category PegaHCPegaHC-Data-Contact CommunicationNumberQualifier Communication Number Qualifier PegaHCPegaHC-Data-Contact CommunicationNumber Communication Number PegaHCPegaHC-Data-Contact ContactName ContactName PegaHCPegaHC-Data-Contact ContactFunctionCode Contact Function Code PegaHC

PegaHC-Data-CPTCodes Code Code PegaHCPegaHC-Data-CPTCodes CodeDescription Code Description PegaHCPegaHC-Data-Diagnosis DiagnosisTypeCode Diagnosis Type Code PegaHCPegaHC-Data-Diagnosis DiagnosisCode DiagnosisCode PegaHCPegaHC-Data-Diagnosis DiagnosisDate DiagnosisDate PegaHCPegaHC-Data-Diagnosis DiagnosisDescription DiagnosisDescription PegaHCPegaHC-Data-Diagnosis DiagnosisCategory DiagnosisCategory PegaHCPegaHC-Data-DRGCodes ArithmeticMeanLOS Arithmetic Mean LOS PegaHCPegaHC-Data-DRGCodes Code ID PegaHCPegaHC-Data-DRGCodes Description Description PegaHCPegaHC-Data-DRGCodes GeometricMeanLOS Geometric Mean LOS PegaHCPegaHC-Data-DRGCodes MDC MDC PegaHCPegaHC-Data-DRGCodes RelativeWeights Relative Weights PegaHCPegaHC-Data-DRGCodes Type Type PegaHCPegaHC-Data-DrugCodes Description Description PegaHCPegaHC-Data-DrugCodes AllowedCharge AllowedCharge PegaHCPegaHC-Data-DrugCodes DrugCode DrugCode PegaHCPegaHC-Data-EligibilityRequest InformationReceiver InformationReceiver PegaHCPegaHC-Data-EligibilityRequest EBRequestInformation Request PegaHCPegaHC-Data-EligibilityRequest TraceNumber TraceNumber PegaHCPegaHC-Data-EligibilityRequest EBRequestedDate EBRequestedDate PegaHCPegaHC-Data-EligibilityRequest InformationSource InformationSource PegaHCPegaHC-Data-EligibilityRequest Patient Patient PegaHCPegaHC-Data-EligibilityRequest EBRequestedDateQualifier EBRequestedDateQualifier PegaHCPegaHC-Data-EligibilityRequest Subscriber Subscriber PegaHCPegaHC-Data-EligibilityRequest TraceNumberIssuedBy TraceNumberIssuedBy PegaHCPegaHC-Data-Enrollment ProviderEffectiveDate Provider Effective Date PegaHCPegaHC-Data-Enrollment ActionCodePLA Action Code PLA segment PegaHCPegaHC-Data-Enrollment IdentificationCardTypeCode IdentificationCardTypeCode PegaHCPegaHC-Data-Enrollment Member Member PegaHC

PegaHC-Data-Enrollment PayerResponsibilitySequenceNumberCode Payer Responsibility Sequence Number Code PegaHCPegaHC-Data-Enrollment Subscriber Subscriber PegaHCPegaHC-Data-Enrollment ContractAmount ContractAmount PegaHCPegaHC-Data-Enrollment FrequencyCode FrequencyCode PegaHCPegaHC-Data-Enrollment MaintenanceEffectiveDate Maintenance Effective Date PegaHCPegaHC-Data-Enrollment MaintenanceReasonCode Maintenance Reason Code PegaHCPegaHC-Data-Enrollment AssignedNumber AssignedNumber PegaHCPegaHC-Data-Enrollment EffectiveDate Effective Date PegaHCPegaHC-Data-Enrollment StatusInformationEffectiveDate StatusInformationEffectiveDate PegaHC

PegaHC-Data-Enrollment CustodialParent Custodial Parent PegaHCPegaHC-Data-Enrollment MaintenanceTypeCode Maintenance Type Code PegaHCPegaHC-Data-Enrollment PaymentCommencementDate Payment Commencement Date PegaHCPegaHC-Data-Enrollment CorrectedPatient Corrected Patient PegaHCPegaHC-Data-Enrollment EnrollmentDate Enrollment Date PegaHCPegaHC-Data-Enrollment Insured Insured PegaHCPegaHC-Data-Enrollment HealthRelatedCode HealthRelatedCode PegaHCPegaHC-Data-Enrollment ActionCodeIDC Action Code IDC segment PegaHCPegaHC-Data-Enrollment ActionCodeBGN Action Code BGN segment PegaHCPegaHC-Data-Enrollment SponsorIdentifier SponsorIdentifier PegaHCPegaHC-Data-Enrollment PriorCoverageMonthCount Prior Coverage Month Count PegaHCPegaHC-Data-Enrollment EntityRelationshipCode Entity Relationship Code PegaHCPegaHC-Data-Enrollment COBRAQualifyingEventCode COBRA Qualifying Event Code PegaHCPegaHC-Data-Enrollment IdentificationCardCount IdentificationCardCount PegaHCPegaHC-Data-Enrollment BenefitStatusCode BenefitStatusCode PegaHCPegaHC-Data-FamilyAccumulators AccPeriodEnd AccPeriodEnd PegaHCPegaHC-Data-FamilyAccumulators FamilyOONDedLimit FamilyOONDedLimit PegaHCPegaHC-Data-FamilyAccumulators FamilyINDedUsed FamilyINDedUsed PegaHCPegaHC-Data-FamilyAccumulators FamilyOONOOPocketLimit FamilyOONOOPocketLimit PegaHCPegaHC-Data-FamilyAccumulators FamilyDedLimitTotal FamilyDedLimitTotal PegaHCPegaHC-Data-FamilyAccumulators FamilyINOOPocketRemain FamilyINOOPocketRemain PegaHCPegaHC-Data-FamilyAccumulators FamilyOONOOPocketUsed FamilyOONOOPocketUsed PegaHCPegaHC-Data-FamilyAccumulators FamilyOOPocketLimitTotal FamilyOOPocketLimitTotal PegaHCPegaHC-Data-FamilyAccumulators AccPeriodBegin AccPeriodBegin PegaHCPegaHC-Data-FamilyAccumulators FamilyINDedLimit FamilyINDedLimit PegaHCPegaHC-Data-FamilyAccumulators FamilyINDedRemain FamilyINDedRemain PegaHCPegaHC-Data-FamilyAccumulators FamilyOONOOPocketRemain FamilyOONOOPocketRemain PegaHCPegaHC-Data-FamilyAccumulators FamilyOOPocketRemainTotal FamilyOOPocketRemainTotal PegaHCPegaHC-Data-FamilyAccumulators FamilyDedUsedTotal FamilyDedUsedTotal PegaHCPegaHC-Data-FamilyAccumulators FamilyINOOPocketUsed FamilyINOOPocketUsed PegaHCPegaHC-Data-FamilyAccumulators FamilyOONDedRemain FamilyOONDedRemain PegaHCPegaHC-Data-FamilyAccumulators FamilyOONDedUsed FamilyOONDedUsed PegaHCPegaHC-Data-FamilyAccumulators PlanID PlanID PegaHCPegaHC-Data-FamilyAccumulators PolicyID PolicyID PegaHCPegaHC-Data-FamilyAccumulators FamilyDedRemainTotal FamilyDedRemainTotal PegaHCPegaHC-Data-FamilyAccumulators FamilyINOOPocketLimit FamilyINOOPocketLimit PegaHCPegaHC-Data-FamilyAccumulators FamilyOOPocketUsedTotal FamilyOOPocketUsedTotal PegaHCPegaHC-Data-FormIdentification FormQuestionList FormQuestionList PegaHCPegaHC-Data-FormIdentification CodeListQualifierCode CodeListQualifierCode PegaHCPegaHC-Data-FormIdentification FormIdentifier FormIdentifier PegaHC

PegaHC-Data-GCNCodes DrugClass Drug Class PegaHCPegaHC-Data-GCNCodes CodeDescription Description PegaHCPegaHC-Data-GCNCodes Code Code PegaHCPegaHC-Data-HCPCSCodes LongDesc Long Desc PegaHCPegaHC-Data-HCPCSCodes HCPC HCPC PegaHCPegaHC-Data-HCPCSCodes ShortDesc Short Desc PegaHCPegaHC-Data-Header TransactionSetControlNumber Transaction Set Control Number PegaHCPegaHC-Data-Header TransactionSetIdentifierCode Transaction Set Identifier Code PegaHCPegaHC-Data-Header ImplementationGuideVersionName Implementation Guide Version Name PegaHCPegaHC-Data-ICD10- Description Description PegaHCPegaHC-Data-ICD10- Code Code PegaHCPegaHC-Data-ICD10-Diagnosis ICD10Description ICD10Description PegaHCPegaHC-Data-IndividualAccumulators IndividualDedRemainTotal IndividualDedRemainTotal PegaHCPegaHC-Data-IndividualAccumulators IndividualDedLimitTotal IndividualDedLimitTotal PegaHCPegaHC-Data-IndividualAccumulators IndividualOONDedLimit IndividualOONDedLimit PegaHCPegaHC-Data-IndividualAccumulators IndividualINOOPocketRemain IndividualINOOPocketRemain PegaHCPegaHC-Data-IndividualAccumulators PlanID PlanID PegaHCPegaHC-Data-IndividualAccumulators IndividualOOPocketRemainTotal IndividualOOPocketRemainTotal PegaHCPegaHC-Data-IndividualAccumulators IndividualOONOOPocketRemain IndividualOONOOPocketRemain PegaHCPegaHC-Data-IndividualAccumulators IndividualINOOPocketUsed IndividualINOOPocketUsed PegaHCPegaHC-Data-IndividualAccumulators IndividualINDedRemain IndividualINDedRemain PegaHCPegaHC-Data-IndividualAccumulators AccPeriodBegin AccPeriodBegin PegaHCPegaHC-Data-IndividualAccumulators IndividualDedUsedTotal IndividualDedUsedTotal PegaHCPegaHC-Data-IndividualAccumulators IndividualINOOPocketLimit IndividualINOOPocketLimit PegaHCPegaHC-Data-IndividualAccumulators IndividualOONDedRemain IndividualOONDedRemain PegaHCPegaHC-Data-IndividualAccumulators IndividualOOPocketLimitTotal IndividualOOPocketLimitTotal PegaHCPegaHC-Data-IndividualAccumulators IndividualINDedLimit IndividualINDedLimit PegaHCPegaHC-Data-IndividualAccumulators IndividualOONOOPocketUsed IndividualOONOOPocketUsed PegaHCPegaHC-Data-IndividualAccumulators IndividualOONOOPocketLimit IndividualOONOOPocketLimit PegaHCPegaHC-Data-IndividualAccumulators IndividualOOPocketUsedTotal IndividualOOPocketUsedTotal PegaHCPegaHC-Data-IndividualAccumulators PolicyID PolicyID PegaHCPegaHC-Data-IndividualAccumulators AccPeriodEnd AccPeriodEnd PegaHCPegaHC-Data-IndividualAccumulators IndividualINDedUsed IndividualINDedUsed PegaHCPegaHC-Data-IndividualAccumulators IndividualOONDedUsed IndividualOONDedUsed PegaHCPegaHC-Data-IndividualAccumulators MemberID MemberID PegaHCPegaHC-Data-InformationCodes HCCodeInformation HCCodeInformation PegaHCPegaHC-Data-Issues Source Source PegaHCPegaHC-Data-Issues PatientID PatientID PegaHCPegaHC-Data-Issues DateCreated DateCreated PegaHCPegaHC-Data-Issues Description Description PegaHC

PegaHC-Data-Issues Type Type PegaHCPegaHC-Data-Issues Status Status PegaHCPegaHC-Data-LabResults Source Source PegaHCPegaHC-Data-LabResults Reviewed Reviewed PegaHCPegaHC-Data-LabResults PatientID PatientID PegaHCPegaHC-Data-LabResults ServiceDateDisplay ServiceDateDisplay PegaHCPegaHC-Data-LabResults TestName TestName PegaHCPegaHC-Data-LabResults RangeEval RangeEval PegaHCPegaHC-Data-LabResults TestResultsQualifier TestResultsQualifier PegaHCPegaHC-Data-LabResults ServiceDate ServiceDate PegaHCPegaHC-Data-LabResults TestResultsValue TestResultsValue PegaHCPegaHC-Data-LabResults Location Location PegaHCPegaHC-Data-LabResults LabDate LabDate PegaHCPegaHC-Data-LabResults LISTING_SEQ_NO ID PegaHCPegaHC-Data-Language Code ID PegaHCPegaHC-Data-Language pyLabel Language PegaHCPegaHC-Data-Measurement Height Height PegaHCPegaHC-Data-Measurement MeasurementQualifier MeasurementQualifier PegaHCPegaHC-Data-Measurement DateCreated DateCreated PegaHCPegaHC-Data-Measurement MeasurementValue MeasurementValue PegaHCPegaHC-Data-Measurement MeasurementDate MeasurementDate PegaHCPegaHC-Data-Measurement BPDiastolic BPDiastolic PegaHCPegaHC-Data-Measurement MeasurementType MeasurementType PegaHCPegaHC-Data-Measurement Weight Weight PegaHCPegaHC-Data-Measurement BPSystolic BPSystolic PegaHCPegaHC-Data-Measurement BodyMassIndex BodyMassIndex PegaHCPegaHC-Data-Measurement NumberofIncidents NumberofIncidents PegaHCPegaHC-Data-Measurement PatientID PatientID PegaHCPegaHC-Data-Measurement Source Source PegaHCPegaHC-Data-MedicalHistory DateCreated DateCreated PegaHCPegaHC-Data-MedicalHistory LISTING_SEQ_NO ID PegaHCPegaHC-Data-MedicalHistory FamilyMember FamilyMember PegaHCPegaHC-Data-MedicalHistory Description Description PegaHCPegaHC-Data-NDCCodes RX_OTC RX_OTC PegaHCPegaHC-Data-NDCCodes TRADENAME TRADENAME PegaHCPegaHC-Data-NDCCodes UNIT UNIT PegaHCPegaHC-Data-NDCCodes PRODCODE PRODCODE PegaHCPegaHC-Data-NDCCodes LBLCODE LBLCODE PegaHCPegaHC-Data-NDCCodes LISTING_SEQ_NO ID PegaHCPegaHC-Data-NDCCodes NDCCode NDCCode PegaHC

PegaHC-Data-NDCCodes STRENGTH STRENGTH PegaHCPegaHC-Data-Notes Type Type PegaHCPegaHC-Data-Notes OperatorID OperatorID PegaHCPegaHC-Data-Notes Note Note PegaHCPegaHC-Data-Notes WorkID Woirk Item ID PegaHCPegaHC-Data-Party AddressLine1 AddressLine1 PegaHCPegaHC-Data-Party AdditionalName Additional Name PegaHCPegaHC-Data-Party HierarchicalChildCode HierarchicalChildCode PegaHCPegaHC-Data-Party MiddleName MiddleName PegaHCPegaHC-Data-Party HierarchicalParentIDNumber HierarchicalParentIDNumber PegaHCPegaHC-Data-Party NewTaxonomyCode NewTaxonomyCode PegaHCPegaHC-Data-Party UCASEFirstName First Name - UPPERCASE PegaHCPegaHC-Data-Party BankIDNumber Bank ID Number PegaHCPegaHC-Data-Party EntityTypeQualifier EntityTypeQualifier PegaHCPegaHC-Data-Party EntityIdentifierCode Entity Identifier Code PegaHCPegaHC-Data-Party AddressLine2 AddressLine2 PegaHCPegaHC-Data-Party HierarchicalIDNumber HierarchicalIDNumber PegaHCPegaHC-Data-Party SecondaryID SecondaryID PegaHCPegaHC-Data-Party ContactFunctionCode Contact Function Code PegaHCPegaHC-Data-Party HierarchicalLevelCode HierarchicalLevelCode PegaHCPegaHC-Data-Party Contact Contact PegaHCPegaHC-Data-Party ReceivingDFIIdentifier Receiving DFI Identifier PegaHCPegaHC-Data-Party GroupNumber GroupNumber PegaHCPegaHC-Data-Party IdentificationCode IdentificationCode PegaHCPegaHC-Data-Party IdentificationCodeQualifier Identification Code Qualifier PegaHCPegaHC-Data-Party DateOfDeath DateOfDeath PegaHCPegaHC-Data-Party UCASELastName Last Name - UPPERCASE PegaHCPegaHC-Data-Party Age Age PegaHCPegaHC-Data-Party FlowType FlowType PegaHCPegaHC-Data-Party IndividualIdentifier IndividualIdentifier PegaHCPegaHC-Data-Party AccountNumber Account Number PegaHCPegaHC-Data-Party BankAccountNumber Bank Account Number PegaHCPegaHC-Data-Party PriorityNote PriorityNote PegaHCPegaHC-Data-Party-Agency TPAOrBrokerAccountNumber TPA Or Broker Account Number PegaHCPegaHC-Data-Party-Agency TPAOrBrokerName TPA Or Broker Name PegaHCPegaHC-Data-Party-Agency EmployerIdentificationNumber EmployerIdentificationNumber PegaHCPegaHC-Data-Party-Agency TPAOrBrokerIdentificationCode TPA Or Broker Identification Code PegaHCPegaHC-Data-Party-Broker TPAOrBrokerIdentificationCode TPA Or Broker Identification Code PegaHCPegaHC-Data-Party-Broker TPAOrBrokerAccountNumber TPA Or Broker Account Number PegaHCPegaHC-Data-Party-Broker TPAOrBrokerName TPA Or Broker Name PegaHC

PegaHC-Data-Party-Broker EmployerIdentificationNumber EmployerIdentificationNumber PegaHCPegaHC-Data-Party-BusinessEntity EndDate EndDate PegaHCPegaHC-Data-Party-BusinessEntity Versions Versions PegaHCPegaHC-Data-Party-BusinessEntity ContractName ContractName PegaHCPegaHC-Data-Party-BusinessEntity PrimaryContact PrimaryContact PegaHCPegaHC-Data-Party-BusinessEntity Description Description PegaHCPegaHC-Data-Party-BusinessEntity TaxIdentificationNumber TaxIdentificationNumber PegaHCPegaHC-Data-Party-BusinessEntity IsContractEntity IsContractEntity PegaHCPegaHC-Data-Party-BusinessEntity BusinessType BusinessType PegaHCPegaHC-Data-Party-BusinessEntity IsOnlyContractEntity IsOnlyContractEntity PegaHCPegaHC-Data-Party-BusinessEntity Locations Locations PegaHCPegaHC-Data-Party-BusinessEntity Contract Contract PegaHCPegaHC-Data-Party-BusinessEntity BEHoldingContractTIN BEHoldingContractTIN PegaHCPegaHC-Data-Party-BusinessEntity BEHoldingContractID BEHoldingContractID PegaHCPegaHC-Data-Party-BusinessEntity Name Name PegaHCPegaHC-Data-Party-BusinessEntity BEHoldingContract BEHoldingContract PegaHCPegaHC-Data-Party-BusinessEntity EffectiveDate Effective Date PegaHCPegaHC-Data-Party-Company OpenEnrollmentPeriod OpenEnrollmentPeriod PegaHCPegaHC-Data-Party-Company PlanSponsor PlanSponsor PegaHCPegaHC-Data-Party-Company SalesRepPhone SalesRepPhone PegaHCPegaHC-Data-Party-Company BrokerName BrokerName PegaHCPegaHC-Data-Party-Company CoHaveLegalSubDesc CoHaveLegalSubDesc PegaHCPegaHC-Data-Party-Company SubSegment SubSegment PegaHCPegaHC-Data-Party-Company TotalEligibles TotalEligibles PegaHCPegaHC-Data-Party-Company AgencyID AgencyID PegaHCPegaHC-Data-Party-Company CheckAmount CheckAmount PegaHCPegaHC-Data-Party-Company IDCardTurnaround IDCardTurnaround PegaHCPegaHC-Data-Party-Company LastEffectiveDate LastEffectiveDate PegaHCPegaHC-Data-Party-Company CoInBusiness CoInBusiness PegaHCPegaHC-Data-Party-Company ContractState ContractState PegaHCPegaHC-Data-Party-Company DBNumber DBNumber PegaHCPegaHC-Data-Party-Company DentalCompetitor DentalCompetitor PegaHCPegaHC-Data-Party-Company EligibilityFormat EligibilityFormat PegaHCPegaHC-Data-Party-Company SiteType SiteType PegaHCPegaHC-Data-Party-Company TotalCovered TotalCovered PegaHCPegaHC-Data-Party-Company TotalDentalEligibles TotalDentalEligibles PegaHCPegaHC-Data-Party-Company TotalMedicalEligibles TotalMedicalEligibles PegaHCPegaHC-Data-Party-Company AgencyName AgencyName PegaHCPegaHC-Data-Party-Company BusinessType BusinessType PegaHCPegaHC-Data-Party-Company ClaimFiduciary ClaimFiduciary PegaHC

PegaHC-Data-Party-Company Cobra Cobra PegaHCPegaHC-Data-Party-Company CompanyList CompanyList PegaHCPegaHC-Data-Party-Company EnrollmentAppTurnaround EnrollmentAppTurnaround PegaHCPegaHC-Data-Party-Company EnrollmentSystem EnrollmentSystem PegaHCPegaHC-Data-Party-Company IndustryCode IndustryCode PegaHCPegaHC-Data-Party-Company NatureofBusiness NatureofBusiness PegaHCPegaHC-Data-Party-Company OfferedDentalCoverage OfferedDentalCoverage PegaHCPegaHC-Data-Party-Company BrokerofRecord BrokerofRecord PegaHCPegaHC-Data-Party-Company CustomerType CustomerType PegaHCPegaHC-Data-Party-Company IndustryCodeDescription IndustryCodeDescription PegaHCPegaHC-Data-Party-Company LastOpportunityID LastOpportunityID PegaHCPegaHC-Data-Party-Company Status Status PegaHCPegaHC-Data-Party-Company BrokerID BrokerID PegaHCPegaHC-Data-Party-Company CoPacketsTo CoPacketsTo PegaHCPegaHC-Data-Party-Company Department Department PegaHCPegaHC-Data-Party-Company EstablishedDate EstablishedDate PegaHCPegaHC-Data-Party-Company FundingArrangement FundingArrangement PegaHCPegaHC-Data-Party-Company ProbEffDtPart ProbEffDtPart PegaHCPegaHC-Data-Party-Company SalesRepName SalesRepName PegaHCPegaHC-Data-Party-Company BillingArrangement BillingArrangement PegaHCPegaHC-Data-Party-Company CoHaveLegalSub CoHaveLegalSub PegaHCPegaHC-Data-Party-Company EnrollmentType EnrollmentType PegaHCPegaHC-Data-Party-Company HealthCompetitor HealthCompetitor PegaHCPegaHC-Data-Party-Company ProbEffDtFull ProbEffDtFull PegaHCPegaHC-Data-Party-Company RenewalMonth RenewalMonth PegaHCPegaHC-Data-Party-Company SpecialReqs SpecialReqs PegaHCPegaHC-Data-Party-Company Address Address PegaHCPegaHC-Data-Party-Company CheckIncluded CheckIncluded PegaHCPegaHC-Data-Party-Company CurrentDentalCoverage CurrentDentalCoverage PegaHCPegaHC-Data-Party-Company EffectiveDate EffectiveDate PegaHCPegaHC-Data-Party-Company EmpTaxID EmpTaxID PegaHCPegaHC-Data-Party-Company PCPAssignTurnaround PCPAssignTurnaround PegaHCPegaHC-Data-Party-Company RateCalculationType RateCalculationType PegaHCPegaHC-Data-Party-Company TotalEmployees TotalEmployees PegaHCPegaHC-Data-Party-Company InternalExternal InternalExternal PegaHCPegaHC-Data-Party-Company Segment Segment PegaHCPegaHC-Data-Party-Company ServiceGuarantee ServiceGuarantee PegaHCPegaHC-Data-Party-Member WageAmount WageAmount PegaHCPegaHC-Data-Party-Member CreditOrDebitCardNumber CreditOrDebitCardNumber PegaHCPegaHC-Data-Party-Member DateOfDeath DateOfDeath PegaHC

PegaHC-Data-Party-Member IndividualDeathDate IndividualDeathDate PegaHCPegaHC-Data-Party-Member LanguageCode LanguageCode PegaHCPegaHC-Data-Party-Member MaritalStatusCode MaritalStatusCode PegaHCPegaHC-Data-Party-Member MedicalRecordNumber MedicalRecordNumber PegaHCPegaHC-Data-Party-Member MemberList MemberList PegaHCPegaHC-Data-Party-Member MemberPolicy Member Policy PegaHCPegaHC-Data-Party-Member AdditionalName AdditionalName PegaHCPegaHC-Data-Party-Member CitizenshipStatusCode CitizenshipStatusCode PegaHCPegaHC-Data-Party-Member ControlNumber ControlNumber PegaHCPegaHC-Data-Party-Member CreditOrDebitCardAuthNumber CreditOrDebitCardAuthNumber PegaHCPegaHC-Data-Party-Member IDCardNumber IDCardNumber PegaHCPegaHC-Data-Party-Member IndividualRelationshipCode IndividualRelationshipCode PegaHCPegaHC-Data-Party-Member LanguageUseIndicator LanguageUseIndicator PegaHCPegaHC-Data-Party-Member MemberSupplementalIDQualifier MemberSupplementalIDQualifier PegaHCPegaHC-Data-Party-Member PatientPrimaryIdentifier PatientPrimaryIdentifier PegaHCPegaHC-Data-Party-Member RaceOrEthnicityCode RaceOrEthnicityCode PegaHCPegaHC-Data-Party-Member SocialSecurityNumber SocialSecurityNumber PegaHCPegaHC-Data-Party-Member StudentStatusCode StudentStatusCode PegaHCPegaHC-Data-Party-Member SubscriberPrimaryIdentifier SubscriberPrimaryIdentifier PegaHCPegaHC-Data-Party-Member AccountNumber AccountNumber PegaHCPegaHC-Data-Party-Member COBCode COBCode PegaHCPegaHC-Data-Party-Member Disability Disability PegaHCPegaHC-Data-Party-Member DisabilityEligibilityDate DisabilityEligibilityDate PegaHCPegaHC-Data-Party-Member DODHealthServiceRegionCode DODHealthServiceRegionCode PegaHCPegaHC-Data-Party-Member GroupNumber GroupNumber PegaHCPegaHC-Data-Party-Member LocationIdentificationCode LocationIdentificationCode PegaHCPegaHC-Data-Party-Member MemberIdentificationNumber MemberIdentificationNumber PegaHCPegaHC-Data-Party-Member PatientAccountNumber PatientAccountNumber PegaHCPegaHC-Data-Party-Member PolicyStatus PolicyStatus PegaHCPegaHC-Data-Party-Member Address Address PegaHCPegaHC-Data-Party-Member ClaimFilingIndicatorCode Claim Filing Indicator Code PegaHCPegaHC-Data-Party-Member PropertyCasualtyClaimNumber PropertyCasualtyClaimNumber PegaHCPegaHC-Data-Party-Member SupplementalIdentifier SupplementalIdentifier PegaHCPegaHC-Data-Party-Member Age Age PegaHCPegaHC-Data-Party-Member CreditOrDebitCardMaximumAmount CreditOrDebitCardMaximumAmount PegaHCPegaHC-Data-Party-Member DateOfBirth DateOfBirth PegaHCPegaHC-Data-Party-Member Height Height PegaHCPegaHC-Data-Party-Member IDCardSerialNumber IDCardSerialNumber PegaHCPegaHC-Data-Party-Member MedicaidRecipientNumber MedicaidRecipientNumber PegaHCPegaHC-Data-Party-Member PolicyNumber PolicyNumber PegaHC

PegaHC-Data-Party-Member SchoolPostalCode SchoolPostalCode PegaHCPegaHC-Data-Party-Member SchoolState SchoolState PegaHCPegaHC-Data-Party-Member TermDate TermDate PegaHCPegaHC-Data-Party-Member ContactName ContactName PegaHCPegaHC-Data-Party-Member DisabilityTypeCode DiabilityTypeCode PegaHCPegaHC-Data-Party-Member EmploymentStatusCode EmploymentStatusCode PegaHCPegaHC-Data-Party-Member GenderCode GenderCode PegaHCPegaHC-Data-Party-Member GroupOrPolicyNumber GroupOrPolicyNumber PegaHCPegaHC-Data-Party-Member HandicapIndicator HandicapIndicator PegaHCPegaHC-Data-Party-Member InsuranceTypeCode InsuranceTypeCode PegaHCPegaHC-Data-Party-Member IssueNumber IssueNumber PegaHCPegaHC-Data-Party-Member LanguageDescription LanguageDescription PegaHCPegaHC-Data-Party-Member LicenseNumberStateCode LicenseNumberStateCode PegaHCPegaHC-Data-Party-Member PCPNumber PCPNumber PegaHCPegaHC-Data-Party-Member Weight Weight PegaHCPegaHC-Data-Party-Member WorkHoursCount WorkHoursCount PegaHCPegaHC-Data-Party-Member COB COB PegaHCPegaHC-Data-Party-Member EffectiveDate EffectiveDate PegaHCPegaHC-Data-Party-Member HealthInsuranceClaimNumber HealthInsuranceClaimNumber PegaHCPegaHC-Data-Party-Member MemberIDQualifier MemberIDQualifier PegaHCPegaHC-Data-Party-Member MiddleName MiddleName PegaHCPegaHC-Data-Party-Member PCPEffectiveDate PCPEffectiveDate PegaHCPegaHC-Data-Party-Member PlanNetworkIdentificationNumber PlanNetworkIdentificationNumber PegaHCPegaHC-Data-Party-Member Policy Policy PegaHCPegaHC-Data-Party-Member SalaryGradeCode SalaryGradeCode PegaHCPegaHC-Data-Party-Member SchoolAddressLine1 SchoolAddressLine1 PegaHC

PegaHC-Data-Party-Member PayerResponsibilitySequenceNumberCode PayerResponsibilitySequenceNumberCode PegaHCPegaHC-Data-Party-Member EligibilityBenefitInformation EligibilityBenefitInformation PegaHCPegaHC-Data-Party-Member EmployeeIdentificationNumber EmployeeIdentificationNumber PegaHCPegaHC-Data-Party-Member InsuredIndicator InsuredIndicator PegaHCPegaHC-Data-Party-Member MemberStatus MemberStatus PegaHCPegaHC-Data-Party-Member NamePrefix NamePrefix PegaHCPegaHC-Data-Party-Member PregnancyIndicator Pregnancy Indicator PegaHCPegaHC-Data-Party-Member Provider Provider PegaHCPegaHC-Data-Party-Member SupplementalDescription SupplementalDescription PegaHCPegaHC-Data-Party-Member PACReferenceIDQualifier PACReferenceIDQualifier PegaHCPegaHC-Data-Party-Member BirthSequenceNumber BirthSequenceNumber PegaHCPegaHC-Data-Party-Member LocationQualifier LocationQualifier PegaHCPegaHC-Data-Party-Member PrivacyRestricted PrivacyRestricted PegaHC

PegaHC-Data-Party-Member SchoolCity SchoolCity PegaHCPegaHC-Data-Party-Member SchoolName SchoolName PegaHCPegaHC-Data-Party-Member Status Status PegaHCPegaHC-Data-Party-Member TestLanguageCode Test LanguageCode PegaHCPegaHC-Data-Party-Payer OtherSubscriber OtherSubscriber PegaHC

PegaHC-Data-Party-Payer PayerResponsibilitySequenceNumberCode Payer Responsibility Sequence Number Code PegaHCPegaHC-Data-Party-Payer AssignmentCertificationIndicator AssignmentCertificationIndicator PegaHCPegaHC-Data-Party-Payer FederalTaxIDQualifier FedaralTaxIDQualifier PegaHCPegaHC-Data-Party-Payer ClaimAdjustmentIndicator ClaimAdjustmentIndicator PegaHCPegaHC-Data-Party-Payer COBDate COBDate PegaHCPegaHC-Data-Party-Payer ContactName ContactName PegaHCPegaHC-Data-Party-Payer EmployerIdentificationNumber EmployerIdentificationNumber PegaHCPegaHC-Data-Party-Payer HealthIndustryNumber HealthIndustryNumber PegaHCPegaHC-Data-Party-Payer RenderingProviderIdentifier RenderingProviderIdentifier PegaHCPegaHC-Data-Party-Payer ResponsibilitySequenceNumber ResponsibilitySequenceNumber PegaHCPegaHC-Data-Party-Payer FederalTaxID FederalTaxID PegaHCPegaHC-Data-Party-Payer OperatingPhysician OperatingPhysician PegaHCPegaHC-Data-Party-Payer PrimaryIdentifier PrimaryIdentifier PegaHCPegaHC-Data-Party-Payer ServiceFacility ServiceFacility PegaHCPegaHC-Data-Party-Payer NationalPlanID NationalPlanID PegaHCPegaHC-Data-Party-Payer Payment Payment PegaHCPegaHC-Data-Party-Payer RenderingProviderSecondaryIdentifier RenderingProviderSecondaryIdentifier PegaHCPegaHC-Data-Party-Payer BillingProvider BillingProvider PegaHCPegaHC-Data-Party-Payer ClaimAdjustmentGroupCode ClaimAdjustmentGroupCode PegaHCPegaHC-Data-Party-Payer OtherInsuranceReleaseofInfoCode OtherInsuranceReleaseofInfoCode PegaHCPegaHC-Data-Party-Payer .pyWorkPartyUri Payer ID PegaHCPegaHC-Data-Party-Payer NAICCode NAICCode PegaHCPegaHC-Data-Party-Payer PatientSecondaryIdentifier PatientSecondaryIdentifier PegaHCPegaHC-Data-Party-Payer SupervisingProviderIdentifier SupervisingProviderIdentifier PegaHCPegaHC-Data-Party-Payer PatientSignatureSourceCode PatientSignatureSourceCode PegaHCPegaHC-Data-Party-Payer AdditionalIdentifier AdditionalIdentifier PegaHCPegaHC-Data-Party-Payer COBCode COBCode PegaHCPegaHC-Data-Party-Payer IdentificationNumber IdentificationNumber PegaHCPegaHC-Data-Party-Payer InsuranceEndDate End Date PegaHCPegaHC-Data-Party-Payer ReferralNumber ReferralNumber PegaHCPegaHC-Data-Party-Payer SecondaryIdentifier SecondaryIdentifier PegaHCPegaHC-Data-Party-Payer OtherPayer OtherPayer PegaHCPegaHC-Data-Party-Payer RenderingProvider RenderingProvider PegaHCPegaHC-Data-Party-Payer SecondaryIDQualifier SecondaryIDQualifier PegaHC

PegaHC-Data-Party-Payer SubmitterIdentifier SubmitterIdentifier PegaHCPegaHC-Data-Party-Payer ClaimControlNumber ClaimControlNumber PegaHCPegaHC-Data-Party-Payer SupervisingProvider SupervisingProvider PegaHCPegaHC-Data-Party-Payer OperatingProviderIdentifier OperatingProviderIdentifier PegaHCPegaHC-Data-Party-Payer OtherProviderIdentifier OtherProviderIdentifier PegaHCPegaHC-Data-Party-Payer PatientLastName PatientLastName PegaHCPegaHC-Data-Party-Payer PriorAuthorizationNumber PriorAuthorizationNumber PegaHCPegaHC-Data-Party-Payer PurchasedServiceProviderIdentifier PurchasedServiceProviderIdentifier PegaHCPegaHC-Data-Party-Payer ReferringProviderList ReferringProviderList PegaHCPegaHC-Data-Party-Payer PatientPrimaryIdentifier PatientPrimaryIdentifier PegaHCPegaHC-Data-Party-Payer PayerName PayerName PegaHCPegaHC-Data-Party-Payer ServiceFacilityLocationIdentfier ServiceFacilityLocationIdentfier PegaHCPegaHC-Data-Party-Payer AdditionalName AdditionalName PegaHCPegaHC-Data-Party-Payer AttendingPhysician AttendingPhysician PegaHCPegaHC-Data-Party-Payer PatientFirstName PatientFirstName PegaHCPegaHC-Data-Party-Payer ServiceFacilityProviderIdentifier ServiceFacilityProviderIdentifier PegaHCPegaHC-Data-Party-Payer OtherOperatingPhysician OtherOperatingPhysician PegaHCPegaHC-Data-Party-PlanSponsor EmployerIdentificationNumber EmployerIdentificationNumber PegaHCPegaHC-Data-Party-PlanSponsor .pyWorkPartyUri Plan Sponsor ID PegaHCPegaHC-Data-Party-PlanSponsor GroupNumber GroupNumber PegaHCPegaHC-Data-Party-PlanSponsor PlanSponsorList PlanSponsorList PegaHCPegaHC-Data-Party-Provider Marketing Marketing PegaHCPegaHC-Data-Party-Provider PractitionerCapacity PractitionerCapacity PegaHCPegaHC-Data-Party-Provider ContractNumber ContractNumber PegaHCPegaHC-Data-Party-Provider EmployerIdentificationNumber EmployerIdentificationNumber PegaHCPegaHC-Data-Party-Provider FacilityNetworkIdentificationNumber FacilityNetworkIdentificationNumber PegaHCPegaHC-Data-Party-Provider GenderRestrict GenderRestrict PegaHCPegaHC-Data-Party-Provider AffiliationData AffiliationData PegaHCPegaHC-Data-Party-Provider CommitteeDate Committee Date PegaHCPegaHC-Data-Party-Provider EffectiveDate EffectiveDate PegaHC

PegaHC-Data-Party-Provider MedicaidEffectiveDate Medicaid Number And State Effective Date PegaHCPegaHC-Data-Party-Provider MedicaidNumberandState MedicaidNumberandState PegaHCPegaHC-Data-Party-Provider CHAMPUSNumber CHAMPUSNumber PegaHCPegaHC-Data-Party-Provider DEAExpDate DEAExpDate PegaHCPegaHC-Data-Party-Provider Gender Gender PegaHCPegaHC-Data-Party-Provider MedicaidProviderNumber MedicaidProviderNumber PegaHCPegaHC-Data-Party-Provider NationalProviderIdentfier NationalProviderIdentfier PegaHCPegaHC-Data-Party-Provider Networks Networks PegaHCPegaHC-Data-Party-Provider PCPIndicator PCPIndicator PegaHC

PegaHC-Data-Party-Provider ProviderCode ProviderCode PegaHCPegaHC-Data-Party-Provider ProviderSiteNumber ProviderSiteNumber PegaHCPegaHC-Data-Party-Provider SupplementalIdentifier Supplemental Identifier PegaHCPegaHC-Data-Party-Provider MedicareNumberEndDate MedicareNumberEndDate PegaHCPegaHC-Data-Party-Provider ProviderAffiliations ProviderAffiliations PegaHCPegaHC-Data-Party-Provider AppointmentEndDate Appointment End Date PegaHCPegaHC-Data-Party-Provider CredentialedSpecialities Credentialed Specialities PegaHCPegaHC-Data-Party-Provider LicenseandState LicenseandState PegaHCPegaHC-Data-Party-Provider MedicareNumberEffectiveDate Medicare Number Effective Date PegaHCPegaHC-Data-Party-Provider Capacity Capacity PegaHCPegaHC-Data-Party-Provider LicenseExpirationFlag LicenseExpirationFlag PegaHCPegaHC-Data-Party-Provider ProviderQuality ProviderQuality PegaHCPegaHC-Data-Party-Provider UniqueSupplierIdentificationNumber UniqueSupplierIdentificationNumber PegaHCPegaHC-Data-Party-Provider UPIN UPIN PegaHCPegaHC-Data-Party-Provider AppointmentStartDate Appointment Start Date PegaHCPegaHC-Data-Party-Provider CredentialingStatus Credentialing Status PegaHCPegaHC-Data-Party-Provider DelegatedCredentialing Delegated Credentialing PegaHCPegaHC-Data-Party-Provider DelegatedParty Delegated Party PegaHCPegaHC-Data-Party-Provider EndDate EndDate PegaHCPegaHC-Data-Party-Provider Languages Languages PegaHCPegaHC-Data-Party-Provider SecondarySpeciality SecondarySpeciality PegaHCPegaHC-Data-Party-Provider AdditionalLanguage1 AdditionalLanguage1 PegaHCPegaHC-Data-Party-Provider AgeGroup AgeGroup PegaHCPegaHC-Data-Party-Provider BlueShieldProviderNumber BlueShieldProviderNumber PegaHCPegaHC-Data-Party-Provider DateOfBirth DateOfBirth PegaHC

PegaHC-Data-Party-Provider ElectronicTransmitterIdentificationNumber ElectronicTransmitterIdentificationNumber PegaHCPegaHC-Data-Party-Provider LocationNumber LocationNumber PegaHCPegaHC-Data-Party-Provider ProviderCommercialNumber ProviderCommercialNumber PegaHCPegaHC-Data-Party-Provider LicenseExpDate LicenseExpDate PegaHCPegaHC-Data-Party-Provider LicenseExpDateTime LicenseExpDateTime PegaHCPegaHC-Data-Party-Provider PaymentCode PaymentCode PegaHCPegaHC-Data-Party-Provider ProviderEffectiveDate Provider Effective Date PegaHCPegaHC-Data-Party-Provider ProviderSupplementalIDQualifier ProviderSupplementalIDQualifier PegaHCPegaHC-Data-Party-Provider DEAEndDate DEAEndDate PegaHCPegaHC-Data-Party-Provider MarketInDirectory MarketInDirectory PegaHCPegaHC-Data-Party-Provider DEAExpDateTime DEAExpDateTime PegaHCPegaHC-Data-Party-Provider EntityRelationshipCode Entity Relationship Code PegaHCPegaHC-Data-Party-Provider GenderCode GenderCode PegaHCPegaHC-Data-Party-Provider NameAdditionalText NameAdditionalText PegaHC

PegaHC-Data-Party-Provider NewPatients NewPatients PegaHCPegaHC-Data-Party-Provider ParticipatingProviders Participating Providers PegaHCPegaHC-Data-Party-Provider ProviderIDQualifier ProviderIDQualifier PegaHCPegaHC-Data-Party-Provider SpecialistIndicator PCPIndicator PegaHCPegaHC-Data-Party-Provider StateIndustrialAccidentProviderNumber StateIndustrialAccidentProviderNumber PegaHCPegaHC-Data-Party-Provider ReferralCircle ReferralCircle PegaHCPegaHC-Data-Party-Provider Description Description PegaHCPegaHC-Data-Party-Provider MedicareNumber MedicareNumber PegaHCPegaHC-Data-Party-Provider TaxIdentificationNumber TaxIdentificationNumber PegaHCPegaHC-Data-Party-Provider ContractName ContractName PegaHCPegaHC-Data-Party-Provider NPIType NPIType PegaHCPegaHC-Data-Party-Provider ClinicNumber ClinicNumber PegaHCPegaHC-Data-Party-Provider Group groups PegaHCPegaHC-Data-Party-Provider HMONumber HMONumber PegaHCPegaHC-Data-Party-Provider ReferringProviderEntityIdentifierCode ReferringProviderEntityIdentifierCode PegaHCPegaHC-Data-Party-Provider ReferringProviderIdentifierCode ReferringProviderIdentifierCode PegaHCPegaHC-Data-Party-Provider AdditionalIdentifier AdditionalIdentifier PegaHCPegaHC-Data-Party-Provider MedicareProviderNumber MedicareProviderNumber PegaHCPegaHC-Data-Party-Provider PersonLastName PersonLastName PegaHCPegaHC-Data-Party-Provider PlanNetworkNumber PlanNetworkNumber PegaHCPegaHC-Data-Party-Provider ProviderList ProviderList PegaHCPegaHC-Data-Party-Provider SocialSecurityNumber SocialSecurityNumber PegaHCPegaHC-Data-Party-Provider StateLicenseNumber StateLicenseNumber PegaHCPegaHC-Data-Party-Provider DEAEffectiveDate DEAEffectiveDate PegaHCPegaHC-Data-Party-Provider ProviderName ProviderName PegaHCPegaHC-Data-Party-Provider CurrencyCode CurrencyCode PegaHCPegaHC-Data-Party-Provider TaxIdentifierQualifer TaxIdentifierQualifer PegaHCPegaHC-Data-Party-Provider AdmittingHospital AdmittingHospital PegaHCPegaHC-Data-Party-Provider ActionCodePLA Action Code PLA segment PegaHCPegaHC-Data-Party-Provider AnesthesiaLicenseNumber AnesthesiaLicenseNumber PegaHCPegaHC-Data-Party-Provider BlueCrossProviderNumber BlueCrossProviderNumber PegaHCPegaHC-Data-Party-Provider DEA DEA PegaHCPegaHC-Data-Party-Provider DEAExpirationFlag DEAExpirationFlag PegaHCPegaHC-Data-Party-Provider FacilityIDNumber FacilityIDNumber PegaHCPegaHC-Data-Party-Provider LicensedState LicensedState PegaHCPegaHC-Data-Party-Provider NABPNumber NABPNumber PegaHCPegaHC-Data-Party-Provider PPONumber PPONumber PegaHCPegaHC-Data-Party-Provider PracticeAddress PracticeAddress PegaHCPegaHC-Data-Party-Provider PrimaryAddressType PrimaryPersonalAddressType PegaHCPegaHC-Data-Party-Provider SecondaryIdentifier SecondaryIdentifier PegaHC

PegaHC-Data-Party-Provider AdditionalLanguage2 AdditionalLanguage2 PegaHCPegaHC-Data-Party-Provider Certifications Certifications PegaHCPegaHC-Data-Party-Provider CreditCardIdentifier CreditCardIdentifier PegaHCPegaHC-Data-Party-Provider DEAState DEAState PegaHCPegaHC-Data-Party-Provider DentistLicenseNumber DentistLicenseNumber PegaHCPegaHC-Data-Party-Provider FederalTaxID FederalTaxID PegaHCPegaHC-Data-Party-Provider MaintenanceReasonCode Maintenance Reason Code PegaHCPegaHC-Data-Party-Provider NationalProviderIdentifier NationalProviderIdentifier PegaHCPegaHC-Data-Party-Provider TaxonomyCode TaxonomyCode PegaHCPegaHC-Data-Party-Provider MedicaidEndDate Medicaid Number And State End Date PegaHCPegaHC-Data-Party-Provider ProviderProfessionType ProviderProfessionType PegaHCPegaHC-Data-Party-Provider SpecialtyList SpecialtyList PegaHCPegaHC-Data-Party-Provider Type Type PegaHCPegaHC-Data-Party-Provider PrimarySpeciality PrimarySpeciality PegaHCPegaHC-Data-Party-Provider SecondaryIDQualifier SecondaryIDQualifier PegaHCPegaHC-Data-Party-Provider AcceptingNewPatients AcceptingNewPatients PegaHCPegaHC-Data-Party-Provider Language Language PegaHC

PegaHC-Data-Party-Provider-Practitioner IsEligibleForPCP IsPCP PegaHC

PegaHC-Data-Party-Provider-Practitioner IsPCP IsPCP PegaHC

PegaHC-Data-Party-Provider-Practitioner Gender Gender PegaHC

PegaHC-Data-Party-Provider-Practitioner TerminationReason TerminationReason PegaHC

PegaHC-Data-Party-Provider-Practitioner Title Title PegaHC

PegaHC-Data-Party-Provider-Practitioner HospitalAdmittingPrivileges HospitalAdmittingPrivileges PegaHC

PegaHC-Data-Party-Provider-Practitioner PractitionerSuffix PractitionerSuffix PegaHC

PegaHC-Data-Party-Provider-ServicingOrg ParentNPI ParentNPI PegaHC

PegaHC-Data-Party-Provider-ServicingOrg TerminationReason TerminationReason PegaHC

PegaHC-Data-Party-Provider-ServicingOrg IsSubpart IsSubpart PegaHC

PegaHC-Data-Party-Provider-ServicingOrg ProviderAliases ProviderAliases PegaHCPegaHC-Data-Payment ExchangeRate ExchangeRate PegaHC

PegaHC-Data-Payment PaidFromPartAMedicareTrustFundAmount PaidFromPartAMedicareTrustFundAmount PegaHC

PegaHC-Data-Payment PaidFromPartBMedicareTrustFundAmount PaidFromPartBMedicareTrustFundAmount PegaHCPegaHC-Data-Payment PaymentActionCode PaymentActionCode PegaHCPegaHC-Data-Payment PaymentMandateCategory4Amount PaymentMandateCategory4Amount PegaHCPegaHC-Data-Payment PPSCapitalFSPDRGAmount PPSCapitalFSPDRGAmount PegaHCPegaHC-Data-Payment PPSCapitalHSPDRGAmount PPSCapitalHSPDRGAmount PegaHCPegaHC-Data-Payment AssignedNumber AssignedNumber PegaHCPegaHC-Data-Payment ClaimIndirectTeachingAmount ClaimIndirectTeachingAmount PegaHCPegaHC-Data-Payment ClaimMSPPassThroughAmount ClaimMSPPassThroughAmount PegaHCPegaHC-Data-Payment ClaimPPSCapitalAmount ClaimPPSCapitalAmount PegaHCPegaHC-Data-Payment DFIIdentificationNumberQualifier DFIIdentificationNumberQualifier PegaHCPegaHC-Data-Payment LineItemProviderPaymentAmount LineItemProviderPaymentAmount PegaHCPegaHC-Data-Payment NonPayableProfComponentBillAmount NonPayableProfComponentBillAmount PegaHCPegaHC-Data-Payment PayerPaidAmount PayerPaidAmount PegaHCPegaHC-Data-Payment PaymentFormatCode PaymentFormatCode PegaHCPegaHC-Data-Payment PaymentMandateCategory2Amount PaymentMandateCategory2Amount PegaHCPegaHC-Data-Payment PPSCapitalDSHDRGAmount PPSCapitalDSHDRGAmount PegaHCPegaHC-Data-Payment TaxAmount TaxAmount PegaHCPegaHC-Data-Payment PostageClaimedAmount PostageClaimedAmount PegaHCPegaHC-Data-Payment RepricingPerDiemOrFlatRateAmount RepricingPerDiemOrFlatRateAmount PegaHCPegaHC-Data-Payment SalesTaxAmount SalesTaxAmount PegaHCPegaHC-Data-Payment SenderBankAccountNumber SenderBankAccountNumber PegaHCPegaHC-Data-Payment TotalClaimBeforeTaxesAmount TotalClaimBeforeTaxesAmount PegaHCPegaHC-Data-Payment TransactionHandlingCode TransactionHandlingCode PegaHCPegaHC-Data-Payment MedicarePaidat80Amount MedicarePaidat80Amount PegaHCPegaHC-Data-Payment PaymentMandateCategory5Amount PaymentMandateCategory5Amount PegaHCPegaHC-Data-Payment PerDayLimitAmount PerDayLimitAmount PegaHCPegaHC-Data-Payment PPSCapitalExceptionAmount PPSCapitalExceptionAmount PegaHCPegaHC-Data-Payment RepricedAllowedAmount RepricedAllowedAmount PegaHCPegaHC-Data-Payment ServiceLinePaidAmount ServiceLinePaidAmount PegaHCPegaHC-Data-Payment TotalActualProviderPaymentAmount TotalActualProviderPaymentAmount PegaHCPegaHC-Data-Payment TotalBloodDeductibleAmount TotalBloodDeductibleAmount PegaHCPegaHC-Data-Payment AdjudicationOrPaymentDate AdjudicationOrPaymentDate PegaHCPegaHC-Data-Payment ClaimAdjustmentIndicator ClaimAdjustmentIndicator PegaHCPegaHC-Data-Payment AdjustmentAmount AdjustmentAmount PegaHCPegaHC-Data-Payment CoveredAmount CoveredAmount PegaHCPegaHC-Data-Payment AdjustmentReasonCode AdjustmentReasonCode PegaHCPegaHC-Data-Payment CheckIssueOrEFTDate CheckIssueOrEFTDate PegaHC

PegaHC-Data-Payment ESRDPaymentAmount ESRDPaymentAmount PegaHCPegaHC-Data-Payment InterestAmount InterestAmount PegaHCPegaHC-Data-Payment MedicarePaidat100Amount MedicarePaidat100Amount PegaHCPegaHC-Data-Payment NonpayableProfComponentAmount NonpayableProfComponentAmount PegaHCPegaHC-Data-Payment OldCapitalAmount OldCapitalAmount PegaHCPegaHC-Data-Payment PaymentMandateCategory3Amount PaymentMandateCategory3Amount PegaHCPegaHC-Data-Payment TotalPurchasedServiceAmount TotalPurchasedServiceAmount PegaHCPegaHC-Data-Payment ClaimPaymentRemarkCode ClaimPaymentRemarkCode PegaHCPegaHC-Data-Payment ClaimDRGOutlierAmount ClaimDRGOutlierAmount PegaHCPegaHC-Data-Payment ClaimHCPCSPayableAmount ClaimHCPCSPayableAmount PegaHCPegaHC-Data-Payment ClaimPaymentAmount ClaimPaymentAmount PegaHCPegaHC-Data-Payment COBTotalChargeAmount COBTotalChargeAmount PegaHCPegaHC-Data-Payment CoverageAmount CoverageAmount PegaHCPegaHC-Data-Payment CurrencyCode CurrencyCode PegaHCPegaHC-Data-Payment LineItemChargeAmount LineItemChargeAmount PegaHC

PegaHC-Data-Payment LineItemDeniedNonCoveredChargeAmount LineItemDeniedNonCoveredChargeAmount PegaHCPegaHC-Data-Payment PatientResponsibilityAmount PatientResponsibilityAmount PegaHCPegaHC-Data-Payment RepricedSavingAmount RepricedSavingAmount PegaHCPegaHC-Data-Payment ClaimDisproportionateShareAmount ClaimDisproportionateShareAmount PegaHCPegaHC-Data-Payment ClaimESRDPaymentAmount ClaimESRDPaymentAmount PegaHCPegaHC-Data-Payment CreditOrDebitFlagCode CreditorDebitFlagCode PegaHCPegaHC-Data-Payment DiscountAmount DiscountAmount PegaHCPegaHC-Data-Payment HCPCSPayableAmount HCPCSPayableAmount PegaHCPegaHC-Data-Payment NonCoveredChargeAmount NonCoveredChargeAmount PegaHCPegaHC-Data-Payment PaymentMandateCategory1Amount PaymentMandateCategory1Amount PegaHCPegaHC-Data-Payment PPSOperatingOutlierAmount PPSOperatingOutlierAmount PegaHCPegaHC-Data-Payment PurchasedServiceChargeAmount PurchasedServiceChargeAmount PegaHCPegaHC-Data-Payment RepricedApprovedAmount RepricedApprovedAmount PegaHCPegaHC-Data-Payment AllowedAmount Allowed Amount PegaHCPegaHC-Data-Payment CheckOrEFTTraceNumber CheckOrEFTTraceNumber PegaHCPegaHC-Data-Payment ClaimDRGAmount ClaimDRGAmount PegaHCPegaHC-Data-Payment ContractAmount ContractAmount PegaHCPegaHC-Data-Payment EstimatedClaimDueAmount EstimatedClaimDueAmount PegaHCPegaHC-Data-Payment NegativeLedgerBalanceAmount NegativeLedgerBalanceAmount PegaHCPegaHC-Data-Payment PatientPaidAmount PatientPaidAmount PegaHCPegaHC-Data-Payment PaymentMethodCode PaymentMethodCode PegaHCPegaHC-Data-Payment PPSCapitalIMEAmount PPSCapitalIMEAmount PegaHC

PegaHC-Data-Payment PPSOperatingHospitalSpecificDRGAmount PPSOperatingHospitalSpecificDRGAmount PegaHC

PegaHC-Data-Payment TotalClaimChargeAmount TotalClaimChargeAmount PegaHC

PegaHC-Data-Payment PPSOperatingFederalSpecificDRGAmount PPSOperatingFederalSpecificDRGAmount PegaHCPegaHC-Data-Payment RepricedApprovedAPGAmount RepricedApprovedAPGAmount PegaHCPegaHC-Data-Payment TotalCapitalAmount TotalCapitalAmount PegaHCPegaHC-Data-Payment ReimbursementRate ReimbursementRate PegaHCPegaHC-Data-Payment Adjustments Adjustments PegaHCPegaHC-Data-Payment AccountNumberQualifier AccountNumberQualifier PegaHCPegaHC-Data-Payment ClaimPPSCapitalOutlierAmount ClaimPPSCapitalOutlierAmount PegaHCPegaHC-Data-Payment DiagnosisCodePointer Diagnosis Code Pointer PegaHCPegaHC-Data-Payment AdjustmentQuantitiy AdjustmentQuantitiy PegaHCPegaHC-Data-Payment ApprovedAmount ApprovedAmount PegaHCPegaHC-Data-Payment ClaimTotalDeniedChargeAmount ClaimTotalDeniedChargeAmount PegaHCPegaHC-Data-Payment-Claim Payee Payee PegaHCPegaHC-Data-Payment-Claim ProviderAdjustmentAmount ProviderAdjustmentAmount PegaHCPegaHC-Data-Payment-Claim TotalDeductibleAmount TotalDeductibleAmount PegaHCPegaHC-Data-Payment-Claim TotalFederalSpecificAmount TotalFederalSpecificAmount PegaHCPegaHC-Data-Payment-Claim TotalNoncoveredDayCount TotalNoncoveredDayCount PegaHCPegaHC-Data-Payment-Claim Payer Payer PegaHCPegaHC-Data-Payment-Claim TotalCoinsuranceAmount TotalCoinsuranceAmount PegaHCPegaHC-Data-Payment-Claim TotalCostOutlierAmount TotalCostOutlierAmount PegaHCPegaHC-Data-Payment-Claim TotalDRGAmount TotalDRGAmount PegaHCPegaHC-Data-Payment-Claim TotalInterestAmount TotalInterestAmount PegaHCPegaHC-Data-Payment-Claim TotalNoncoveredChargeAmount TotalNoncoveredChargeAmount PegaHCPegaHC-Data-Payment-Claim TotalPIPClaimCount TotalPIPClaimCount PegaHCPegaHC-Data-Payment-Claim TotalProviderPaymentAmount TotalProviderPaymentAmount PegaHCPegaHC-Data-Payment-Claim UnitsOfServicePaidCount UnitsOfServicePaidCount PegaHCPegaHC-Data-Payment-Claim CorrPriorityPayerIdentifier CorrPriorityPayerIdentifier PegaHCPegaHC-Data-Payment-Claim DRGWeight DRGWeight PegaHCPegaHC-Data-Payment-Claim LifetimePsychiatricDaysCount Lifetime Psychiatric Days Count PegaHCPegaHC-Data-Payment-Claim ProviderAdjustmentIdentifier ProviderAdjustmentIdentifier PegaHCPegaHC-Data-Payment-Claim ServiceSupplementalQuantityCount ServiceSupplementalQuantityCount PegaHCPegaHC-Data-Payment-Claim TotalCostReportDayCount TotalCostReportDayCount PegaHCPegaHC-Data-Payment-Claim TotalCoveredDayCount TotalCoveredDayCount PegaHCPegaHC-Data-Payment-Claim TotalDayOutlierAmount TotalDayOutlierAmount PegaHCPegaHC-Data-Payment-Claim TotalMSPPayerAmount TotalMSPPayerAmount PegaHCPegaHC-Data-Payment-Claim TotalPPSCapitalFSPDRGAmount TotalPPSCapitalFSPDRGAmount PegaHCPegaHC-Data-Payment-Claim ProductionDate ProductionDate PegaHCPegaHC-Data-Payment-Claim Receiver Receiver PegaHCPegaHC-Data-Payment-Claim TotalCoveredChargeAmount TotalCoveredChargeAmount PegaHC

PegaHC-Data-Payment-Claim TotalDeniedChargeAmount TotalDeniedChargeAmount PegaHCPegaHC-Data-Payment-Claim TotalDisproportionateShareAmount TotalDisproportionateShareAmount PegaHCPegaHC-Data-Payment-Claim TotalGrammRudmanReductionAmount TotalGrammRudmanReductionAmount PegaHCPegaHC-Data-Payment-Claim TotalHCPCPPayableAmount TotalHCPCPPayableAmount PegaHCPegaHC-Data-Payment-Claim TotalMSPPassThroughAmount TotalMSPPassThroughAmount PegaHCPegaHC-Data-Payment-Claim TotalNonLabChargeAmount TotalNonLabChargeAmount PegaHCPegaHC-Data-Payment-Claim AverageDRGWeight AverageDRGWeight PegaHCPegaHC-Data-Payment-Claim CostReportDayCount Cost Report Day Count PegaHCPegaHC-Data-Payment-Claim ClaimContactCommNumber ClaimContactCommNumber PegaHCPegaHC-Data-Payment-Claim ClaimContactName ClaimContactName PegaHCPegaHC-Data-Payment-Claim FiscalPeriodDate FiscalPeriodDate PegaHCPegaHC-Data-Payment-Claim ClaimDate ClaimDate PegaHCPegaHC-Data-Payment-Claim OriginatingCompanySupplementalCode OriginatingCompanySupplementalCode PegaHCPegaHC-Data-Payment-Claim AverageDRGLengthOfStay AverageDRGLengthOfStay PegaHCPegaHC-Data-Payment-Claim Claim Claim PegaHCPegaHC-Data-Payment-Claim ClaimStatusCode Claim Status Code PegaHCPegaHC-Data-Payment-Claim SenderDFIIdentifier SenderDFIIdentifier PegaHCPegaHC-Data-Payment-Claim TotalHospitalSpecificAmount TotalHospitalSpecificAmount PegaHCPegaHC-Data-Payment-Claim TotalPatientReimbursementAmount TotalPatientReimbursementAmount PegaHCPegaHC-Data-Payment-Claim TotalProfessionalComponentAmount TotalProfessionalComponentAmount PegaHCPegaHC-Data-Payment-Claim OtherClaimRelatedIdentifier OtherClaimRelatedIdentifier PegaHCPegaHC-Data-Payment-Claim TotalHCPCSReportedChargeAmount TotalHCPCSReportedChargeAmount PegaHCPegaHC-Data-Payment-Claim TotalIndirectMedicalEducationAmount TotalIndirectMedicalEducationAmount PegaHCPegaHC-Data-Payment-Claim TotalPPSCapitalHSPDRGAmount TotalPPSCapitalHSPDRGAmount PegaHCPegaHC-Data-Payment-Claim TotalPPSDSHDRGAmount TotalPPSDSHDRGAmount PegaHCPegaHC-Data-Payment-Claim CorrPriorityPayerName CorrPriorityPayerName PegaHCPegaHC-Data-Payment-Claim DischargeFraction DischargeFraction PegaHCPegaHC-Data-Payment-Claim ReimbursementRate Reimbursement Rate PegaHCPegaHC-Data-Payment-Claim TotalContractualAdjustmentAmount TotalContractualAdjustmentAmount PegaHCPegaHC-Data-Payment-Claim TotalDischargeCount TotalDischargeCount PegaHCPegaHC-Data-Payment-Claim TotalMedicarePaidAmount TotalMedicarePaidAmount PegaHCPegaHC-Data-Payment-Claim TotalMSPPatientLiabilityMetAmount TotalMSPPatientLiabilityMetAmount PegaHCPegaHC-Data-Payment-Claim TotalOutlierDayCount TotalOutlierDayCount PegaHCPegaHC-Data-Payment-Claim TotalPIPAdjustmentAmount TotalPIPAdjustmentAmount PegaHCPegaHC-Data-Payment-Claim VersionIdentificationCode VersionIdentificationCode PegaHCPegaHC-Data-Payment-Claim ServiceSupplementalAmount ServiceSupplementalAmount PegaHCPegaHC-Data-Payment-Claim TotalClaimCount TotalClaimCount PegaHCPegaHC-Data-Payment-Premium InsuranceRemittanceReferenceNumber InsuranceRemittanceReferenceNumber PegaHCPegaHC-Data-Payment-Premium Receiver Receiver PegaHCPegaHC-Data-Payment-Premium OriginatingDFIIdentiffier OriginatingDFIIdentiffier PegaHC

PegaHC-Data-Payment-Premium PremiumPayer PremiumPayer PegaHCPegaHC-Data-Payment-Premium ContractNumber ContractNumber PegaHCPegaHC-Data-Payment-Premium DetailPremiumPaymentAmount DetailPremiumPaymentAmount PegaHCPegaHC-Data-Payment-Premium LineItemControlNumber LineItemControlNumber PegaHCPegaHC-Data-Payment-Premium TotalPremiumPaymentAmount TotalPremiumPaymentAmount PegaHCPegaHC-Data-Payment-Premium CoveragePeriod CoveragePeriod PegaHCPegaHC-Data-Payment-Premium DeliveryDate DeliveryDate PegaHCPegaHC-Data-Payment-Premium HeadCount HeadCount PegaHCPegaHC-Data-Payment-Premium OrganizationIdentificationCode OrganizationIdentificationCode PegaHCPegaHC-Data-Payment-Premium OriginatingCompanySupplementalCode OriginatingCompanySupplementalCode PegaHCPegaHC-Data-Payment-Premium ReceiverReferenceIdentifier ReceiverReferenceIdentifier PegaHCPegaHC-Data-Payment-Premium BilledPremiumAmount BilledPremiumAmount PegaHCPegaHC-Data-Payment-Premium ConInvAccGrpPolNumber ConInvAccGrpPolNumber PegaHCPegaHC-Data-Payment-Premium InformationOnlyIndicator InformationOnlyIndicator PegaHCPegaHC-Data-Payment-Premium PayerProcessDate PayerProcessDate PegaHCPegaHC-Data-Payment-Premium PremiumAmount PremiumAmount PegaHCPegaHC-Data-Payment-Premium OriginatingCompanyIdentifier OriginatingCompanyIdentifier PegaHCPegaHC-Data-PCPSpecialities InstanceKey InstanceKey PegaHCPegaHC-Data-PCPSpecialities Select Select PegaHCPegaHC-Data-PCPSpecialities Specialities Specialities PegaHCPegaHC-Data-PCPSpecialities DeselectAll Deselect All PegaHCPegaHC-Data-PCPSpecialities Classification Classification PegaHCPegaHC-Data-PCPSpecialities Type Type PegaHCPegaHC-Data-Policy ActionCodeIDC Action Code IDC segment PegaHCPegaHC-Data-Policy CopaymentAmount CopaymentAmount PegaHCPegaHC-Data-Policy BenefitStatusCode BenefitStatusCode PegaHCPegaHC-Data-Policy PolicyStatus PolicyStatus PegaHCPegaHC-Data-Policy PriorCoverageMonthCount Prior Coverage Month Count PegaHCPegaHC-Data-Policy SubscriberNumber SubscriberNumber PegaHCPegaHC-Data-Policy Benefit Benefit PegaHCPegaHC-Data-Policy TermDate TermDate PegaHCPegaHC-Data-Policy Insured Insured PegaHCPegaHC-Data-Policy ElectedAmount ElectedAmount PegaHCPegaHC-Data-Policy BenefitRelatedEntity BenefitRelatedEntity PegaHCPegaHC-Data-Policy RemainingAmount RemainingAmount PegaHCPegaHC-Data-Policy PlanCoverageDescription PlanCoverageDescription PegaHCPegaHC-Data-Policy MaintenanceReasonCode Maintenance Reason Code PegaHCPegaHC-Data-Policy EndDate EndDate PegaHCPegaHC-Data-Policy CoveragePeriod CoveragePeriod PegaHCPegaHC-Data-Policy Subscriber Subscriber PegaHC

PegaHC-Data-Policy PolicyList Policy List PegaHCPegaHC-Data-Policy AuthorizationOrCertificationIndicator AuthorizationOrCertificationIndicator PegaHCPegaHC-Data-Policy DeductibleAmount DeductibleAmount PegaHCPegaHC-Data-Policy FlexSpendingInd Flex Spending Indicator PegaHCPegaHC-Data-Policy InsuranceTypeCode InsuranceTypeCode PegaHCPegaHC-Data-Policy InsurerIdentificationCode InsurerIdentificationCode PegaHCPegaHC-Data-Policy MemberNumber MemberNumber PegaHCPegaHC-Data-Policy PlanSponsor PlanSponsor PegaHCPegaHC-Data-Policy SponsorIdentifier SponsorIdentifier PegaHCPegaHC-Data-Policy Dependent Dependent PegaHCPegaHC-Data-Policy EligibilityOrBenefitDateTimePeriod EligibilityOrBenefitDateTimePeriod PegaHCPegaHC-Data-Policy MaintenanceTypeCode Maintenance Type Code PegaHCPegaHC-Data-Policy PlanNumber PlanNumber PegaHCPegaHC-Data-Policy Plans Plans PegaHCPegaHC-Data-Policy SpendDownAmount SpendDownAmount PegaHCPegaHC-Data-Policy EffectiveDate EffectiveDate PegaHCPegaHC-Data-Policy GroupNumber GroupNumber PegaHCPegaHC-Data-Policy InsuranceLineCode InsuranceLineCode PegaHCPegaHC-Data-Policy MasterPolicyNumber MasterPolicyNumber PegaHCPegaHC-Data-Policy PlanName PlanName PegaHCPegaHC-Data-Policy PolicyNumber PolicyNumber PegaHCPegaHC-Data-Policy UsedAmount UsedAmount PegaHCPegaHC-Data-Policy CoinsuranceAmount CoinsuranceAmount PegaHCPegaHC-Data-Policy InsurerName InsurerName PegaHCPegaHC-Data-Policy MedicarePlanCode MedicarePlanCode PegaHCPegaHC-Data-Policy Members Members PegaHCPegaHC-Data-Policy PolicyRole PolicyRole PegaHCPegaHC-Data-Policy BenefitCoverageLevelCode BenefitCoverageLevelCode PegaHCPegaHC-Data-Policy GroupName GroupName PegaHCPegaHC-Data-Policy LastPaidDate LastPaidDate PegaHCPegaHC-Data-Population PopulationName Population PegaHCPegaHC-Data-Population DateOfBirth DateOfBirth PegaHCPegaHC-Data-Population Certainty Certainty PegaHCPegaHC-Data-Population MemberFirstName First Name PegaHCPegaHC-Data-Population Campaign Campaign PegaHCPegaHC-Data-Population MemberID Member ID PegaHCPegaHC-Data-Population Status Status PegaHCPegaHC-Data-Population MemberLastName Last Name PegaHCPegaHC-Data-Population EffectiveDate EffectiveDate PegaHCPegaHC-Data-Population TermDate TermDate PegaHC

PegaHC-Data-Population StatusReason StatusReason PegaHCPegaHC-Data-Population GenderCode GenderCode PegaHCPegaHC-Data-Prescription LISTING_SEQ_NO LISTING_SEQ_NO PegaHCPegaHC-Data-Prescription Active Active PegaHCPegaHC-Data-Procedure ProcedureCode ProcedureCode PegaHCPegaHC-Data-Procedure ProcedureDescription ProcedureDescription PegaHCPegaHC-Data-Product Benefit ===DEPRECATED=== PegaHCPegaHC-Data-Product ValueStatement ValueStatement PegaHCPegaHC-Data-Product ClaimCostPMPM ClaimCostPMPM PegaHCPegaHC-Data-Product FamilyOOPMaxMultiplierOON FamilyOOPMaxMultiplier PegaHCPegaHC-Data-Product MedicarePlanCode Medicare Plan Code PegaHCPegaHC-Data-Product RateEffectiveDate RateEffectiveDate PegaHCPegaHC-Data-Product ProductList ProductList PegaHCPegaHC-Data-Product ProductNumber PlanNumber PegaHCPegaHC-Data-Product RateTermDate RateTermDate PegaHCPegaHC-Data-Product ShortDescription ShortDescription PegaHCPegaHC-Data-Product DependentEligibilityAgeMax DependentEligibilityAgeMax PegaHCPegaHC-Data-Product NetworkRestriction Network Restriction PegaHCPegaHC-Data-Product PlanNumber PlanNumber PegaHCPegaHC-Data-Product CoInsurance CoInsurance PegaHCPegaHC-Data-Product FamilyDeductible FamilyDeductible PegaHCPegaHC-Data-Product FamilyDeductibleMultiplier FamilyDeductibleMultiplier PegaHCPegaHC-Data-Product InsuranceLineCode Insurance Line Code PegaHCPegaHC-Data-Product InsuranceTypeCode InsuranceTypeCode PegaHCPegaHC-Data-Product BenefitGroup BenefitGroup PegaHCPegaHC-Data-Product CoInsuranceOON CoInsurance PegaHCPegaHC-Data-Product MaximumGroupSize MaximumGroupSize PegaHCPegaHC-Data-Product OfficeVisitCopay OfficeVisitCopay PegaHCPegaHC-Data-Product ProductName ProductName PegaHCPegaHC-Data-Product Availability Availability PegaHCPegaHC-Data-Product CertificationConditionIndicator Certification Condition Indicator PegaHCPegaHC-Data-Product EffectiveDate Effective Date PegaHCPegaHC-Data-Product FamilyOOPMax FamilyOOPMax PegaHCPegaHC-Data-Product FamilyOOPMaxMultiplier FamilyOOPMaxMultiplier PegaHCPegaHC-Data-Product FamilyOOPMaxOON FamilyOOPMax PegaHCPegaHC-Data-Product GroupSizeHigh GroupSizeHigh PegaHCPegaHC-Data-Product PCPRequired PCP Required PegaHCPegaHC-Data-Product ProductCategory Product Category PegaHCPegaHC-Data-Product StudentEligibilityAgeMax StudentEligibilityAgeMax PegaHCPegaHC-Data-Product FamilyDeductibleOON FamilyDeductible PegaHC

PegaHC-Data-Product IndividualDeductibleOON IndividualDeductible PegaHCPegaHC-Data-Product IndividualOOPMaxOON IndividualOOPMax PegaHCPegaHC-Data-Product LifeTimeMaxOON LifeTimeMax PegaHCPegaHC-Data-Product IndividualOOPMax IndividualOOPMax PegaHCPegaHC-Data-Product LifeTimeMax LifeTimeMax PegaHCPegaHC-Data-Product MemberOOP Member OOP PegaHCPegaHC-Data-Product PlanName Plan Name PegaHCPegaHC-Data-Product Category Category PegaHCPegaHC-Data-Product EndDate End Date PegaHCPegaHC-Data-Product FamilyDeductibleMultiplierOON FamilyDeductibleMultiplier PegaHCPegaHC-Data-Product IndividualDeductible IndividualDeductible PegaHCPegaHC-Data-Product OfficeVisitCopayOON OfficeVisitCopay PegaHCPegaHC-Data-Product OutOfNetworkIndicator OutOfNetworkIndicator PegaHCPegaHC-Data-Product PlanCoverageDescription Plan Coverage Description PegaHCPegaHC-Data-ProductGroup InsuranceTypeCode InsuranceTypeCode PegaHCPegaHC-Data-ProductGroup ProductGroupID ProductGroupID PegaHCPegaHC-Data-ProductGroup AsofDate AsofDate PegaHCPegaHC-Data-ProductGroup GroupCategory GroupCategory PegaHCPegaHC-Data-ProductGroup CoveredProducts CoveredProducts PegaHCPegaHC-Data-ProductGroup Name Name PegaHCPegaHC-Data-ProductGroup Description Description PegaHCPegaHC-Data-ProductGroup Category Category PegaHCPegaHC-Data-ProviderAffiliation AgeRestriction AgeRestriction PegaHCPegaHC-Data-ProviderAffiliation EffectiveDate EffectiveDate PegaHCPegaHC-Data-ProviderAffiliation PrimaryAdmittingHospital PrimaryAdmittingHospital PegaHCPegaHC-Data-ProviderAffiliation EndDate EndDate PegaHCPegaHC-Data-ProviderAffiliation BusinessEntityEndDate BEEndDate PegaHCPegaHC-Data-ProviderAffiliation BEContract BEContract PegaHCPegaHC-Data-ProviderAffiliation TypeofProvider TypeofProvider-Provider/Practitioner PegaHCPegaHC-Data-ProviderAffiliation MarketInDirectory MarketInDirectory PegaHCPegaHC-Data-ProviderAffiliation IsPrimaryCare IsPrimaryCare PegaHCPegaHC-Data-ProviderAffiliation ContractEffectiveDate ContractEffectiveDate PegaHCPegaHC-Data-ProviderAffiliation ClaimFilingLimitOverride ClaimFilingLimitOverride PegaHCPegaHC-Data-ProviderAffiliation ProviderEndDate ProviderEndDate PegaHCPegaHC-Data-ProviderAffiliation ProviderEffectiveDate ProviderEffectiveDate PegaHCPegaHC-Data-ProviderAffiliation PrimaryHospEndDate PrimaryHospEndDate PegaHCPegaHC-Data-ProviderAffiliation PrimaryHospEffectiveDate PrimaryHospEffectiveDate PegaHCPegaHC-Data-ProviderAffiliation ProviderID ProviderID PegaHCPegaHC-Data-ProviderAffiliation BusinessEntityEffectiveDate BusinessEntityEffectiveDate PegaHCPegaHC-Data-ProviderAffiliation SecondarySpecialities Secondary Specialities PegaHC

PegaHC-Data-ProviderAffiliation TaxIdentificationNumber TaxIdentificationNumber PegaHCPegaHC-Data-ProviderAffiliation ProviderName ProviderName PegaHCPegaHC-Data-ProviderAffiliation NationalProviderIdentifier NaionalProviderIdentifier PegaHCPegaHC-Data-ProviderAffiliation AffiliationAddresses AffiliationAddresses PegaHCPegaHC-Data-ProviderAffiliation SecondaryHospitalAdmittingPrevilege SecondaryHospitalAdmittingPrevilege PegaHCPegaHC-Data-ProviderAffiliation PrimarySpecialtyEndDate PrimarySpecialtyEndDate PegaHCPegaHC-Data-ProviderAffiliation PrimarySpecialityCode PrimarySpecialityCode PegaHCPegaHC-Data-ProviderAffiliation Locations AffiliationAddresses PegaHCPegaHC-Data-ProviderAffiliation ContractName Contract Name PegaHCPegaHC-Data-ProviderAffiliation BusinessEntityID BusinessEntityID PegaHCPegaHC-Data-ProviderAffiliation Versions Versions PegaHCPegaHC-Data-ProviderAffiliation hasErrors hasErrors PegaHCPegaHC-Data-ProviderAffiliation PractitionerCapacity PractitionerCapacity PegaHCPegaHC-Data-ProviderAffiliation AcceptingNewPatients AcceptingNewPatients PegaHCPegaHC-Data-ProviderAffiliation IsSpecialist IsSpecialist PegaHCPegaHC-Data-ProviderAffiliation PrimarySpeciality PrimarySpeciality PegaHCPegaHC-Data-ProviderAffiliation PrimarySpecialtyEffectiveDate PrimarySpecialtyEffectiveDate PegaHCPegaHC-Data-ProviderAffiliation ProviderProfessionType ProviderProfessionType PegaHCPegaHC-Data-ProviderContract ReferralCircles ReferralCircles PegaHCPegaHC-Data-ProviderContract CoveredProducts CoveredProducts PegaHCPegaHC-Data-ProviderContract FirstReferralCircle FirstReferralCircle PegaHCPegaHC-Data-ProviderContract SearchProductPrdCategory SearchProductPrdCategory PegaHCPegaHC-Data-ProviderContract CoveredProductGroups CoveredProducts PegaHCPegaHC-Data-ProviderContract ContractName ContractName PegaHCPegaHC-Data-ProviderContract ContractType ContractType PegaHCPegaHC-Data-ProviderContract TerminationReason TerminationReason PegaHCPegaHC-Data-ProviderContract IsCreateFlow IsCreateFlow PegaHCPegaHC-Data-ProviderContract SearchProductNumber SearchProductNumber PegaHCPegaHC-Data-ProviderContract EffectiveDate EffectiveDate PegaHCPegaHC-Data-ProviderContract ContractStates ContractStates PegaHCPegaHC-Data-ProviderContract AsofDate EndDate PegaHCPegaHC-Data-ProviderContract ContractID Party ID PegaHCPegaHC-Data-ProviderContract SearchProductCategory SearchProductCategory PegaHCPegaHC-Data-ProviderContract SearchProductType InsuranceTypeCode PegaHCPegaHC-Data-ProviderContract EndDate EndDate PegaHCPegaHC-Data-ProviderContract ContractVersion ContractVersion PegaHCPegaHC-Data-ProviderContract ContactInfo ContactInfo PegaHCPegaHC-Data-ProviderSearch Hospital Hospital PegaHCPegaHC-Data-ProviderSearch ProviderAffiliation ProviderAffiliation PegaHCPegaHC-Data-ProviderSearch BusinessEntity BusinessEntity PegaHC

PegaHC-Data-ProviderSearch Language Language PegaHCPegaHC-Data-ProviderSearch ProviderSearchResults ProviderSearchResults PegaHCPegaHC-Data-ProviderSearch ProviderRole ProviderRole PegaHCPegaHC-Data-ProviderSearch Speciality Specialization PegaHCPegaHC-Data-ProviderSearch Contract Contract PegaHCPegaHC-Data-ReferralCircle EndDate EndDate PegaHCPegaHC-Data-ReferralCircle ReferralCircleType ReferralCircleType PegaHCPegaHC-Data-ReferralCircle EffectiveDate EffectiveDate PegaHCPegaHC-Data-ReferralCircle ReferralCircleName ReferralCircleName PegaHCPegaHC-Data-ReferralCircle ReferralCircleID ReferralCircleID PegaHCPegaHC-Data-ReferralCircle Status Status PegaHCPegaHC-Data-ReferralCircle TerminationReason TerminationReason PegaHCPegaHC-Data-ReferralCircle Versions Versions PegaHCPegaHC-Data-RemarkCodes Code ID PegaHCPegaHC-Data-RemarkCodes Description Description PegaHCPegaHC-Data-Risk DateAssessed DateAssessed PegaHCPegaHC-Data-Risk Condition DiseaseName PegaHCPegaHC-Data-Risk DiseaseName DiseaseName PegaHCPegaHC-Data-Risk RiskLevel RiskLevel PegaHCPegaHC-Data-Risk LISTING_SEQ_NO ID PegaHCPegaHC-Data-Service FileInformation FileInformation PegaHC

PegaHC-Data-Service UnitOrBasisForMeasurementCodeForService UnitOrBasisForMeasurementCodeForService PegaHCPegaHC-Data-Service AuthorizationDecision AuthorizationDecision PegaHCPegaHC-Data-Service BenefitBeginDate BenefitBeginDate PegaHCPegaHC-Data-Service BenefitEndDate BenefitEndDate PegaHCPegaHC-Data-Service ConditionCodePatient Condition Code - Patient PegaHCPegaHC-Data-Service CoveragePeriod CoveragePeriod PegaHCPegaHC-Data-Service DaysofSupply DaysofSupply PegaHCPegaHC-Data-Service ProcedureCodeDescription Procedure Code Description PegaHCPegaHC-Data-Service ServiceIdentificationCode Service Identification Code PegaHCPegaHC-Data-Service UnitorBasisforMeasurementCode Unit or Basis for Measurement Code PegaHCPegaHC-Data-Service AmbulancePickup AmbulancePickup PegaHCPegaHC-Data-Service EPSDTIndicator EPSDTIndicator PegaHCPegaHC-Data-Service AdmissionDiagnosis AdmissionDiagnosis PegaHCPegaHC-Data-Service AdmissionSourceCode Admission Source Code PegaHC

PegaHC-Data-Service CLIANumber

Clinical Laboratory Improvement

Amendment Number PegaHCPegaHC-Data-Service DailyOxygenUseCount Daily Oxygen Use Count PegaHCPegaHC-Data-Service EligibilityDate Eligibility Date PegaHC

PegaHC-Data-Service EligibilityOrBenefitInformation EligibilityOrBenefitInformation PegaHCPegaHC-Data-Service OriginalUnitsofServiceCount Original Units of Service Count PegaHCPegaHC-Data-Service OxygenFlowRate Oxygen Flow Rate PegaHCPegaHC-Data-Service OxygenTestFindingsCode Oxygen Test Findings Code PegaHCPegaHC-Data-Service PrescriptionNumber PrescriptionNumber PegaHCPegaHC-Data-Service PrincipalDiagnosisDate PrincipalDiagnosisDate PegaHCPegaHC-Data-Service ProcedureCode Procedure Code PegaHCPegaHC-Data-Service ProcedureQuantity Procedure Quantity PegaHCPegaHC-Data-Service ProductCode ProductCode PegaHCPegaHC-Data-Service QuantityDispensed QuantityDispensed PegaHCPegaHC-Data-Service QuantityQualifier Quantity Qualifier PegaHCPegaHC-Data-Service ServiceFromDate Service From Date PegaHCPegaHC-Data-Service ShipDeliveryorCalendarPatternCode Ship Delivery or Calendar Pattern Code PegaHCPegaHC-Data-Service AmbulanceDropOffStateCode Ambulance Drop Off State Code PegaHCPegaHC-Data-Service AmbulancePickUpCity Ambulance Pick Up City PegaHCPegaHC-Data-Service AmbulanceTransportCode Ambulance Transport Code PegaHCPegaHC-Data-Service AmbulanceTripOriginAddress Ambulance Trip Origin Address PegaHCPegaHC-Data-Service ConditionCode Condition Code PegaHCPegaHC-Data-Service CurrentHealthConditionCode Current Health Condition Code PegaHCPegaHC-Data-Service Diagnosis Diagnosis PegaHCPegaHC-Data-Service DiagnosisCodePointer Diagnosis Code Pointer PegaHCPegaHC-Data-Service InsuranceTypeCode InsuranceTypeCode PegaHCPegaHC-Data-Service LastAdmissionPeriod Last Admission Period PegaHCPegaHC-Data-Service PrescriptionDate Prescription Date PegaHCPegaHC-Data-Service NumberofVisits Number of Visits PegaHCPegaHC-Data-Service ProposedAdmissionDate Proposed Admission Date PegaHCPegaHC-Data-Service ProposedDischargeDate Proposed Discharge Date PegaHCPegaHC-Data-Service RepricedApprovedServiceUnitCount Repriced Approved Service Unit Count PegaHCPegaHC-Data-Service ServiceFacilityName Service Facility Name PegaHCPegaHC-Data-Service TransportDistance Transport Distance PegaHCPegaHC-Data-Service PlaceOfProfessionalServiceCode PlaceOfProfessionalServiceCode PegaHCPegaHC-Data-Service AccidentDate Accident Date PegaHCPegaHC-Data-Service AmbulancePickUpPostalCode Ambulance Pick Up Postal Code PegaHCPegaHC-Data-Service AnesthesiaRelatedSurgicalProcedure Anesthesia Related Surgical Procedure PegaHCPegaHC-Data-Service BeginTherapyDate Begin Therapy Date PegaHCPegaHC-Data-Service ConditionCodeEPSDTReferral Condition Code - EPSDT Referral PegaHCPegaHC-Data-Service ConditionDescriptionPatient Condition Description - Patient PegaHCPegaHC-Data-Service DurationofVisitsNumberofUnits Duration of Visits Number of Units PegaHCPegaHC-Data-Service DurationofVisitsUnits Duration of Visits Units PegaHCPegaHC-Data-Service Frequency Frequency PegaHC

PegaHC-Data-Service FrequencyPeriod Frequency Period PegaHCPegaHC-Data-Service ICDVersion ICDVersion PegaHCPegaHC-Data-Service OralCavityDesignationCode Oral Cavity Designation Code PegaHCPegaHC-Data-Service PatientStatusCode PatientStatusCode PegaHCPegaHC-Data-Service RoundTripPurposeDescription Round Trip Purpose Description PegaHCPegaHC-Data-Service ServiceDate Service Date PegaHCPegaHC-Data-Service ServiceLineRevenueCode Service Line Revenue Code PegaHCPegaHC-Data-Service ServiceValid ServiceValid PegaHCPegaHC-Data-Service SubluxationLevelCode Subluxation Level Code PegaHCPegaHC-Data-Service TreatmentSeriesNumber Treatment Series Number PegaHCPegaHC-Data-Service ProcedureCodeQualifier Procedure Code Qualifier PegaHC

PegaHC-Data-Service ServiceFacilityLocationSecondaryIdentifier Service Facility Location Secondary Identifier PegaHCPegaHC-Data-Service ServiceToDate Service To Date PegaHCPegaHC-Data-Service ServiceTypeCode Service Type Code PegaHCPegaHC-Data-Service SurgicalProcedureCode Surgical Procedure Code PegaHCPegaHC-Data-Service CertificationTypeCodeValues CertificationTypeCodeValues PegaHCPegaHC-Data-Service ConditionAdditionalDescriptionPatient ConditionAdditionalDescriptionPatient PegaHCPegaHC-Data-Service ActionCode Action Code PegaHCPegaHC-Data-Service ActualDischargeDate Actual Discharge Date PegaHCPegaHC-Data-Service AmbulanceTripDestinationAddress Ambulance Trip Destination Address PegaHCPegaHC-Data-Service AuthorizedUnitCount Authorized Service Unit Count PegaHCPegaHC-Data-Service ConditionCodeAmbulance Condition Code - Ambulance Transport PegaHCPegaHC-Data-Service ConditionCodeVision Condition Code - Vision PegaHCPegaHC-Data-Service Dose Dose PegaHCPegaHC-Data-Service OxygenSaturationTestDate Oxygen Saturation Test Date PegaHCPegaHC-Data-Service PrincipalDiagnosis PrincipalDiagnosis PegaHCPegaHC-Data-Service PriorIncorrectInsured Prior Incorrect Insured PegaHCPegaHC-Data-Service ReferringProviderList ReferringProviderList PegaHCPegaHC-Data-Service ActivitiesPermittedCode Activities Permitted Code PegaHCPegaHC-Data-Service AdmissionTypeCode Admission Type Code PegaHCPegaHC-Data-Service ArterialBloodGasQuantity Arterial Blood Gas Quantity PegaHCPegaHC-Data-Service AssumedRelinqCareDate Assumed or Relinquished Care Date PegaHCPegaHC-Data-Service BenefitQuantity BenefitQuantity PegaHCPegaHC-Data-Service CodeListQualifierCode Code List Qualifier Code PegaHCPegaHC-Data-Service ComplicationIndicator Complication Indicator PegaHCPegaHC-Data-Service CoveredDaysorVisitsCount Covered Days or Visits Count PegaHCPegaHC-Data-Service DeliveryPatternTimeCode Delivery Pattern Time Code PegaHCPegaHC-Data-Service FrequencyCount Frequency Count PegaHCPegaHC-Data-Service InitialTreatmentDate Initial Treatment Date PegaHC

PegaHC-Data-Service InPlanNetworkIndicator InPlanNetworkIndicator PegaHCPegaHC-Data-Service MonthlyTreatmentCount Monthly Treatment Count PegaHCPegaHC-Data-Service OrderDate Order Date PegaHCPegaHC-Data-Service OxygenTestConditionCode Oxygen Test Condition Code PegaHCPegaHC-Data-Service ProcedureModifier Procedure Modifier PegaHCPegaHC-Data-Service RelatedCausesCode Related Causes Code PegaHCPegaHC-Data-Service ServiceLineRate Service Line Rate PegaHCPegaHC-Data-Service ServiceUnitCount Service Unit Count PegaHCPegaHC-Data-Service TreatmentPeriodCount Treatment Period Count PegaHCPegaHC-Data-Service ValidService ValidService PegaHCPegaHC-Data-Service ClaimServicePeriod Claim Service Period PegaHCPegaHC-Data-Service DeliveryFrequencyCode Delivery Frequency Code PegaHCPegaHC-Data-Service PendCodes PendCodes PegaHCPegaHC-Data-Service PeriodCount PeriodCount PegaHCPegaHC-Data-Service PlaceofServiceCode PlaceofServiceCode PegaHCPegaHC-Data-Service OnsetofCurrentIllnessorInjury Onset of Current Illness or Injury PegaHCPegaHC-Data-Service OxygenSaturationQuantity Oxygen Saturation Quantity PegaHCPegaHC-Data-Service ProcedureModifiers Procedure Modifier PegaHCPegaHC-Data-Service SurgeryDate Surgery Date PegaHCPegaHC-Data-Service TimePeriodQualifier Time Period Qualifier PegaHCPegaHC-Data-Service AmbulanceDropOff AmbulanceDropOff PegaHCPegaHC-Data-Service AcuteManifestationDate Acute Manifestation Date PegaHCPegaHC-Data-Service AmbulanceTransportReasonCode Ambulance Transport Reason Code PegaHCPegaHC-Data-Service BenefitAmount BenefitAmount PegaHCPegaHC-Data-Service CertificationPeriodProjVisitCount Certification Period Projected Visit Count PegaHCPegaHC-Data-Service Date Date PegaHCPegaHC-Data-Service OtherOperatingPhysician OtherOperatingPhysician PegaHCPegaHC-Data-Service AuthorizationReason AuthorizationReason PegaHCPegaHC-Data-Service BenefitCoverageLevelCode BenefitCoverageLevelCode PegaHCPegaHC-Data-Service BenefitPercent BenefitPercent PegaHCPegaHC-Data-Service CertificationConditionIndicator Certification Condition Indicator PegaHCPegaHC-Data-Service ConditionCodeAbortion Condition Code - Abortion PegaHCPegaHC-Data-Service FacilityTypeCode FacilityTypeCode PegaHCPegaHC-Data-Service IssueDate Issue Date PegaHCPegaHC-Data-Service PrescriptionFillNumber PrescriptionNumber PegaHCPegaHC-Data-Service ProcedureDate Procedure Date PegaHCPegaHC-Data-Service RevenueCode Revenue Code PegaHCPegaHC-Data-Service SampleSelectionModulus Sample Selection Modulus PegaHCPegaHC-Data-Service ServiceLineDate Service Line Date PegaHCPegaHC-Data-Service StretcherPurposeDescription Stretcher Purpose Description PegaHC

PegaHC-Data-Service TreatmentCount Treatment Count PegaHCPegaHC-Data-Service ActualAdmissionDate Actual Admission Date PegaHCPegaHC-Data-Service AdmissionDate Admission Date PegaHCPegaHC-Data-Service AmbulanceDropOffCity Ambulance Drop Off City PegaHCPegaHC-Data-Service AmbulanceDropOffPostalCode Ambulance Drop Off Postal Code PegaHCPegaHC-Data-Service AmbulancePickUpStateCode Ambulance Pick Up State Code PegaHCPegaHC-Data-Service AssessmentDate Assessment Date PegaHCPegaHC-Data-Settings MessagingServerURL MessagingServerURL PegaHCPegaHC-Data-Settings EnableQueue EnableQueue PegaHCPegaHC-Data-Settings ClaimProcessingServiceURL ClaimProcessingServiceURL PegaHCPegaHC-Data-Settings N837QueueName N837QueueName PegaHCPegaHC-Data-Settings JMXServiceURL JMXServiceURL PegaHCPegaHC-Data-Settings MessagingBrokerName MessagingBrokerName PegaHCPegaHC-Data-Settings ApplicationName Application PegaHCPegaHC-Data-Settings MaxActiveConsumers MaxActiveConsumers PegaHCPegaHC-Data-Settings SettingsID SettingsID PegaHCPegaHC-Data-Test Code ID PegaHCPegaHC-Data-ToothCodes Code ID PegaHCPegaHC-Data-Trailer TransactionSetControlNumber Transaction Set Control Number PegaHCPegaHC-Data-Trailer TransactionSegmentCount Transaction Segment Count PegaHCPegaHC-EDI-Work X12FileName X12 File Name PegaHCPegaHC-EDI-Work X12OutMessage X12InMessage PegaHCPegaHC-EDI-Work X12InMessage X12InMessage PegaHCPegaHC-EDI-Work-ClaimStatusRequest TraceNumber TraceNumber PegaHCPegaHC-EDI-Work-ClaimStatusRequest ServiceFromDate Service From Date PegaHCPegaHC-EDI-Work-ClaimStatusRequest CSTN277_Path Claim Submitter Trace Number PegaHCPegaHC-EDI-Work-ClaimStatusRequest PaidAmount PayerPaidAmount PegaHCPegaHC-EDI-Work-ClaimStatusRequest ServiceToDate Service To Date PegaHCPegaHC-EDI-Work-ClaimStatusRequest ClaimStatusCategory Claim Status Category PegaHCPegaHC-EDI-Work-ClaimStatusRequest ServiceIdentificationQualifier Service Identification Qualifier PegaHCPegaHC-EDI-Work-ClaimStatusRequest LineServiceToDate Claim Line Service To Date PegaHCPegaHC-EDI-Work-ClaimStatusRequest ClaimStatus ClaimStatus PegaHCPegaHC-EDI-Work-ClaimStatusRequest StatusEffectiveDate StatusEffectiveDate PegaHCPegaHC-EDI-Work-ClaimStatusRequest ServiceUnitCount Service Unit Count PegaHCPegaHC-EDI-Work-ClaimStatusRequest LineServiceFromDate Claim Line Service From Date PegaHCPegaHC-EDI-Work-ClaimStatusRequest BillTypeIdentifier Bill Type Identifier PegaHCPegaHC-EDI-Work-ClaimStatusRequest PayerClaimControlNumber PayerClaimControlNumber PegaHCPegaHC-EDI-Work-ClaimStatusRequest LineChargeAmount Line Charge Amount PegaHCPegaHC-EDI-Work-ClaimStatusRequest ClaimIdentificationQualifier Claim Identification Qualifier PegaHCPegaHC-EDI-Work-ClaimStatusRequest ChargeAmount Charge Amount PegaHC

PegaHC-EDI-Work-ClaimStatusRequest MedicalRecordNumber Medical Record Number PegaHCPegaHC-EDI-Work-ClaimStatusRequest RevenueCode Revenue Code PegaHCPegaHC-EDI-Work-ClaimStatusRequest ProcedureCode Procedure Code PegaHCPegaHC-EDI-Work-EligibilityRequest RequestValidationStatus RequestValidationStatus PegaHCPegaHC-EDI-Work-EligibilityRequest parallel_271Path parallel 271 Path PegaHCPegaHC-EDI-Work-EligibilityRequest TraceNumberIssuedBy TraceNumberIssuedBy PegaHCPegaHC-EDI-Work-EligibilityRequest EBInfo EBInfo PegaHCPegaHC-EDI-Work-EligibilityRequest X12Data Deprecated - X12Data PegaHCPegaHC-EDI-Work-EligibilityRequest TraceNumber TraceNumber PegaHCPegaHC-EDI-Work-EligibilityRequest EQNumber MaximumEQLimit PegaHCPegaHC-EDI-Work-EligibilityRequest EBRequest EBRequest PegaHCPegaHC-EDI-Work-EligibilityRequest X12_834Data X12_834Data PegaHCPegaHC-EDI-Work-EligibilityRequest MaximumEQLimit MaximumEQLimit PegaHCPegaHC-EDI-Work-EligibilityRequest ValidationContinue Validation Continue PegaHCPegaHC-EDI-Work-EligibilityRequest SubscriberCounter Subscriber Counter PegaHCPegaHC-Maintenance-Work CodeGroup CodeGroup PegaHCPegaHC-Maintenance-Work ICD9ProcedureCode ICD9ProcedureCode PegaHCPegaHC-Maintenance-Work HCPCSCode HCPCS Code PegaHCPegaHC-Maintenance-Work ICDCodeType ICDCodeType PegaHCPegaHC-Maintenance-Work CMMaterials CMMaterials PegaHCPegaHC-Maintenance-Work IndustryCodeType IndustryCodeType PegaHCPegaHC-Maintenance-Work SelectedWizardTemplate SelectedWizardTemplate PegaHCPegaHC-Maintenance-Work NDCCode NDCCode PegaHCPegaHC-Maintenance-Work SaveOption Save Option PegaHCPegaHC-Maintenance-Work IndustryCodeTypeGroups IndustryCodeTypeGroups PegaHCPegaHC-Maintenance-Work Member Member PegaHCPegaHC-Maintenance-Work SelObjectModel SelObjectModel PegaHCPegaHC-Maintenance-Work DrugIDCode CPTCode PegaHCPegaHC-Maintenance-Work CPTCode CPTCode PegaHCPegaHC-Maintenance-Work ICD10Code ICD10Code PegaHCPegaHC-Maintenance-Work ICD9Code ICD9Code PegaHCPegaHC-Maintenance-Work ObjectModel Object Model PegaHCRule-File- FileType File Type PegaHCRule-File- RelativePath Relative Path PegaHCData-Corr-Letter AdditionalInfoRequest Additional Information Request PegaHCAGMEmbed-CustomFields RefID RefID PegaHCAGMEmbed-CustomFields RefNumber RefNumber PegaHCAGMPegaHC-AG-Data-GrievanceReason Detail Detail PegaHCAGMPegaHC-AG-Data-GrievanceReason ID ID PegaHCAGMPegaHC-AG-Data-GrievanceReason Category Category PegaHCAGM

PegaHC-AG-Data-Service FirstName FirstName PegaHCAGMPegaHC-AG-Data-Service FacilityName FacilityName PegaHCAGMPegaHC-AG-Data-Service ProviderID ProviderID PegaHCAGMPegaHC-AG-Data-Service LastName LastName PegaHCAGMPegaHC-AG-Data-Service StartDate StartDate PegaHCAGMPegaHC-AG-Data-Service ServiceType ServiceType PegaHCAGMPegaHC-AG-Data-Service DischargeDate DischargeDate PegaHCAGMPegaHC-AG-Data-Service AdmitDate AdmitDate PegaHCAGMPegaHC-AG-Data-Service NumberOfUnits NumberOfUnits PegaHCAGM

PegaHC-AG-Work MDFeedback

Comments field for feedback from Medical

Director PegaHCAGMPegaHC-AG-Work Member Member PegaHCAGMPegaHC-AG-Work MRUFeedback Comments field for feedback from MRU PegaHCAGMPegaHC-AG-Work pyProblemSource Problem Source PegaHCAGMPegaHC-AG-Work RequestDate RequestDate PegaHCAGMPegaHC-AG-Work ClaimDisputeAmount ClaimDisputeAmount PegaHCAGMPegaHC-AG-Work DenialType DenialType PegaHCAGMPegaHC-AG-Work Level2AppealDescription Level 2 Appeal Description PegaHCAGMPegaHC-AG-Work ComplaintOwner ComplaintOwner PegaHCAGMPegaHC-AG-Work GrievanceReasonCategory Grievance Reason Category PegaHCAGMPegaHC-AG-Work MedicalPolicyDate MedicalPolicyDate PegaHCAGMPegaHC-AG-Work pyCustomer Customer ID PegaHCAGMPegaHC-AG-Work ServicesMbrID ServicesMbrID PegaHCAGMPegaHC-AG-Work MedicalPolicyName MedicalPolicyName PegaHCAGMPegaHC-AG-Work Level3AppealDescription Level 3 Appeal Description PegaHCAGMPegaHC-AG-Work pyAgeFromDate Age From date PegaHCAGMPegaHC-AG-Work ServiceProvider ServiceProvider PegaHCAGMPegaHC-AG-Work AdditionalInfoRequest Additional Information Request PegaHCAGMPegaHC-AG-Work ClaimLineNumbers ClaimLineNumbers PegaHCAGMPegaHC-AG-Work DischargeDate Discharge Date PegaHCAGMPegaHC-AG-Work GrievanceReason GrievanceReason PegaHCAGMPegaHC-AG-Work MedicalPolicyNumber MedicalPolicyNumber PegaHCAGM

PegaHC-AG-Work PNSFeedback

Comments field for feedback from PNS

department PegaHCAGM

PegaHC-AG-Work ProviderQINotes

Comments field for notes on Provider QI

Review PegaHCAGM

PegaHC-AG-Work UMFeedback

Comments field for feedback from UM

department PegaHCAGMPegaHC-AG-Work UMGuidelineNumber UMGuidelineNumber PegaHCAGMPegaHC-AG-Work AppealType AppealType PegaHCAGM

PegaHC-AG-Work ComplaintDescription Description PegaHCAGMPegaHC-AG-Work FlowStep AppealLevel PegaHCAGMPegaHC-AG-Work GrievanceReasonDetail Grievance Reason Detail PegaHCAGMPegaHC-AG-Work ProviderFeedback Comments field for provider feedback PegaHCAGMPegaHC-AG-Work RequestSource RequestSource PegaHCAGMPegaHC-AG-Work ServicesPrvID ServicesPrvID PegaHCAGMPegaHC-AG-Work UMGuidelineName UMGuidelineName PegaHCAGMPegaHC-AG-Work Urgency Urgency PegaHCAGMPegaHC-AG-Work Claim Claim PegaHCAGM

PegaHC-AG-Work ClaimsFeedback

Comments field for feedback from claims

department PegaHCAGMPegaHC-AG-Work MedicalPolicyDescription MedicalPolicyDescription PegaHCAGMPegaHC-AG-Work Service Service PegaHCAGMPegaHC-AG-Work pyProblemType Problem Type PegaHCAGM

PegaHC-AG-Work MDFeedbackRequest

Comments field for requesting feedback

from Medical Director PegaHCAGMPegaHC-AG-Work FinalDisposition FinalDisposition PegaHCAGMPegaHC-AG-Work ClaimServiceCodes ClaimServiceCodes PegaHCAGMPegaHC-AG-Work AppealLevel AppealLevel PegaHCAGMPegaHC-AG-Work pyContactChannel Contact Channel PegaHCAGMPegaHC-AG-Work Policy Policy PegaHCAGMPegaHC-AG-Work DispositionSummary DispositionSummary PegaHCAGMPegaHC-AG-Work DesiredOutcome DesiredOutcome PegaHCAGMPegaHC-AG-Work Authorization Authorization PegaHCAGMPegaHC-AG-Work UMGuidelinePageNumber UMGuidelinePageNumber PegaHCAGMPegaHC-AG-Work UMGuidelineDescription UMGuidelineDescription PegaHCAGMPegaHC-Data- AppealLevel3Disposition AppealLevel3Disposition PegaHCAGMPegaHC-Data- AppealLevel2Disposition AppealLevel2Disposition PegaHCAGMPegaHC-Data- AppealLevel1Disposition AppealLevel1Disposition PegaHCAGMPegaHC-Data-Authorization AuthorizedAmount Authorized Amount PegaHCAGMPegaHC-Data-Authorization RequestedAmount Requested Amount PegaHCAGMPegaHC-Data-Authorization AuthDeniedDate Denied Date PegaHCAGMPegaHC-Data-Authorization RequestDate RequestDate PegaHCAGMPegaHC-Data-Authorization FacilityID FacilityID PegaHCAGMPegaHC-Data-Authorization PrimaryDiagnosis Primary Diagnosis PegaHCAGMPegaHC-Data-Claim TotalCoinsuranceAmount Total Coinsurance Amount PegaHCAGMPegaHC-Data-Claim ClaimLineDetail ClaimLineDetail PegaHCAGMPegaHC-Data-Party-Member DateOfBirth DateOfBirth PegaHCAGMPegaHC-Data-Service ServiceDate Service Date PegaHCAGMPegaHC-Data-Policy TempSubscriberName TempSubscriberName PegaHCEDI

PegaHC-Data-Product TempSubscriberName TempSubscriberName PegaHCEDIPegaHC-EDI-Work X12VersionCode X12VersionCode PegaHCEDIPegaHC-EDI-Work-EligibilityRequest X12VersionCode X12VersionCode PegaHCEDIPegaHC-Data-Party-Payer COBRelatedEntity COBRelatedEntity PegaHCLPPegaHC-Landing AppealandGrievances AppealandGrievances PegaHCLPPegaHC-Landing X12N276FileName X12N276FileName PegaHCLPPegaHC-Landing ProcessSampleX12EDI4010 ProcessSampleX12EDI4010 PegaHCLPPegaHC-Landing X125010N276FileName X125010N276FileName PegaHCLPPegaHC-Landing FV_278_Req_File_SC1 FV_278_Req_File_SC1 PegaHCLPPegaHC-Landing HL7Parameters HL7Parameters PegaHCLPPegaHC-Landing NewMemberEnrollment NewMenberEnrollment PegaHCLPPegaHC-Landing ManageSampleDataInstance ManageSampleDataInstance PegaHCLPPegaHC-Landing X125010N270FileName X125010N270FileName PegaHCLPPegaHC-Landing X125010N834FileName X125010N834FileName PegaHCLPPegaHC-Landing X12N270FileName X12 File Name PegaHCLPPegaHC-Landing ProcessSampleX12EDI ProcessSampleX12EDI PegaHCLPPegaHC-Landing AuthorizationManagementSolution AuthorizationManagementSolution PegaHCLPPegaHC-Landing X125010N837FileName X125010N837FileName PegaHCLPPegaHC-Landing X12FileName X12FileName PegaHCLP@baseclass WellnessCriteria WellnessCriteria PegaHC-PCS-Foundation@baseclass pcsLPIcon pcsLPIcon PegaHC-PCS-Foundation@baseclass PCSReleaseVersion PCSReleaseVersion PegaHC-PCS-Foundation@baseclass SubCategory SubCategory PegaHC-PCS-Foundation@baseclass MetaData Embed MetaData of rules PegaHC-PCS-Foundation@baseclass Required Required PegaHC-PCS-Foundation@baseclass NodeUpdateOperator NodeUpdateOperator PegaHC-PCS-Foundation@baseclass WellnessRewards WellnessRewards PegaHC-PCS-Foundation@baseclass ProductKey ProductKey PegaHC-PCS-Foundation@baseclass IsCovered IsCovered PegaHC-PCS-Foundation@baseclass NodeStatus NodeStatus PegaHC-PCS-Foundation@baseclass DisplayDate DisplayDate PegaHC-PCS-Foundation@baseclass ProductLine Product Line PegaHC-PCS-Foundation@baseclass AliasName AliasName PegaHC-PCS-Foundation@baseclass BSTreeFlag BSTreeFlag PegaHC-PCS-Foundation@baseclass Description Description PegaHC-PCS-Foundation@baseclass Name Name PegaHC-PCS-Foundation@baseclass Category Category PegaHC-PCS-FoundationCode-AutoTest-Difference LocationDisplay Location Display PegaHC-PCS-FoundationCode-AutoTest-Difference PropertyDisplay Property Display PegaHC-PCS-FoundationData-Portal SelectCategory SelectCategory PegaHC-PCS-Foundation

Data-Portal TermBenefitLinkViewName TermBenefitLinkViewName PegaHC-PCS-FoundationData-Portal NewSelectCategory New Portal Select Category PegaHC-PCS-FoundationEmbed-HC-PCS- Content Content PegaHC-PCS-FoundationEmbed-HC-PCS- Name Name PegaHC-PCS-FoundationEmbed-HC-PCS- SetAsDefault SetAsDefault PegaHC-PCS-FoundationEmbed-HC-PCS- Type Code Group or Code Set PegaHC-PCS-FoundationEmbed-HC-PCS- WellnessBenefit Required PegaHC-PCS-FoundationEmbed-HC-PCS- FederalMandateEffectiveDate EffectiveDate PegaHC-PCS-FoundationEmbed-HC-PCS- GeneratedSPD GeneratedSPD PegaHC-PCS-FoundationEmbed-HC-PCS- IsMasterList IsMasterList PegaHC-PCS-FoundationEmbed-HC-PCS- ProductCategory ProductCategory PegaHC-PCS-FoundationEmbed-HC-PCS- Required Required PegaHC-PCS-FoundationEmbed-HC-PCS- TempKey TempKey PegaHC-PCS-FoundationEmbed-HC-PCS- CodeGroupCategory CodeGroupCategory PegaHC-PCS-FoundationEmbed-HC-PCS- EffectiveDate EffectiveDate PegaHC-PCS-FoundationEmbed-HC-PCS- LOBOffering LOBOffering PegaHC-PCS-FoundationEmbed-HC-PCS- ShortDescription ShortDescription PegaHC-PCS-FoundationEmbed-HC-PCS- AgeUnits AgeUnits PegaHC-PCS-FoundationEmbed-HC-PCS- Amount Amount PegaHC-PCS-FoundationEmbed-HC-PCS- CodeGroupLabel CodeGroupLabel PegaHC-PCS-FoundationEmbed-HC-PCS- IsOverrideCodeGroup Is Override Code Group PegaHC-PCS-FoundationEmbed-HC-PCS- IsWellnessBenefit Required PegaHC-PCS-FoundationEmbed-HC-PCS- StateMandateEffectiveDate EffectiveDate PegaHC-PCS-FoundationEmbed-HC-PCS- DisplayDate DisplayDate PegaHC-PCS-FoundationEmbed-HC-PCS- NotePage NotePage PegaHC-PCS-FoundationEmbed-HC-PCS- SPDDescription CoCDescription PegaHC-PCS-FoundationEmbed-HC-PCS- TempInsName TempInsName PegaHC-PCS-FoundationEmbed-HC-PCS- TermDate TermDate PegaHC-PCS-FoundationEmbed-HC-PCS- CodeSetClass CodeGroupCategory PegaHC-PCS-FoundationEmbed-HC-PCS- CostShares CostShares PegaHC-PCS-FoundationEmbed-HC-PCS- EditMode EditMode PegaHC-PCS-FoundationEmbed-HC-PCS- HasError HasError PegaHC-PCS-FoundationEmbed-HC-PCS- SummaryDescription SummaryDescription PegaHC-PCS-FoundationEmbed-HC-PCS- Draft Draft PegaHC-PCS-FoundationEmbed-HC-PCS- RelativityFactor RelativityFactor PegaHC-PCS-FoundationEmbed-HC-PCS-Authorization- AuthorizationTypeSelected AuthorizationTypeSelected PegaHC-PCS-FoundationEmbed-HC-PCS-Authorization- AuthorizationType AuthorizationType PegaHC-PCS-FoundationEmbed-HC-PCS-Benefit- IsCovered IsCovered PegaHC-PCS-FoundationEmbed-HC-PCS-Benefit- Rank Rank PegaHC-PCS-FoundationEmbed-HC-PCS-Benefit- IsAddedFromBU IsAddedFromBU PegaHC-PCS-Foundation

Embed-HC-PCS-Benefit- NonCoverageMapping NonCoverageMapping PegaHC-PCS-FoundationEmbed-HC-PCS-Benefit- IsRemovedFromBU IsAddedFromBU PegaHC-PCS-FoundationEmbed-HC-PCS-Benefit- CoverageMapping CoverageMapping PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitConflict- DiagnosisGroup Diagnosis Group PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitConflict- PlaceOfService Place Of Service PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitConflict- ServiceGroup ServiceGroup PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitConflict- BillType Bill Type PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitConflict- Benefits Benefits PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitConflict- CustomCode CustomCode PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitConflict- Specialty Specialty PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitSet SetDescription SetDescription PegaHC-PCS-FoundationEmbed-HC-PCS-BenefitSet SetName SetName PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- TypeOfConditionRx TypeOfCondition PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Value Value PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- PlaceOfService PlaceOfService PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- ToAge To Age PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- DeliveryType DeliveryType PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- PreferredProvider PreferredProvider PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Generic Generic PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Maintenance Maintenance PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- ServiceBy ServiceBy PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- DrugType DrugType PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Gender Gender PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Jurisdiction Jurisdiction PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- SpecialConditionType SpecialConditionType PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- TypeOfCondition TypeOfCondition PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- BillType BillType PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- FromAge From Age PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Specialty Specialty PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Authorized Authorized PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- ParticipatingProvider ParticipatingProvider PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- Referral Referral PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- ProviderRanking ProviderRanking PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- ProviderType ProviderType PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- ReferralRx ReferralRx PegaHC-PCS-FoundationEmbed-HC-PCS-Condition- ServiceGroup ServiceGroup PegaHC-PCS-FoundationEmbed-HC-PCS-ConsumerNote- TermDateNotOverlapped EffectiveDateNotOverlapped PegaHC-PCS-FoundationEmbed-HC-PCS-ConsumerNote- Note Note PegaHC-PCS-FoundationEmbed-HC-PCS-ConsumerNote- FileName AttachFileName PegaHC-PCS-FoundationEmbed-HC-PCS-ConsumerNote- AttachFileName AttachFileName PegaHC-PCS-Foundation

Embed-HC-PCS-ConsumerNote- Label Label PegaHC-PCS-FoundationEmbed-HC-PCS-ConsumerNote- EffectiveDateNotOverlapped EffectiveDateNotOverlapped PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- BenefitName Benefit Name PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- Property Property PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- Type Type PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- AfterValue After Value PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- ProductName Product Name PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- GrouperName Grouper Name PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- NetworkName Network Name PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- LocationDisplay LocationDisplay PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- BeforeValue Before Value PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- Object Object PegaHC-PCS-FoundationEmbed-HC-PCS-ContractDelta- PropertyDisplay PropertyDisplay PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetCoinsuranceMasterList SetCopayMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetCopayMasterList SetCopayMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetDeductibleMasterList SetCopayMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetExclusionsMasterList SetExclusionsMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetLimitsMasterList SetLimitsMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxIncrement SingleMaxIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLifetimeSelectionFlag SingleMaxLifetimeSelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLowLifeTime SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxRangeValues AmountRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TierGroup TierGroup PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyMax UnlimitedFamilyMax PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleMaxDefaultSel UnlimitedSingleMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountIncrement AmountIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AnnualMaxRangeValues AnnualMaxRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CalculationMethodSelection CalculationMethodSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverHigh CarryoverHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CopayInstructions CopayInstructions PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- EventType EventType PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- ExceptionApprovalFlag NeedsExceptionApproval PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyHigh FamilyHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyIncrement FamilyIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxAnnualIncrement SingleMaxIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- PeriodType PeriodType PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountSelection AmountSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountSelectionApproval AmountSelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CalculationMethods CalculationMethods PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverSelectionFlag CarryoverSelectionFlag PegaHC-PCS-Foundation

Embed-HC-PCS-CostShare- FamilyMLifeTimeDefaultSelCount FamilyMaxDefaultSelCount PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilySelection FamilySelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- HasMasterList MasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxIncrement AmountIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxSelectionFlag LifetimeMaxSelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LimitRangeValues LimitRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- PeriodHigh PeriodHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- PeriodLow PeriodLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- PeriodSelectionFlag Period Selected Value PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetAdmCopayMasterList SetCopayMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLifeTimeIncrement SingleMaxIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLow SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxRangeDefaultSelCount SingleMaxRangeDefaultSelCount PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TimeMethods Methods PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedAnnualMaxVal UnlimitedAnnualMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxVariations LifetimeMaxVariations PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- OutOfPocketInstructions OutOfPocketInstructions PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- OutOfPocketVariations OutOfPocketVariations PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- PeriodIncrement PeriodIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TierEventType TierEventType PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleAnnualMax UnlimitedLifetimeMax PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleLifeTimeDefault UnlimitedFamilyMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleMax UnlimitedSingleMax PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleMaxVal UnlimitedSingleMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountLow AmountLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountRangeDefaultCount AmountRangeDefaultSelCount PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AnnualMaxSelectionFlag AnnualMaxSelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverVariation CarryoverVariation PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CoinsuranceInstructions CoinsuranceInstructions PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CoinsuranceVariations Coinsurance Variations PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CopayVariations CopayVariations PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- DeductibleInstructions DeductibleInstructions PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxLifeTimeIncrement SingleMaxIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountSelectionFlag AmountSelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverIncrement CarryoverIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverLow CarryoverLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxAnnualLow SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxDefaultSelCount FamilyMaxDefaultSelCount PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyRangeValues AmountRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxLow LifetimeMaxLow PegaHC-PCS-Foundation

Embed-HC-PCS-CostShare- PeriodRangeValues Period Range Values PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLifeTimeHigh SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyAnnualMax UnlimitedSingleMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyLifetimeVal UnlimitedLifetimeMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyMaxVal UnlimitedFamilyMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedLifetimeMax UnlimitedLifetimeMax PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxLifeTimeRangeValues LifetimeMaxRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxRangeValues FamilyMaxRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxSelection FamilyMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- NextStep NextStep PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- OccurrenceMethods OccurrenceMethods PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- PeriodSelection PeriodSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetAuthorizationMasterList SetAuthorizationMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxAnnualIncrement SingleMaxIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLifeTimeLow SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLifetimeSelection LifetimeMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxSelection SingleMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxSelectionFlag SingleMax Selected Value PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- Time Time PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedAnnualMax UnlimitedAnnualMax PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyMaxDefault UnlimitedFamilyMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyMaxDefaultSel UnlimitedSingleMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedLifetimeMaxVal UnlimitedLifetimeMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AdmCopayVariations AdmCopayVariations PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AdmissionCopayInstructions AdmissionCopayInstructions PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountHigh AmountHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverVariations CarryoverVariations PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CostShareException CostShareException PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- DeductibleVariations Deductible Variations PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxHigh FamilyMaxHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxLifeTimeHigh SingleMaxHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountRangeLifeTimeFMaxCnt AmountRangeDefaultSelCount PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AmountRangeValues AmountRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AnnualMaxHigh AnnualMaxHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AnnualMaxIncrement AnnualMaxIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AnnualMaxLow AnnualMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AnnualMaxSelection AnnualMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverRangeValues CarryoverRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverSelectionApproval CarryoverSelectionApproval PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxAnnualRangeValues AmountRangeValues PegaHC-PCS-Foundation

Embed-HC-PCS-CostShare- FamilyMaxAnnualSelection LifetimeMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxSelectionApproval FamilyMaxSelectionApproval PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilySelectionFlag FamilySelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- MasterListEditLock MasterListEditLock PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- OccurrenceMethodSelection OccurenceMethodSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxAnnualSelection LifetimeMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TierDurationType TierDurationType PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TierLimitType TierLimitType PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TiersHasAgeRanges TiersHasLimitRange PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TierType TierType PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TimeMethodsSelection TimeMethodsSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- Type Type PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleLifetimeMax UnlimitedLifetimeMax PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilySelectionApproval FamilySelectionApproval PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxRangeValues LifetimeMaxRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxSelection LifetimeMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxSelectionApproval LifetimeMaxSelectionApproval PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- MasterList MasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetCoverageMasterList SetCoverageMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxAnnualHigh SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxAnnualRangeValues AmountRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- TiersHasLimitRanges TiersHasLimitRange PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyAnnualVal UnlimitedLifetimeMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyLifeTimeDefault UnlimitedFamilyMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleAnnualVal UnlimitedLifetimeMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleMaxDefault UnlimitedSingleMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMLifeTimeDefaultSelCount FamilyMaxDefaultSelCount PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedFamilyLifeTimeMax UnlimitedSingleMaxDefault PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- UnlimitedSingleLifetimeVal UnlimitedLifetimeMaxVal PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AnnualMaxSelectionApproval AnnualMaxSelectionApproval PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyLow FamilyLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxIncrement FamilyMaxIncrement PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxLifeTimeLow SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- AgeRangeValues AgeRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- CarryoverSelection AmountSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- Content Content PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxAnnualHigh SingleMaxHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxLifetimeSelection LifetimeMaxSelection PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxLifetimeSelectionFlag FamilyMaxLifetimeSelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- FamilyMaxLow FamilyMaxLow PegaHC-PCS-Foundation

Embed-HC-PCS-CostShare- FamilyMaxSelectionFlag FamilyMaxSelectionFlag PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- LifetimeMaxHigh LifetimeMaxHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- MaximumVariation MaximumVariation PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SetOutOfPocketMasterList SetCopayMasterList PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxAnnualLow SingleMaxLow PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxHigh SingleMaxHigh PegaHC-PCS-FoundationEmbed-HC-PCS-CostShare- SingleMaxLifeTimeRangeValues LifetimeMaxRangeValues PegaHC-PCS-FoundationEmbed-HC-PCS-Coverage- MaxAge MaxAge PegaHC-PCS-FoundationEmbed-HC-PCS-Coverage- AgeCalculationMethods AgeCalculationMethods PegaHC-PCS-FoundationEmbed-HC-PCS-Coverage- MinAge MinAge PegaHC-PCS-FoundationEmbed-HC-PCS-Coverage- Content Content PegaHC-PCS-FoundationEmbed-HC-PCS-CoverageLevel- Selected Selected PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- PendCode Pend Code PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- Qualifier Exclusion Qualifier Type PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- Selected Selected PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- AllowProductChanges Allow Product Changes PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- ExclusionMethod ExclusionMethod PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- ExclusionSex ExclusionSex PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- YearsOld YearsOld PegaHC-PCS-FoundationEmbed-HC-PCS-Exclusion- DenialCode Denial Code PegaHC-PCS-FoundationEmbed-HC-PCS-Grouper- GrouperType GrouperType PegaHC-PCS-FoundationEmbed-HC-PCS-Grouper- TypeOfGrouper AliasName PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- PCPRequired PCPRequired PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- Network2 Network2 PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- Amount Amount PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- Applies PCPRequired PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- CostShareList CostShareList PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- Relationship Relationship PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- AuthRequired AuthRequired PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- Method ExclusionMethod PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- Network Network PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- CostShare CostShare PegaHC-PCS-FoundationEmbed-HC-PCS-GuardrailRule- AliasName AliasName PegaHC-PCS-FoundationEmbed-HC-PCS-Instructions- CarryoverEvents CarryoverEvents PegaHC-PCS-FoundationEmbed-HC-PCS-Instructions- PendInstruction PendInstruction PegaHC-PCS-FoundationEmbed-HC-PCS-Instructions- Type Type PegaHC-PCS-FoundationEmbed-HC-PCS-Instructions- MaximumsEvents MaximumsEvents PegaHC-PCS-FoundationEmbed-HC-PCS-Instructions- Event Event PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- EffectiveDatePeriodUnits Effective Date Period Units PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- AllowLimitChangesOnProduct AllowLimitChangesOnProduct PegaHC-PCS-Foundation

Embed-HC-PCS-Limit- FromDate From Date PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- LimitPeriod Limit Period PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- MaxAllowedRanges MaxAllowedRanges PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- PendCode Pend Code PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- MaxDays MaxDays PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- MaximumAllowed Maximum Allowed PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- DenialCode Denial Code PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- ToDate To Date PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- TypeOfLimit LimitType PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- MaxUnits MaxUnits PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- MaxVisits MaxVisits PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- TypeOfEffectiveDatePeriod Type of Effective Date Period PegaHC-PCS-FoundationEmbed-HC-PCS-Limit- UnitOfMeasurement Unit Of Measurement PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- BillType BillType PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- TypeOfService ServiceType PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- PlaceOfService PlaceOfService PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- Specialty Specialty PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- ServiceCode ServiceCode PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- ServiceGroup ServiceGroup PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- DiagnosisCode DiagnosisCode PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- CodeGroup CodeGroup PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- DiagnosisGroup DiagnosisGroup PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- CustomCode CustomCode PegaHC-PCS-FoundationEmbed-HC-PCS-MapData- OverrideServiceGroup OverrideServiceGroup PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- PlaceOfServices PlaceOfServices PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- DiagnosisGroups DiagnosisGroups PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- SPDBenefitAliasName SPDBenefitName PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- OverrideServiceGroups OverrideServiceGroups PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- Notes Notes PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- DiagnosisCodes DiagnosisCodes PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- TypeOfServices TypeOfServices PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- SPDBenefitName SPDBenefitName PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- DefinedMapValues DefinedMapValues PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- Specialties Specialties PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- ServiceCodes ServiceCodes PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- CodeGroup CodeGroup PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- ServiceGroups ServiceGroups PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- CustomCode CustomCode PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- SPDGrouperName SPD Grouper Name PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- OverrideClaimLines OverrideClaimLines PegaHC-PCS-Foundation

Embed-HC-PCS-Mapping- BillTypes BillType PegaHC-PCS-FoundationEmbed-HC-PCS-Mapping- CustomCodes CustomCodes PegaHC-PCS-FoundationEmbed-HC-PCS-Method- Code Code PegaHC-PCS-FoundationEmbed-HC-PCS-Method- Selected Selected PegaHC-PCS-FoundationEmbed-HC-PCS-Network- CarveOutFlag CarveOutFlag PegaHC-PCS-FoundationEmbed-HC-PCS-PolicyCacheEntry- Key Key PegaHC-PCS-FoundationEmbed-HC-PCS-PolicyCacheEntry- Value Value PegaHC-PCS-FoundationEmbed-HC-PCS-PolicyTag Tag Tag PegaHC-PCS-FoundationEmbed-HC-PCS-Pricing- ProductTypeCode Product Type Code PegaHC-PCS-FoundationEmbed-HC-PCS-Pricing- Region Region PegaHC-PCS-FoundationEmbed-HC-PCS-Pricing- ProductFamily Product Family PegaHC-PCS-FoundationEmbed-HC-PCS-Pricing- NetworkRestriction Network Restriction PegaHC-PCS-FoundationEmbed-HC-PCS-Pricing- Category Category PegaHC-PCS-FoundationEmbed-HC-PCS-ProductLine- ProductLine ProductLine PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- ToAge To Age PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- FromAgeMonths From Age PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- FromAmount FromAmount PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- Visits Visits PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- Days Days PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- Period Period PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- Units Units PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- ToAmount ToAmount PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- Code Code PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- PeriodAmount PeriodAmount PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- ToAgeMonths To Age PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- AmountDefault AmountDefault PegaHC-PCS-FoundationEmbed-HC-PCS-RangeValues- FromAge From Age PegaHC-PCS-FoundationEmbed-HC-PCS-Regions Region Region PegaHC-PCS-FoundationEmbed-HC-PCS-TestBenefitSet- ServiceCode ServiceCode PegaHC-PCS-FoundationEmbed-HC-PCS-TestBenefitSet- DiagnosisCode DiagnosisCode PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodAdmCopay CalculationMethodAdmCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodUnit Calculation Method Units PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CostShareType2 CostShareType2 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- FloatingUnits Units PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- AuthorizationType AuthorizationType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodDollarRx Calculation Method DollarRx PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodOutOfPocket CalculationMethodOutOfPocket PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- ChildrenMax ChildrenMax PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CostShareType1 CostShareType1 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CostShareTypeIndicator CostShareTypeIndicator PegaHC-PCS-Foundation

Embed-HC-PCS-Variation- CustomLimitEndDate CustomLimitEndDate PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- FamilyMax FamilyMax PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDCopay GeneratedSPDCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- IsDefault IsDefault PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- LimitFixed LimitFixed PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- LimitTypeRx LimitTypeRx PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- OutOfPocketFamilyMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- OutOfPocketMethods OutOfPocketMethods PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- PolicyType PolicyType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- ServiceGroup ServiceGroup PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- Tier TierGroup PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodCoinsurance CalculationMethodCoinsurance PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodPrescriptionRx CalculationMethodUnitRx PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodService Calculation Method Service PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodServiceRx Calculation Method ServiceRx PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- Conditions Conditions PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CostShareType CostShareType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- OutOfPocketSingleMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- ServicePeriod ServicePeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- SupplyDaysEnd SupplyDaysEnd PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- Units Units PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- VisitPeriod VisitPeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodDescription CalculationMethodDescription PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodVisit Calculation Method Visits PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CoinsuranceAmount CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CopayAmount CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CostShareCompare CostShareCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- EventType EventType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- FixedOrCompare FixedOrCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- FloatingPeriod1Type FloatingPeriod1Type PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDAdmCopay GeneratedSPDAdmCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDCarryover GeneratedSPDCarryover PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- Guidelines Guidelines PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLAdmCopayConditionSet MLAdmCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLOutOfPocketConditionSet MLOutOfPocketConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- SpouseMax SpouseMax PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- UnitPeriodType Period PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDCoverage GeneratedSPDCoverage PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- LimitCompareOperator LimitCompareOperator PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLAuthorizationConditionSet MLCopayConditionSet PegaHC-PCS-Foundation

Embed-HC-PCS-Variation- MLCoverageConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- PeriodType PeriodType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- PlaceOfService PlaceOfService PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- TiersInc TiersInc PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- Visits Visits PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- AdmCopayAmount CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- OtherGuidelines OtherGuidelines PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- PrescriptionMethodUnitRx CalculationMethodDollarRx PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- SingleMax SingleMax PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- TiersCoverage TiersCoverage PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- TiersLimitRange TiersLimitRange PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CopayGuidelinesReadOnly CopayGuidelinesReadOnly PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CostShareCompareOperator Cost Share Compare Operator PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CustomLimitEffectiveDate CustomLimitEffectiveDate PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- ExclusionSPD ExclusionSPD PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- FloatingPeriod1 FloatingPeriod1 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDMaximum GeneratedSPDMaximum PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- InterRowCalc InterRowCalc PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLLimitsConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodDeductible CalculationMethodDeductible PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodDollar Calculation Method Dollar PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodMaximum CalculationMethodMaximum PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodUnitRx CalculationMethodUnitRx PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- FloatingPeriod2 FloatingPeriod2 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- FloatingPeriod2Type FloatingPeriod2Type PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDAuthorization GeneratedSPDAuthorization PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDDeductible GeneratedSPDDeductible PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDExclusions GeneratedSPDExclusions PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- LimitType LimitType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- QuickSetLimitType QuickSetLimitType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- SupplyDaysStart SupplyDaysStart PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- UnitPeriod UnitPeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- AuthorizationTypes Authorization Types PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethod CalculationMethod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CostShareCalculationMethod CostShareCalculationMethod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- DeductibleSingleMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDCoinsurance GeneratedSPDCoinsurance PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GreaterLessor GreaterLessor PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- InterRowCompare InterRowCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- LimitAmount LimitAmount PegaHC-PCS-Foundation

Embed-HC-PCS-Variation- LimitPeriod LimitPeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLCoinsuranceConditionSet MLCoinsuranceConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLCopayConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- TiersAgeRange TiersAgeRange PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- UsageRate Usage Rate PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- AccumulatorSelect AccumulatorSelect PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalcOrder CalcOrder PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodCarryover CalculationMethodCarryover PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- CalculationMethodCopay CalculationMethodCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- DeductibleFamilyMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDLimits GeneratedSPDLimits PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- GeneratedSPDOutOfPocket GeneratedSPDOutOfPocket PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- LimitCompare LimitCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLDeductibleConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- MLExclusionsConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- NumberFamilyMembers NumberFamilyMembers PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- PeriodAmount PeriodAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- WaitingPeriodMonths WaitingPeriodMonths PegaHC-PCS-FoundationEmbed-HC-PCS-Variation- VisitPeriodType Period PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- UnitPeriodType Period PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- AdmCopayAmount CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethod CalculationMethod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- Conditions Conditions PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CostShareType2 CostShareType2 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CustomLimitEndDate CustomLimitEndDate PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- DeductibleFamilyMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- ExclusionSPD ExclusionSPD PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- FloatingPeriod2 FloatingPeriod2 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- FloatingPeriod2Type FloatingPeriod2Type PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDCarryover GeneratedSPDCarryover PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDExclusions GeneratedSPDExclusions PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- Tier TierGroup PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- AccumulatorSelect AccumulatorSelect PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- AuthorizationType AuthorizationType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalcOrder CalcOrder PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodCopay CalculationMethodCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodMaximum CalculationMethodMaximum PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodUnit Calculation Method Units PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CoinsuranceAmount CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CopayAmount CopayAmount PegaHC-PCS-Foundation

Embed-HC-PCS-Variation-Rx- CostShareType CostShareType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CostShareType1 CostShareType1 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CostShareTypeIndicator CostShareTypeIndicator PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodAdmCopay CalculationMethodAdmCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodOutOfPocket CalculationMethodOutOfPocket PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDCopay GeneratedSPDCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- IsDefault IsDefault PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- LimitPeriod LimitPeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- LimitType LimitType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLCopayConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- PlaceOfService PlaceOfService PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLDeductibleConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- QuickSetLimitType QuickSetLimitType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- SpouseMax SpouseMax PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- EventType EventType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDLimits GeneratedSPDLimits PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDOutOfPocket GeneratedSPDOutOfPocket PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- LimitFixed LimitFixed PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLAdmCopayConditionSet MLAdmCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLExclusionsConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLOutOfPocketConditionSet MLOutOfPocketConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- PeriodType PeriodType PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- TiersInc TiersInc PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- UnitPeriod UnitPeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- UsageRate Usage Rate PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CostShareCompareOperator Cost Share Compare Operator PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- TiersAgeRange TiersAgeRange PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodDollar Calculation Method Dollar PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodService Calculation Method Service PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodVisit Calculation Method Visits PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- FloatingUnits Units PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDCoverage GeneratedSPDCoverage PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLCoverageConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- ServiceGroup ServiceGroup PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- WaitingPeriodMonths WaitingPeriodMonths PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- AuthorizationTypes Authorization Types PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodCarryover CalculationMethodCarryover PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodDeductible CalculationMethodDeductible PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodDescription CalculationMethodDescription PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- ChildrenMax ChildrenMax PegaHC-PCS-Foundation

Embed-HC-PCS-Variation-Rx- CostShareCalculationMethod CostShareCalculationMethod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CalculationMethodCoinsurance CalculationMethodCoinsurance PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CostShareCompare CostShareCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDAdmCopay GeneratedSPDAdmCopay PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDAuthorization GeneratedSPDAuthorization PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDCoinsurance GeneratedSPDCoinsurance PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- InterRowCalc InterRowCalc PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- LimitCompare LimitCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- NumberFamilyMembers NumberFamilyMembers PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- OutOfPocketFamilyMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- PeriodAmount PeriodAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- DeductibleSingleMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- FloatingPeriod1Type FloatingPeriod1Type PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GreaterLessor GreaterLessor PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- OutOfPocketSingleMax CopayAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- SupplyDaysEnd SupplyDaysEnd PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- SupplyDaysStart SupplyDaysStart PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- InterRowCompare InterRowCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- CustomLimitEffectiveDate CustomLimitEffectiveDate PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- FixedOrCompare FixedOrCompare PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDMaximum GeneratedSPDMaximum PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- Guidelines Guidelines PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- LimitCompareOperator LimitCompareOperator PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLCoinsuranceConditionSet MLCoinsuranceConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- OtherGuidelines OtherGuidelines PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- ServicePeriod ServicePeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- FloatingPeriod1 FloatingPeriod1 PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- GeneratedSPDDeductible GeneratedSPDDeductible PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- LimitAmount LimitAmount PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLAuthorizationConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- MLLimitsConditionSet MLCopayConditionSet PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- OutOfPocketMethods OutOfPocketMethods PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- TiersCoverage TiersCoverage PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- Units Units PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- VisitPeriod VisitPeriod PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- VisitPeriodType Period PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- Visits Visits PegaHC-PCS-FoundationEmbed-HC-PCS-Variation-Rx- TiersLimitRange TiersLimitRange PegaHC-PCS-FoundationHistory- pxTimeCreated Time PegaHC-PCS-FoundationIndex-CircumstanceDefinition TemplateFlag TemplateFlag PegaHC-PCS-Foundation

Index-HC-PCS-BenefitMapping Network Network PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping MapIndicator MapIndicator PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping CustomCode CustomCode PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping Specialty Specialty PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping ServiceCode ServiceCode PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BenefitKey BenefitKey PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BenefitDescription BenefitDescription PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping ServiceGroup ServiceGroup PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BenefitAliasName BenefitAliasName PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BenefitClassName BenefitClassName PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BenefitName BenefitName PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping DiagnosisGroup DiagnosisGroup PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping PlaceOfService PlaceOfService PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BillType BillType PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BenefitOffering BenefitOffering PegaHC-PCS-FoundationIndex-HC-PCS-BenefitMapping BenefitCategory BenefitCategory PegaHC-PCS-FoundationIndex-HC-PCS-Contract CustomerName CustomerName PegaHC-PCS-FoundationIndex-HC-PCS-Contract EffectiveDate EffectiveDate PegaHC-PCS-FoundationIndex-HC-PCS-Contract GroupID GroupID PegaHC-PCS-FoundationIndex-HC-PCS-Contract CustomerID CustomerID PegaHC-PCS-FoundationIndex-HC-PCS-Contract ContractID ContractID PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta GrouperName Grouper Name PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta Type Type PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta BenefitName Benefit Name PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta ContractID ContractID PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta ProductName Product Name PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta Object Object PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta BeforeValue Before Value PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta AfterValue After Value PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta NetworkName Network Name PegaHC-PCS-FoundationIndex-HC-PCS-ContractDelta Property Property PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermCreatedBy TermCreatedBy PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermStartsWhen TermStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitClassName BenefitClassName PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitName BenefitName PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetAliasName BenefitSetAliasName PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetCategory BenefitCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetDescription BenefitDescription PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetLOB BenefitLOB PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractClassName Contract Class Name PegaHC-PCS-Foundation

Index-HC-PCS-Rule GrouperCreatedOn Grouper Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperDescription GrouperDescription PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkClassName NetworkClassName PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentCreatedBy ParentCreatedBy PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentUpdatedBy ParentUpdatedBy PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductTemplateFlag ProductTemplateFlag PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitEndsWhen BenefitEndsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitLOB BenefitLOB PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitRequired Benefit Required PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractLOB Contract LOB PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperClassName GrouperClassName PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentAliasName ParentCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductEndsWhen ProductEndsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductKey ProductKey PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductTemplateAliasName ProductTemplateAliasName PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermEndsWhen BenefitEndsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermName Term Name PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitDescription BenefitDescription PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitKey BenefitKey PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitKeyLong BenefitKeyLong PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetCreatedOn BenefitSet Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractCreatedOn Contract Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule ExclusionVariationFlag Exclusion Variation Flag PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperHandle GrouperHandle PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkKey NetworkKey PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentCategory ParentCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentClassName ParentClassName PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductCategory ProductCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductStartsWhen ProductStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitCreatedOn Benefit Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetEndsWhen BenefitSetEndsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractDescription Contract Description PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractKey Contract Key PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperStartsWhen GrouperStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule IsLockedByBenefitSet IsLockedByBenefitSet PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkCategory NetworkCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkEndsWhen NetworkEndsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkHandle NetworkHandle PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentEndsWhen ParentEndsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentKey ParentKey PegaHC-PCS-Foundation

Index-HC-PCS-Rule ParentLOB ParentLOB PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentStartsWhen ParentStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductClassName ProductClassName PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductCreatedOn Product Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkDescription NetworkDescription PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkName NetworkName PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkStartsWhen NetworkStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentCreatedOn Parent Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentProductLine ParentProductLine PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermKey TermKey PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitHandle BenefitHandle PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitRank BenefitRank PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperCategory GrouperCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperEndsWhen GrouperEndsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperName GrouperName PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentDraft ParentDraft PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentName ParentName PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductDescription ProductDescription PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductLOB ProductLOB PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermCreatedOn Term Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitAliasName BenefitAliasName PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetHandle BenefitSetHandle PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetKey Benefit Set Key PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractCategory BenefitCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractHandle Contract Handle PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractStartsWhen Contract Starts When PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperKey GrouperKey PegaHC-PCS-FoundationIndex-HC-PCS-Rule LimitVariationFlag Limit Variation Flag PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductName ProductName PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermTag Term Tag PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermUpdatedBy TermUpdatedBy PegaHC-PCS-FoundationIndex-HC-PCS-Rule UpdateDateTime ParentStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule AuthorizationVariationFlag Authorization Variation Flag PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitCategory BenefitCategory PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractEndsWhen Contract Ends When PegaHC-PCS-FoundationIndex-HC-PCS-Rule ContractName Contract Name PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperAliasName GrouperAliasName PegaHC-PCS-FoundationIndex-HC-PCS-Rule GrouperLOB GrouperLOB PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkCreatedOn Network Created On PegaHC-PCS-FoundationIndex-HC-PCS-Rule NetworkLOB NetworkLOB PegaHC-PCS-Foundation

Index-HC-PCS-Rule ParentDescription ParentDescription PegaHC-PCS-FoundationIndex-HC-PCS-Rule ParentHandle ParentHandle PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductAliasName ProductAliasName PegaHC-PCS-FoundationIndex-HC-PCS-Rule ProductHandle ProductHandle PegaHC-PCS-FoundationIndex-HC-PCS-Rule TermHandle TermHandle PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetClassName BenefitClassName PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetName Benefit Set Name PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitSetStartsWhen BenefitSetStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule BenefitStartsWhen BenefitStartsWhen PegaHC-PCS-FoundationIndex-HC-PCS-Rule CoverageVariationFlag Coverage Variation Flag PegaHC-PCS-FoundationIndex-HC-PCS-Rule MedicalPolicyFlag Medical Policy Flag PegaHC-PCS-FoundationPegaPCS-Data- CopyOrNew Copy Or New PegaHC-PCS-FoundationPegaPCS-Data-Claim NumberOfTransactions NumberOfTransactions PegaHC-PCS-FoundationPegaPCS-Data-Claim Claim Claim PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps Specialty Specialty PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps ClaimLineNo ClaimLineNo PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps BenefitName BenefitName PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps PlaceOfService PlaceOfService PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps BenefitCategory BenefitCategory PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps Service Service PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps ServiceDate ServiceDate PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps Diagnosis Diagnosis PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps ClaimID ClaimID PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestProps BillType BillType PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestResult ClaimLine ClaimLine PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestResult BenefitTestResult Note PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestResult BenefitName Note PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestResult Note Note PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestResult Type Type PegaHC-PCS-FoundationPegaPCS-Data-ClaimTestResult ClaimID ClaimID PegaHC-PCS-FoundationPegaPCS-Data-Config OutOfPocketInstructions OutOfPocketInstructions PegaHC-PCS-FoundationPegaPCS-Data-Config CoverageInstructions Coverage Instructions PegaHC-PCS-FoundationPegaPCS-Data-Config CarryoverInstructions CarryoverInstructions PegaHC-PCS-FoundationPegaPCS-Data-Config ClaimSystemDescription ClaimSystemDescription PegaHC-PCS-FoundationPegaPCS-Data-Config ClaimSystemName ClaimSystemName PegaHC-PCS-FoundationPegaPCS-Data-Config AnnualMaxInstructions AnnualMaxInstructions PegaHC-PCS-FoundationPegaPCS-Data-Config CoinsuranceInstructions CoinsuranceInstructions PegaHC-PCS-FoundationPegaPCS-Data-Config LimitInstructions Limit Instructions PegaHC-PCS-FoundationPegaPCS-Data-Config DeductibleInstructions DeductibleInstructions PegaHC-PCS-FoundationPegaPCS-Data-Config CopayInstructions Authorizations Instructions PegaHC-PCS-Foundation

PegaPCS-Data-Config LifetimeMaxInstructions LifetimeMaxInstructions PegaHC-PCS-FoundationPegaPCS-Data-Config EditMode EditMode PegaHC-PCS-FoundationPegaPCS-Data-Config IsEdit EditFlag PegaHC-PCS-FoundationPegaPCS-Data-Config AdmCopayInstructions AdmCopayInstructions PegaHC-PCS-FoundationPegaPCS-Data-Config AuthorizationInstructions Authorizations Instructions PegaHC-PCS-FoundationPegaPCS-Data-Config ExculsionsInstructions Exclusions Instructions PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductCategory ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductDescription ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductInsKey ProductInsKey PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductTermDate ProductTermDate PegaHC-PCS-FoundationPegaPCS-Data-Contract TermDate TermDate PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductAliasName ProductAliasName PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductHandle ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductName ProductName PegaHC-PCS-FoundationPegaPCS-Data-Contract WorkParties Parties PegaHC-PCS-FoundationPegaPCS-Data-Contract ContractID ContractID PegaHC-PCS-FoundationPegaPCS-Data-Contract ContractPlanType ContractPlanType PegaHC-PCS-FoundationPegaPCS-Data-Contract CopiedFrom CopiedFrom PegaHC-PCS-FoundationPegaPCS-Data-Contract CopyContract CopyContract PegaHC-PCS-FoundationPegaPCS-Data-Contract CustomerName CustomerName PegaHC-PCS-FoundationPegaPCS-Data-Contract GroupID GroupID PegaHC-PCS-FoundationPegaPCS-Data-Contract NewOrCopy NewOrCopy PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductCreatedOn ProductEffectiveDate PegaHC-PCS-FoundationPegaPCS-Data-Contract LOBOffering ProductLOBOffering PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductClassName ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductLOBOffering ProductLOBOffering PegaHC-PCS-FoundationPegaPCS-Data-Contract CustomerID CustomerID PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductID ProductID PegaHC-PCS-FoundationPegaPCS-Data-Contract SubscriberID SubscriberID PegaHC-PCS-FoundationPegaPCS-Data-Contract EffectiveDate EffectiveDate PegaHC-PCS-FoundationPegaPCS-Data-Contract ProductEffectiveDate ProductEffectiveDate PegaHC-PCS-FoundationPegaPCS-Data-Party CustomerName CustomerName PegaHC-PCS-FoundationPegaPCS-Data-Party-Broker PartyIDType PartyIDType PegaHC-PCS-FoundationPegaPCS-Data-Party-Insurer PartyIDType PartyIDType PegaHC-PCS-FoundationPegaPCS-Data-Party-PlanSponsor PartyIDType PartyIDType PegaHC-PCS-FoundationPegaPCS-Data-Party-Subscriber PartyIDType PartyIDType PegaHC-PCS-FoundationPegaPCS-Data-Party-TPA PartyIDType PartyIDType PegaHC-PCS-FoundationPegaPCS-Data-Plan CopiedFrom CopiedFrom PegaHC-PCS-FoundationPegaPCS-Data-Plan TermDate Term Date PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductID Product ID PegaHC-PCS-Foundation

PegaPCS-Data-Plan ProductLOBOffering ProductLOBOffering PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductCreatedOn ProductEffectiveDate PegaHC-PCS-FoundationPegaPCS-Data-Plan SubscriberID SubscriberID PegaHC-PCS-FoundationPegaPCS-Data-Plan CustomerName CustomerName PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductEffectiveDate ProductEffectiveDate PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductDescription ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Plan LOBOffering ProductLOBOffering PegaHC-PCS-FoundationPegaPCS-Data-Plan CopyContract CopyContract PegaHC-PCS-FoundationPegaPCS-Data-Plan NewOrCopy NewOrCopy PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductName ProductName PegaHC-PCS-FoundationPegaPCS-Data-Plan WorkParties Parties PegaHC-PCS-FoundationPegaPCS-Data-Plan ContractPlanType ContractPlanType PegaHC-PCS-FoundationPegaPCS-Data-Plan ContractID Contract ID PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductAliasName ProductAliasName PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductCategory ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductClassName ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductHandle ProductCategory PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductInsKey ProductInsKey PegaHC-PCS-FoundationPegaPCS-Data-Plan EffectiveDate Effective Date PegaHC-PCS-FoundationPegaPCS-Data-Plan GroupID GroupID PegaHC-PCS-FoundationPegaPCS-Data-Plan ProductTermDate ProductTermDate PegaHC-PCS-FoundationPegaPCS-Data-Plan ContractDate Contract Date PegaHC-PCS-FoundationPegaPCS-Data-Plan CustomerID Customer ID PegaHC-PCS-FoundationPegaPCS-Data-PolicyCache Cache Cache PegaHC-PCS-FoundationPegaPCS-Data-Setting PropertyFilter PropertyFilter PegaHC-PCS-FoundationPegaPCS-Data-Setting DentalProductClass Dental Product Class PegaHC-PCS-FoundationPegaPCS-Data-Setting MedicalProductClass Medical Product Class PegaHC-PCS-FoundationPegaPCS-Data-Setting PolicyFlowEnabled PolicyFlowEnabled PegaHC-PCS-FoundationPegaPCS-Data-Setting ConsumerNotes ConsumerNotes PegaHC-PCS-FoundationPegaPCS-Data-Setting DentalProductTemplateClass Dental Product Template Class PegaHC-PCS-FoundationPegaPCS-Data-Setting MethodClass Method Class PegaHC-PCS-FoundationPegaPCS-Data-Setting PrototypePrefix PrototypePrefix PegaHC-PCS-FoundationPegaPCS-Data-Setting SubCategoryEnabled SubCategoryEnabled PegaHC-PCS-FoundationPegaPCS-Data-Setting BenefitClass Benefit Class PegaHC-PCS-FoundationPegaPCS-Data-Setting DraftModeEnabled DraftModeEnabled PegaHC-PCS-FoundationPegaPCS-Data-Setting PolicyClass Policy Class PegaHC-PCS-FoundationPegaPCS-Data-Setting MedicalProductTemplateClass MedicalProductTemplate PegaHC-PCS-FoundationPegaPCS-Data-Setting VisionProductClass visionProduct Class PegaHC-PCS-FoundationPegaPCS-Data-Setting GrouperClass Grouper Class PegaHC-PCS-FoundationPegaPCS-Data-Setting NotesLabels NotesLabels PegaHC-PCS-Foundation

PegaPCS-Data-Setting VisionProductTemplateClass Vision product Template Class PegaHC-PCS-FoundationPegaPCS-Data-Setting DentalContractClass Dental Contract Class PegaHC-PCS-FoundationPegaPCS-Data-Setting MandateClass Mandate Class PegaHC-PCS-FoundationPegaPCS-Data-Setting MedicalContractClass Miedical Contract Class PegaHC-PCS-FoundationPegaPCS-Data-Setting Test Test PegaHC-PCS-FoundationPegaPCS-Data-Setting BenefitSetClass Benefit Set Class PegaHC-PCS-FoundationPegaPCS-Data-Setting BulkUpdateClass Bulk Update Class PegaHC-PCS-FoundationPegaPCS-Data-Setting ClaimSystems ClaimSystems PegaHC-PCS-FoundationPegaPCS-Data-Setting PCSClasses PCSClasses PegaHC-PCS-FoundationPegaPCS-Data-Setting VisionContractClass Vision Contract Class PegaHC-PCS-FoundationPegaPCS-Data-Setting DictionaryDefaultFilterExclusions DictionaryDefaultFilterExclusions PegaHC-PCS-FoundationPegaPCS-Data-Setting LoaderClass loader Class PegaHC-PCS-FoundationPegaPCS-Data-Setting MaxRangeIncrements MaxRangeIncrements PegaHC-PCS-FoundationPegaPCS-Data-Setting PCSReleaseVersion PCSReleaseVersion PegaHC-PCS-FoundationPegaPCS-Data-UnionData UnionDataKey Computed Key PegaHC-PCS-FoundationPegaPCS-Data-UnionData WorkObjectID WorkObjectID PegaHC-PCS-FoundationPegaPCS-Data-UnionData UnionDataRule UnionDataRule PegaHC-PCS-FoundationPegaPCS-HC-USA-Landing ConsumerNotes ConsumerNotes PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator BenefitSet BenefitSet PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator SelectedBenefit SelectedBenefit PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator FlowName FlowName PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator SelectedBenefitKey SelectedBenefit PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator Policy Policy PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator Term Term PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator Grouper Grouper PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator Limit Limit PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator TaskName TaskName PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator OldCopiedFromBenefit OldCopiedFromBenefit PegaHC-PCS-FoundationPegaPCS-HC-Work-Accelerator Benefit Benefit PegaHC-PCS-FoundationRule-HC- TermDate TermDate PegaHC-PCS-FoundationRule-HC- EffectiveDate EffectiveDate PegaHC-PCS-FoundationRule-HC- ExclusionVariationFlag Exclusion Variation Flag PegaHC-PCS-FoundationRule-HC- HasExclusionVariation HasExclusionVariation PegaHC-PCS-FoundationRule-HC- HasLimitVariation HasLimitVariation PegaHC-PCS-FoundationRule-HC- LimitVariations LimitVariations PegaHC-PCS-FoundationRule-HC- MedicalPolicy Medical Policy PegaHC-PCS-FoundationRule-HC- MedicalPolicyFlag Medical Policy Flag PegaHC-PCS-FoundationRule-HC- ProductCategory ProductCategory PegaHC-PCS-FoundationRule-HC- ProductMasterList ProductMasterList PegaHC-PCS-FoundationRule-HC- HasAuthorizationVariation HasAuthorizationVariation PegaHC-PCS-Foundation

Rule-HC- WorkObjectInsKey WorkObjectInsKey PegaHC-PCS-FoundationRule-HC- DisplayDate DisplayDate PegaHC-PCS-FoundationRule-HC- ExclusionVariations Exclusion Variations PegaHC-PCS-FoundationRule-HC- HistoryDateCreated HistoryDateCreated PegaHC-PCS-FoundationRule-HC- LimitVariationFlag Limit Variation Flag PegaHC-PCS-FoundationRule-HC- NewOrCopy NewOrCopy PegaHC-PCS-FoundationRule-HC- AssignmentExists AssignmentExists PegaHC-PCS-FoundationRule-HC- BenefitOrGrouper BenefitOrGrouper PegaHC-PCS-FoundationRule-HC- CoverageVariations Exclusion Variations PegaHC-PCS-FoundationRule-HC- DisplayName DisplayName PegaHC-PCS-FoundationRule-HC- ShortDescription ShortDescription PegaHC-PCS-FoundationRule-HC- AuthorizationVariationFlag Authorization Variation Flag PegaHC-PCS-FoundationRule-HC- AuthorizationVariations Authorization Variations PegaHC-PCS-FoundationRule-HC- AliasName AliasName PegaHC-PCS-FoundationRule-HC- ConsumerNotes ConsumerNotes PegaHC-PCS-FoundationRule-HC- LOBOffering LOBOffering PegaHC-PCS-FoundationRule-HC- CostShareTiers CostShareSteps PegaHC-PCS-FoundationRule-HC- HasMedicalPolicy HasMedicalPolicy PegaHC-PCS-FoundationRule-HC- CopyOrNew Copy Or New PegaHC-PCS-FoundationRule-HC- HasCoverageVariation HasCoveragePolicy PegaHC-PCS-FoundationRule-HC- Name Name PegaHC-PCS-FoundationRule-HC- Retired Retired PegaHC-PCS-FoundationRule-HC- RetireDate TermDate PegaHC-PCS-FoundationRule-HC- RuleHistory Rule History PegaHC-PCS-FoundationRule-HC- TempKey TempKey PegaHC-PCS-FoundationRule-HC- ClaimInstructions Limit Instructions PegaHC-PCS-FoundationRule-HC- CoverageVariationFlag Coverage Variation Flag PegaHC-PCS-FoundationRule-HC- Draft Draft PegaHC-PCS-FoundationRule-HC- DraftOperatorName DraftOperatorName PegaHC-PCS-FoundationRule-HC- PolicyMasterList ProductMasterList PegaHC-PCS-FoundationRule-HC-PCS- CopiedFrom CopiedFrom PegaHC-PCS-FoundationRule-HC-PCS- Deleted Deleted PegaHC-PCS-FoundationRule-HC-PCS- FromLink FromLink PegaHC-PCS-FoundationRule-HC-PCS- GrpDropDownCategory Category PegaHC-PCS-FoundationRule-HC-PCS- PolicyKey PolicyKey PegaHC-PCS-FoundationRule-HC-PCS- PUnionDataObj UnionDataObj PegaHC-PCS-FoundationRule-HC-PCS- SummaryDescription SummaryDescription PegaHC-PCS-FoundationRule-HC-PCS- Templates Templates PegaHC-PCS-FoundationRule-HC-PCS- WorkObjectInsKey WorkObjectInsKey PegaHC-PCS-FoundationRule-HC-PCS- CopyOrNew Copy Or New PegaHC-PCS-Foundation

Rule-HC-PCS- GeneratedSPDNotes GeneratedSPD PegaHC-PCS-FoundationRule-HC-PCS- HasProductMasterList MasterList PegaHC-PCS-FoundationRule-HC-PCS- ProductLine Product Line PegaHC-PCS-FoundationRule-HC-PCS- ReferencedList ReferencedList PegaHC-PCS-FoundationRule-HC-PCS- ShortDescription ShortDescription PegaHC-PCS-FoundationRule-HC-PCS- SPDDescription SPDDescription PegaHC-PCS-FoundationRule-HC-PCS- TempKey TempKey PegaHC-PCS-FoundationRule-HC-PCS- WellnessBenefit WellnessBenefit PegaHC-PCS-FoundationRule-HC-PCS- BaseRate BaseRate PegaHC-PCS-FoundationRule-HC-PCS- ChildItem ChildItem PegaHC-PCS-FoundationRule-HC-PCS- CoverageConsumerNotes CoverageConsumerNotes PegaHC-PCS-FoundationRule-HC-PCS- CUnionDataObj UnionDataObj PegaHC-PCS-FoundationRule-HC-PCS- HasMasterList MasterList PegaHC-PCS-FoundationRule-HC-PCS- Limit Limit PegaHC-PCS-FoundationRule-HC-PCS- Limits Limits PegaHC-PCS-FoundationRule-HC-PCS- RelativityFactor RelativityFactor PegaHC-PCS-FoundationRule-HC-PCS- AuthIfMapping AuthIfMapping PegaHC-PCS-FoundationRule-HC-PCS- BenefitSetTree BenefitSetTree PegaHC-PCS-FoundationRule-HC-PCS- CopiedMode CopiedMode PegaHC-PCS-FoundationRule-HC-PCS- CostShares CostShares PegaHC-PCS-FoundationRule-HC-PCS- CreatedFrom CopiedFrom PegaHC-PCS-FoundationRule-HC-PCS- Draft Draft PegaHC-PCS-FoundationRule-HC-PCS- GeneratedSPD GeneratedSPD PegaHC-PCS-FoundationRule-HC-PCS- MandateFlag MandateFlag PegaHC-PCS-FoundationRule-HC-PCS- NodeUpdateOperator NodeUpdateOperator PegaHC-PCS-FoundationRule-HC-PCS- ChangesApplied ChangesApplied PegaHC-PCS-FoundationRule-HC-PCS- ConsumerNotes ConsumerNotes PegaHC-PCS-FoundationRule-HC-PCS- Cost Cost PegaHC-PCS-FoundationRule-HC-PCS- DropDownCategory Category PegaHC-PCS-FoundationRule-HC-PCS- Exclusions Exclusions PegaHC-PCS-FoundationRule-HC-PCS- HasCostShares HasCostShares PegaHC-PCS-FoundationRule-HC-PCS- HasPolicyMasterList MasterList PegaHC-PCS-FoundationRule-HC-PCS- NewOrCopy NewOrCopy PegaHC-PCS-FoundationRule-HC-PCS- Rank Rank PegaHC-PCS-FoundationRule-HC-PCS- Retired Retired PegaHC-PCS-FoundationRule-HC-PCS- TemplateFlag TemplateFlag PegaHC-PCS-FoundationRule-HC-PCS- CarveOutFlag CarveOutFlag PegaHC-PCS-FoundationRule-HC-PCS- CopyFromOrCreateNew Copy Or New PegaHC-PCS-FoundationRule-HC-PCS- EditFlag EditFlag PegaHC-PCS-FoundationRule-HC-PCS- IsWellnessBenefit IsWellnessBenefit PegaHC-PCS-Foundation

Rule-HC-PCS- RetireDate TermDate PegaHC-PCS-FoundationRule-HC-PCS- RuleDeleteError RuleDeleted PegaHC-PCS-FoundationRule-HC-PCS- SelectedBenefit SelectedBenefit PegaHC-PCS-FoundationRule-HC-PCS- SkipThis SkipThis PegaHC-PCS-FoundationRule-HC-PCS- TermDate TermDate PegaHC-PCS-FoundationRule-HC-PCS- AgeAttainment AgeAttainment PegaHC-PCS-FoundationRule-HC-PCS- ConfigureMode ConfigureMode PegaHC-PCS-FoundationRule-HC-PCS- CostShareViewName CostShareViewName PegaHC-PCS-FoundationRule-HC-PCS- Coverages Coverages PegaHC-PCS-FoundationRule-HC-PCS- CoverageVariationFlag Coverage Variation Flag PegaHC-PCS-FoundationRule-HC-PCS- EffectiveDate EffectiveDate PegaHC-PCS-FoundationRule-HC-PCS- Policy Policy PegaHC-PCS-FoundationRule-HC-PCS- PolicyName PolicyName PegaHC-PCS-FoundationRule-HC-PCS- PreviousSelectedBenefitSet Selected BenefitSet PegaHC-PCS-FoundationRule-HC-PCS- Category Category PegaHC-PCS-FoundationRule-HC-PCS- CopiedUnionDataFlag CopiedUnionDataFlag PegaHC-PCS-FoundationRule-HC-PCS- CostShareException CostShareException PegaHC-PCS-FoundationRule-HC-PCS- NodeStatus NodeStatus PegaHC-PCS-FoundationRule-HC-PCS- ReferencedListCount ReferencedListCount PegaHC-PCS-FoundationRule-HC-PCS- Required Required PegaHC-PCS-FoundationRule-HC-PCS- RuleDeleteStatus RuleDeleteStatus PegaHC-PCS-FoundationRule-HC-PCS- SelectedBenefitSet Selected BenefitSet PegaHC-PCS-FoundationRule-HC-PCS- TempInsName TempInsName PegaHC-PCS-FoundationRule-HC-PCS- UnionDataObj UnionDataObj PegaHC-PCS-FoundationRule-HC-PCS-Benefit AuthPendCode AuthPendCode PegaHC-PCS-FoundationRule-HC-PCS-Benefit BenefitSetName FromBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit BenefitSets BenefitSets PegaHC-PCS-FoundationRule-HC-PCS-Benefit DisplayName DisplayName PegaHC-PCS-FoundationRule-HC-PCS-Benefit MappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit Policy Policy PegaHC-PCS-FoundationRule-HC-PCS-Benefit AuthIfMappingGroups AuthIfMappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit NonCoverageMapping NonCoverageMapping PegaHC-PCS-FoundationRule-HC-PCS-Benefit Category Category PegaHC-PCS-FoundationRule-HC-PCS-Benefit CoverageNotes CoverageNotes PegaHC-PCS-FoundationRule-HC-PCS-Benefit CoveredIfNotes CoverageNotes PegaHC-PCS-FoundationRule-HC-PCS-Benefit IsCovered IsCovered PegaHC-PCS-FoundationRule-HC-PCS-Benefit NewOrCopy NewOrCopy PegaHC-PCS-FoundationRule-HC-PCS-Benefit OriginalBenefitSet OriginalBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit Rank Rank PegaHC-PCS-FoundationRule-HC-PCS-Benefit AuthRequired Auth Required PegaHC-PCS-Foundation

Rule-HC-PCS-Benefit BenefitKey BenefitSetKey PegaHC-PCS-FoundationRule-HC-PCS-Benefit CopyOfBenefit CopyOfBenefit PegaHC-PCS-FoundationRule-HC-PCS-Benefit CoverageMapping CoverageMapping PegaHC-PCS-FoundationRule-HC-PCS-Benefit Networks Networks PegaHC-PCS-FoundationRule-HC-PCS-Benefit CoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit Exclusions Exclusions PegaHC-PCS-FoundationRule-HC-PCS-Benefit SelectedBenefit SelectedBenefit PegaHC-PCS-FoundationRule-HC-PCS-Benefit DefinedMapValues DefinedMapValues PegaHC-PCS-FoundationRule-HC-PCS-Benefit Mapping Mappings PegaHC-PCS-FoundationRule-HC-PCS-Benefit NonCoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit BenefitSetKey BenefitSetKey PegaHC-PCS-FoundationRule-HC-PCS-Benefit IsLockedByBenefitSet IsLockedByBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit IsWellnessBenefit IsWellnessBenefit PegaHC-PCS-FoundationRule-HC-PCS-Benefit SelectedBenefitSet Selected BenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx Networks Networks PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx NonCoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx BenefitKey BenefitSetKey PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx IsCovered IsCovered PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx IsLockedByBenefitSet IsLockedByBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx IsWellnessBenefit IsWellnessBenefit PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx AuthIfMappingGroups AuthIfMappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx AuthRequired Auth Required PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx BenefitSetKey BenefitSetKey PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx CoverageMapping CoverageMapping PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx CoverageNotes CoverageNotes PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx DisplayName DisplayName PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx SelectedBenefit SelectedBenefit PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx BenefitSetName FromBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx Category Category PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx CoveredIfNotes CoverageNotes PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx MappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx SelectedBenefitSet Selected BenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx NewOrCopy NewOrCopy PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx OriginalBenefitSet OriginalBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx Policy Policy PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx Rank Rank PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx Exclusions Exclusions PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx NonCoverageMapping NonCoverageMapping PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx CopyOfBenefit CopyOfBenefit PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx AuthPendCode AuthPendCode PegaHC-PCS-Foundation

Rule-HC-PCS-Benefit-Rx BenefitSets BenefitSets PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx CoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx DefinedMapValues DefinedMapValues PegaHC-PCS-FoundationRule-HC-PCS-Benefit-Rx Mapping Mappings PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet BulkTestFilename BatchClaimsTestFilename PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet OriginalBenefitSetProductCategory Original Benefit Set Product Category PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testCustom testCustom PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testDiagnosisCode testDiagnosisCode PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testServiceLines testServiceLines PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet BenefitConflicts BenefitConflicts PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet Benefits Benefits PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet BenefitsBeforeBU BenefitsBeforeBU PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet Category Category PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet DetectedConflicts DetectedConflicts PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet OriginalBenefitSetLOBOffering Original Benefit Set LOB Offering PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testDiagnosisCodesI testDiagnosisCodesI PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet TestMappings TestMappings PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testProviderSpecialty testProviderSpecialty PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet SelectedAttachment SelectedAttachment PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testPlaceOfService testPlaceOfService PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testServiceCodes testServiceCodes PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet BulkClaimTests BulkClaimTests PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testTypeOfService testTypeOfService PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet BenefitSetKey BenefitSetKey PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet Groupers Groupers PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet NewOrCopy NewOrCopy PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet BenefitSetTree BenefitSetTree PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet TestClaimType ClaimType PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testServiceCode testServiceCode PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet OriginalBenefitSet OriginalBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testBillType testBillType PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet testDiagnosisCodes testDiagnosisCodes PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet OriginalBenefitSetEffectiveDate Original Benefit Set Effective Date PegaHC-PCS-FoundationRule-HC-PCS-BenefitSet SelectedGrouperRule SelectedGrouperRule PegaHC-PCS-FoundationRule-HC-PCS-CostShare AnnualMaxLow AnnualMaxLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare DependentRangeValues AmountRangeValues PegaHC-PCS-FoundationRule-HC-PCS-CostShare EmployeeLow EmployeeLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare OccurenceMethod Occurence Method PegaHC-PCS-FoundationRule-HC-PCS-CostShare AmountRangeValues AmountRangeValues PegaHC-PCS-FoundationRule-HC-PCS-CostShare AnnualMaxRangeValues AnnualMaxRangeValues PegaHC-PCS-Foundation

Rule-HC-PCS-CostShare CalculationMethod Calculation Method PegaHC-PCS-FoundationRule-HC-PCS-CostShare EmployeeIncrement EmployeeIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyLow FamilyLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare LifetimeMax LifetimeMax PegaHC-PCS-FoundationRule-HC-PCS-CostShare PeriodLow PeriodLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare SingleMaxHigh SingleMaxHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare SingleMaxLow SingleMaxLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare AnnualMaxHigh AnnualMaxHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare AnnualMaxSelection AnnualMaxSelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyMaxIncrement FamilyMaxIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilySelection FamilySelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare OccurrenceMethodSelection OccurenceMethodSelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare PeriodIncrement PeriodIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare SingleMax SingleMax PegaHC-PCS-FoundationRule-HC-PCS-CostShare SingleMaxSelection SingleMaxSelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare Time Time PegaHC-PCS-FoundationRule-HC-PCS-CostShare TimeCode TimeCode PegaHC-PCS-FoundationRule-HC-PCS-CostShare SpouseIncrement SpouseIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare SpouseLow SpouseLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare AmountLow AmountLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare CalculationMethodSelection CalculationMethodSelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare CarryoverIncrement CarryoverIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare DependentIncrement DependentIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare DependentLow DependentLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyMax FamilyMax PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyMaxLow FamilyMaxLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyMaxSelection FamilyMaxSelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare Methods Methods PegaHC-PCS-FoundationRule-HC-PCS-CostShare OccurrenceMethods Methods PegaHC-PCS-FoundationRule-HC-PCS-CostShare SpouseHigh SpouseHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare Type Type PegaHC-PCS-FoundationRule-HC-PCS-CostShare AmountIncrement AmountIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare AmountSelection AmountSelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare AnnualMaxIncrement AnnualMaxIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare DependentHigh DependentHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare Employee Employee PegaHC-PCS-FoundationRule-HC-PCS-CostShare Family Family PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyMaxRangeValues FamilyMaxRangeValues PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyRangeValues AmountRangeValues PegaHC-PCS-FoundationRule-HC-PCS-CostShare Period Period PegaHC-PCS-Foundation

Rule-HC-PCS-CostShare PeriodHigh PeriodHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare PeriodSelection PeriodSelection PegaHC-PCS-FoundationRule-HC-PCS-CostShare SingleMaxRangeValues AmountRangeValues PegaHC-PCS-FoundationRule-HC-PCS-CostShare SpouseRangeValues AmountRangeValues PegaHC-PCS-FoundationRule-HC-PCS-CostShare TimeMethods Methods PegaHC-PCS-FoundationRule-HC-PCS-CostShare AnnualMax AnnualMax PegaHC-PCS-FoundationRule-HC-PCS-CostShare CalculationMethods Methods PegaHC-PCS-FoundationRule-HC-PCS-CostShare EmployeeHigh EmployeeHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyHigh FamilyHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyIncrement FamilyIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare FamilyMaxHigh FamilyMaxHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare LifetimeMaxHigh LifetimeMaxHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare LifetimeMaxIncrement LifetimeMaxIncrement PegaHC-PCS-FoundationRule-HC-PCS-CostShare LifetimeMaxLow LifetimeMaxLow PegaHC-PCS-FoundationRule-HC-PCS-CostShare Deductible Deductible PegaHC-PCS-FoundationRule-HC-PCS-CostShare EmployeeRangeValues Employee Range Values PegaHC-PCS-FoundationRule-HC-PCS-CostShare LifetimeMaxRangeValues LifetimeMaxRangeValues PegaHC-PCS-FoundationRule-HC-PCS-CostShare PeriodRangeValues Period Range Values PegaHC-PCS-FoundationRule-HC-PCS-CostShare Spouse Spouse PegaHC-PCS-FoundationRule-HC-PCS-CostShare AmountHigh AmountHigh PegaHC-PCS-FoundationRule-HC-PCS-CostShare Amount Amount PegaHC-PCS-FoundationRule-HC-PCS-CostShare SingleMaxIncrement SingleMaxIncrement PegaHC-PCS-FoundationRule-HC-PCS-Coverage MaxAge MaxAge PegaHC-PCS-FoundationRule-HC-PCS-Coverage EligibilityDescription EligibilityDescription PegaHC-PCS-FoundationRule-HC-PCS-Coverage MinAge MinAge PegaHC-PCS-FoundationRule-HC-PCS-Coverage Methods Methods PegaHC-PCS-FoundationRule-HC-PCS-CoverageLevels CoverageDescription CoverageDescription PegaHC-PCS-FoundationRule-HC-PCS-Grouper Validations Validations PegaHC-PCS-FoundationRule-HC-PCS-Grouper Exclusions Exclusions PegaHC-PCS-FoundationRule-HC-PCS-Grouper Networks Networks PegaHC-PCS-FoundationRule-HC-PCS-Grouper GrouperType GrouperType PegaHC-PCS-FoundationRule-HC-PCS-Grouper Groupers Groupers PegaHC-PCS-FoundationRule-HC-PCS-Grouper Benefits Benefits PegaHC-PCS-FoundationRule-HC-PCS-Grouper BenefitList BenefitList PegaHC-PCS-FoundationRule-HC-PCS-Grouper NewOrCopy NewOrCopy PegaHC-PCS-FoundationRule-HC-PCS-Grouper AuthRequired Auth Required PegaHC-PCS-FoundationRule-HC-PCS-Grouper AuthIfMapping AuthIfMapping PegaHC-PCS-FoundationRule-HC-PCS-Grouper CoverageMapping CoverageMapping PegaHC-PCS-FoundationRule-HC-PCS-Grouper CoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Grouper AuthIfMappingGroups AuthIfMappingGroups PegaHC-PCS-Foundation

Rule-HC-PCS-Grouper DetectedConflicts DetectedConflicts PegaHC-PCS-FoundationRule-HC-PCS-Grouper NonCoverageMapping NonCoverageMapping PegaHC-PCS-FoundationRule-HC-PCS-Grouper OriginalBenefitSet OriginalBenefitSet PegaHC-PCS-FoundationRule-HC-PCS-Grouper NonCoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-PCS-Guardrail OtherRules OtherRules PegaHC-PCS-FoundationRule-HC-PCS-Guardrail NetworkRules NetworkRules PegaHC-PCS-FoundationRule-HC-PCS-Guardrail CostShareRules CostShareRules PegaHC-PCS-FoundationRule-HC-PCS-Limit AgeQualifier Age Qualifier PegaHC-PCS-FoundationRule-HC-PCS-Limit LimitPeriod Limit Period PegaHC-PCS-FoundationRule-HC-PCS-Limit MaximumAllowed Maximum Allowed PegaHC-PCS-FoundationRule-HC-PCS-Limit DefineAgeLimit Define Age Limit PegaHC-PCS-FoundationRule-HC-PCS-Limit FromAge FromAge PegaHC-PCS-FoundationRule-HC-PCS-Limit LimitType LimitType PegaHC-PCS-FoundationRule-HC-PCS-Limit ToAge To Age PegaHC-PCS-FoundationRule-HC-PCS-Mandate State State PegaHC-PCS-FoundationRule-HC-PCS-Mandate MandateID MandateID PegaHC-PCS-FoundationRule-HC-PCS-Method CopyOfMethod CopyOfBenefit PegaHC-PCS-FoundationRule-HC-PCS-Method Type Type Of the method PegaHC-PCS-FoundationRule-HC-PCS-Network Authorizations Authorizations PegaHC-PCS-FoundationRule-HC-PCS-Network Benefits Benefits PegaHC-PCS-FoundationRule-HC-PCS-Network Coverages Coverages PegaHC-PCS-FoundationRule-HC-PCS-Network Groupers Groupers PegaHC-PCS-FoundationRule-HC-PCS-Network RiskSharingMethod RiskSharingMethod PegaHC-PCS-FoundationRule-HC-PCS-Network CoverageLevels CoverageLevels PegaHC-PCS-FoundationRule-HC-PCS-Network Validations Validations PegaHC-PCS-FoundationRule-HC-PCS-Network Limits Limits PegaHC-PCS-FoundationRule-HC-PCS-Network NetworkDescription NetworkDescription PegaHC-PCS-FoundationRule-HC-PCS-Network NetworkType NetworkType PegaHC-PCS-FoundationRule-HC-PCS-Policy Benefit Benefit PegaHC-PCS-FoundationRule-HC-PCS-Policy Category Category PegaHC-PCS-FoundationRule-HC-PCS-Policy PolicyText PolicyText PegaHC-PCS-FoundationRule-HC-PCS-Product NewProductFamily NewProductFamily PegaHC-PCS-FoundationRule-HC-PCS-Product Validations Validations PegaHC-PCS-FoundationRule-HC-PCS-Product BenefitSetKey BenefitSetKey PegaHC-PCS-FoundationRule-HC-PCS-Product ProductCategory ProductCategory PegaHC-PCS-FoundationRule-HC-PCS-Product Region Regions PegaHC-PCS-FoundationRule-HC-PCS-Product BenefitSetName BenefitSetName PegaHC-PCS-FoundationRule-HC-PCS-Product Chap4IntroData Chap 4 Intro Data PegaHC-PCS-FoundationRule-HC-PCS-Product CoverageLevels CoverageLevels PegaHC-PCS-FoundationRule-HC-PCS-Product ProductTypeCode Product Type Code PegaHC-PCS-Foundation

Rule-HC-PCS-Product Chap4IntroHeading Chap 4 Intro Heading PegaHC-PCS-FoundationRule-HC-PCS-Product MarketSegment MarketSegment PegaHC-PCS-FoundationRule-HC-PCS-Product BenefitSetLabel BenefitSetLabel PegaHC-PCS-FoundationRule-HC-PCS-Product EligibilityRules Eligibility Rules PegaHC-PCS-FoundationRule-HC-PCS-Product GeneratedNameTest GeneratedNameTest PegaHC-PCS-FoundationRule-HC-PCS-Product Guardrail Guardrails PegaHC-PCS-FoundationRule-HC-PCS-Product IsSeniorProduct Available to Seniors PegaHC-PCS-FoundationRule-HC-PCS-Product ProductFamily Product Family PegaHC-PCS-FoundationRule-HC-PCS-Product SubCategory SubCategory PegaHC-PCS-FoundationRule-HC-PCS-Product HighLevelInfo HighLevelInfo PegaHC-PCS-FoundationRule-HC-PCS-Product LegalEntity Legal Entity PegaHC-PCS-FoundationRule-HC-PCS-Product Chap4Heading Chap 4 Heading PegaHC-PCS-FoundationRule-HC-PCS-Product Groupers Groupers PegaHC-PCS-FoundationRule-HC-PCS-Product WellnessBenefitTree BenefitSetTree PegaHC-PCS-FoundationRule-HC-PCS-Product BenefitSetTree BenefitSetTree PegaHC-PCS-FoundationRule-HC-PCS-Product Category Category PegaHC-PCS-FoundationRule-HC-PCS-Product MemberOOP Member Out-of-Pocket PegaHC-PCS-FoundationRule-HC-PCS-Product NetworkRestriction Network Restriction PegaHC-PCS-FoundationRule-HC-PCS-Product Networks Networks PegaHC-PCS-FoundationRule-HC-PCS-Product NewOrCopyPT NewOrCopyPT PegaHC-PCS-FoundationRule-HC-PCS-Product RegionAvailability Region Availablilty PegaHC-PCS-FoundationRule-HC-PCS-Product PMPMBaseRate PMPM Base Rate PegaHC-PCS-FoundationRule-HC-PCS-UnionData UnionDataKey Computed Key PegaHC-PCS-FoundationRule-HC-Policy TermDate TermDate PegaHC-PCS-FoundationRule-HC-Policy PolicyText PolicyText PegaHC-PCS-FoundationRule-HC-Policy PolicyFlagIndex PolicyFlagIndex PegaHC-PCS-FoundationRule-HC-Policy CopyOfPolicy CopyOfPolicy PegaHC-PCS-FoundationRule-HC-Policy ProductLinesLongName ProductLinesLongName PegaHC-PCS-FoundationRule-HC-Policy PolicyTermIndex PolicyTermIndex PegaHC-PCS-FoundationRule-HC-Policy CopiedFrom CopiedFrom PegaHC-PCS-FoundationRule-HC-Policy SelectedGrouperRule SelectedGrouperRule PegaHC-PCS-FoundationRule-HC-Policy Terms Terms PegaHC-PCS-FoundationRule-HC-Policy SelectedBenefitRule SelectedBenefitRule PegaHC-PCS-FoundationRule-HC-Policy SelectedGrouper SelectedBenefit PegaHC-PCS-FoundationRule-HC-Policy NewTermFlag NewTermFlag PegaHC-PCS-FoundationRule-HC-Policy SelectedPolicy SelectedPolicy PegaHC-PCS-FoundationRule-HC-Policy ProductLines ProductLines PegaHC-PCS-FoundationRule-HC-Policy PolicyBenefitIndex Policy Benefit Index PegaHC-PCS-FoundationRule-HC-Policy SelectedBenefit SelectedBenefit PegaHC-PCS-FoundationRule-HC-Policy FoundDraftContents FoundDraftContents PegaHC-PCS-Foundation

Rule-HC-Term TermGrouperIndex TermGrouperIndex PegaHC-PCS-FoundationRule-HC-Term CoverageMapping CoverageMapping PegaHC-PCS-FoundationRule-HC-Term SelectedTerm SelectedTerm PegaHC-PCS-FoundationRule-HC-Term TermBenefitIndex TermBenefitIndex PegaHC-PCS-FoundationRule-HC-Term AuthorizationInstructions Authorizations Instructions PegaHC-PCS-FoundationRule-HC-Term BenefitOrGrouper Copy Or New PegaHC-PCS-FoundationRule-HC-Term DisplayName DisplayName PegaHC-PCS-FoundationRule-HC-Term ExculsionsInstructions Exclusions Instructions PegaHC-PCS-FoundationRule-HC-Term LimitConfigureMode LimitConfigureMode PegaHC-PCS-FoundationRule-HC-Term MappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-Term MedPolicyConfigureMode MedPolicyConfigureMode PegaHC-PCS-FoundationRule-HC-Term SelectedGrouper SelectedBenefit PegaHC-PCS-FoundationRule-HC-Term ServiceIsCovered ServiceIsCovered PegaHC-PCS-FoundationRule-HC-Term Limits Limits PegaHC-PCS-FoundationRule-HC-Term SelectedGrouperRule SelectedGrouperRule PegaHC-PCS-FoundationRule-HC-Term Tag3 Tag PegaHC-PCS-FoundationRule-HC-Term ConfigureMode ConfigureMode PegaHC-PCS-FoundationRule-HC-Term CoverageInstructions Coverage Instructions PegaHC-PCS-FoundationRule-HC-Term LimitInstructions Limit Instructions PegaHC-PCS-FoundationRule-HC-Term NonCoverageMapping NonCoverageMapping PegaHC-PCS-FoundationRule-HC-Term CoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-Term GeneratedSPD GeneratedSPD PegaHC-PCS-FoundationRule-HC-Term HasAgeExclusion HasAgeExclusion PegaHC-PCS-FoundationRule-HC-Term Tag Tag PegaHC-PCS-FoundationRule-HC-Term ExclusionConfigureMode ExclusionConfigureMode PegaHC-PCS-FoundationRule-HC-Term HasGenderExclusion HasGenderExclusion PegaHC-PCS-FoundationRule-HC-Term CoverageConfigureMode CoverageConfigureMode PegaHC-PCS-FoundationRule-HC-Term CopyOrNew Copy Or New PegaHC-PCS-FoundationRule-HC-Term CopyOfTerm CopyOfBenefit PegaHC-PCS-FoundationRule-HC-Term AttachedToBenefitAliasName AttachedToBenefitAliasName PegaHC-PCS-FoundationRule-HC-Term SelectedBenefitRule SelectedBenefitRule PegaHC-PCS-FoundationRule-HC-Term SelectedBenefit SelectedBenefit PegaHC-PCS-FoundationRule-HC-Term Mapping Mappings PegaHC-PCS-FoundationRule-HC-Term LinkViewName LinkViewName PegaHC-PCS-FoundationRule-HC-Term Exclusions Exclusions PegaHC-PCS-FoundationRule-HC-Term DefinedMapValues DefinedMapValues PegaHC-PCS-FoundationRule-HC-Term CopiedFrom CopiedFrom PegaHC-PCS-FoundationRule-HC-Term AuthorizationConfigureMode AuthorizationConfigureMode PegaHC-PCS-FoundationRule-HC-Term AuthIfMappingGroups AuthIfMappingGroups PegaHC-PCS-FoundationRule-HC-Term TagList Tag List PegaHC-PCS-Foundation

Rule-HC-Term NonCoverageMappingGroups MappingGroups PegaHC-PCS-FoundationRule-HC-Term Tag2 Tag PegaHC-PCS-FoundationRule-PCS- DisplayDate DisplayDate PegaHC-PCS-FoundationData-Portal OperatorImage OperatorImage PegaHL7Index-CircumstanceDefinition VersionID VersionID PegaHL7PegaHC-HL7-Data- PV1_PatientVisit PV1_PatientVisit PegaHL7PegaHC-HL7-Data- UB1_UB82Data UB1_UB82Data PegaHL7PegaHC-HL7-Data- IN_Insurance IN_Insurance PegaHL7PegaHC-HL7-Data- MSH_MessageHeader MSH_MessageHeader PegaHL7PegaHC-HL7-Data- PD1_PatientAddDemographic PD1_PatientAddDemographic PegaHL7PegaHC-HL7-Data- AL1_PatientAllergy AL1_PatientAllergy PegaHL7PegaHC-HL7-Data- DG1_Diagnosis DG1_Diagnosis PegaHL7PegaHC-HL7-Data- FieldSep ComponentSep PegaHL7PegaHC-HL7-Data- RepetitionSep ComponentSep PegaHL7PegaHC-HL7-Data- BTS_BatchTrailer BTS_BatchTrailerSegment PegaHL7PegaHC-HL7-Data- PV2_PatientVisitAdditional PV2_PatientVisitAdditional PegaHL7PegaHC-HL7-Data- FTS_FileTrailer FTS_FileTrailerSegment PegaHL7PegaHC-HL7-Data- GT1_Guarantor GR1_Guarantor PegaHL7PegaHC-HL7-Data- MessageType MessageType PegaHL7PegaHC-HL7-Data- QRD_QueryDefinition QRD_QueryDefinition PegaHL7PegaHC-HL7-Data- SubcomponentSep ComponentSep PegaHL7PegaHC-HL7-Data- EscapeCharacter ComponentSep PegaHL7PegaHC-HL7-Data- EVN_EventType EVN_EventType PegaHL7PegaHC-HL7-Data- MRG_MergePatient MRG_MergePatient PegaHL7PegaHC-HL7-Data- UB2_UB92Data UB2_UB92Data PegaHL7PegaHC-HL7-Data- BHS_BatchHeader BHS_BatchHeader PegaHL7PegaHC-HL7-Data- FHS_FileHeader FHS_FileHeader PegaHL7PegaHC-HL7-Data- OBX_Observation OBX_Observation PegaHL7PegaHC-HL7-Data- PR1_Procedures PR1_Procedures PegaHL7PegaHC-HL7-Data- QRF_QueryFilter QRF_QueryFilter PegaHL7PegaHC-HL7-Data- ComponentSep ComponentSep PegaHL7PegaHC-HL7-Data- DB1_DisabilitySegment DB1_DisabilitySegment PegaHL7PegaHC-HL7-Data- HL7Message HL7Message PegaHL7PegaHC-HL7-Data- NK1_NextofKin NK1_NextofKin PegaHL7PegaHC-HL7-Data- PID_PatientIdentification PID_PatientIdentification PegaHL7PegaHC-HL7-Data- VersionID VersionID PegaHL7PegaHC-HL7-Data- ACC_Accident ACC_Accident PegaHL7PegaHC-HL7-Data-ACC_Accident ACC_03_AccidentLocation ACC_03_AccidentLocation PegaHL7PegaHC-HL7-Data-ACC_Accident ACC_02_AccidentCode ACC_02_AccidentCode PegaHL7PegaHC-HL7-Data-ACC_Accident ACC_01_AccidentDateTime ACC_01_AccidentDateTime PegaHL7

PegaHC-HL7-Data-ACK_Acknowledgement MSA_MessageAcknowledgement MSA_MessageAcknowledgement PegaHL7

PegaHC-HL7-Data-ACK_Acknowledgement MSH_MessageHeader MSH_MessageHeader PegaHL7PegaHC-HL7-Data-Address Address_02_OtherDesignation PID_11_02_OtherDesignation PegaHL7PegaHC-HL7-Data-Address Address_23_09_CountryParishCode Address_09_CountryParishCode PegaHL7PegaHC-HL7-Data-Address Address_23_10_CensusTract Address_10_CensusTract PegaHL7

PegaHC-HL7-Data-Address Address_08_OtherGeographicDesignation PID_11_08_OtherGeographicDesignation PegaHL7PegaHC-HL7-Data-Address Address_01_StreetAddress PID_11_01_StreetAddress PegaHL7PegaHC-HL7-Data-Address Address_04_StateOrProvince PID_11_04_StateOrProvince PegaHL7PegaHC-HL7-Data-Address Address_07_Type PID_11_07_Type PegaHL7PegaHC-HL7-Data-Address Address_05_ZipOrPostalCode PID_11_05_ZipOrPostalCode PegaHL7PegaHC-HL7-Data-Address Address_03_City PID_11_03_City PegaHL7PegaHC-HL7-Data-Address Address_06_Country PID_11_06_Country PegaHL7PegaHC-HL7-Data-AdmitNumber Admit_03_CheckDigitScheme Check Digit Scheme PegaHL7PegaHC-HL7-Data-AdmitNumber Admit_06_AssigningFacilityId Assigning Facility Id PegaHL7PegaHC-HL7-Data-AdmitNumber Admit_04_AssigningAuthority Assigning Authority PegaHL7PegaHC-HL7-Data-AdmitNumber Admit_01_Id Id PegaHL7PegaHC-HL7-Data-AdmitNumber Admit_02_CheckDigit Check Digit PegaHL7PegaHC-HL7-Data-AdmitNumber Admit_05_IdentifierTypeCode Identifier Type Code PegaHL7PegaHC-HL7-Data-AL1_PatientAllergy AL1_02_AllergyType AL1_02_AllergyType PegaHL7PegaHC-HL7-Data-AL1_PatientAllergy AL1_05_AllergyReaction AL1_05_AllergyReaction PegaHL7PegaHC-HL7-Data-AL1_PatientAllergy AL1_04_AllergySeverity AL1_04_AllergySeverity PegaHL7PegaHC-HL7-Data-AL1_PatientAllergy AL1_06_IdentificationDate AL1_06_IdentificationDate PegaHL7PegaHC-HL7-Data-AL1_PatientAllergy AL1_01_SetID AL1_01_SetID PegaHL7PegaHC-HL7-Data-AL1_PatientAllergy AL1_03_AllergyCode AL1_03_AllergyCode PegaHL7PegaHC-HL7-Data-BatchStatistics DateReceived Date Received PegaHL7PegaHC-HL7-Data-BatchStatistics ProcessingRate ProcessingRate PegaHL7PegaHC-HL7-Data-BatchStatistics NumberOfMessages Number Of HL7 Messages PegaHL7PegaHC-HL7-Data-BatchStatistics NumberFunctionalGroups NumberFunctionalGroups PegaHL7PegaHC-HL7-Data-BatchStatistics FileName FileName PegaHL7PegaHC-HL7-Data-BatchStatistics StartTime Start Time PegaHL7PegaHC-HL7-Data-BatchStatistics EndTime End Time PegaHL7PegaHC-HL7-Data-BatchStatistics BatchID Batch ID PegaHL7PegaHC-HL7-Data-BatchStatistics NumberWorkObjectsCreated Number WorkObjects Created PegaHL7PegaHC-HL7-Data-BatchStatistics NumberMessagesInError Number Messages In Error PegaHL7PegaHC-HL7-Data-BatchStatistics BatchClaimsDetails Batch Claims Details PegaHL7PegaHC-HL7-Data-BatchStatistics StraightThroughProcess StraightThroughProcess PegaHL7PegaHC-HL7-Data-BatchStatistics ClaimsRoutedToWB Claims Routed To WB PegaHL7

PegaHC-HL7-Data-BHS_BatchHeader BHS_06_BatchReceivingFacility BHS_06_BatchReceivingFacility PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_07_BatchCreationDateTime BHS_07_BatchCreationDateTime PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_02_BatchEncodingCharacters BHS_02_BatchEncodingCharacters PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_10_BatchComment BHS_10_BatchComment PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_12_ReferenceBatchControlID BHS_12_ReferenceBatchControlID PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_01_BatchFieldSeparator BHS_01_BatchFieldSeparator PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_08_BatchSecurity BHS_08_BatchSecurity PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_04_BatchSendingFacility BHS_04_BatchSendingFacility PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_03_BatchSendingApplication BHS_03_BatchSendingApplication PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_11_BatchControlID BHS_11_BatchControlID PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_09_BatchNameOrIDOrType BHS_09_BatchNameOrIDOrType PegaHL7PegaHC-HL7-Data-BHS_BatchHeader BHS_05_BatchReceivingApplication BHS_05_BatchReceivingApplication PegaHL7PegaHC-HL7-Data-

BTS_BatchTrailerSegment BTS_02_BatchComment BTS_02_BatchComment PegaHL7PegaHC-HL7-Data-

BTS_BatchTrailerSegment BTS_01_BatchMessageCount BTS_01_BatchMessageCount PegaHL7PegaHC-HL7-Data-

BTS_BatchTrailerSegment BTS_03_BatchTotals BTS_03_BatchTotals PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_07_DisabilityReturnToWorkDate DisabilityReturnToWorkDate PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_06_DisabilityEndDate DisabilityEndDate PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_03_DisabledPersonIdentifier DisabledPersonIdentifier PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_02_DisabledPersonCode DisabledPersonCode PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_08_DisabilityUnableToWorkDate DisabilityUnableToWorkDate PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_05_DisabilityStartDate DisabilityStartDate PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_01_SetID SetID PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DisabledPersonIdentifier DisabledPersonIdentifier PegaHL7

PegaHC-HL7-Data-DB1_DisabilitySegment DB1_04_DisabledIndicator DisabledIndicator PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_11_OutlierType DG1_11_OutlierType PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_15_DiagnosisDRGPriority DG1_15_DiagnosisDRGPriority PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_02_DiagnosisCodingMethod DG1_02_DiagnosisCodingMethod PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_05_DiagnosisDateTime DG1_05_DiagnosisDateTime PegaHL7

PegaHC-HL7-Data-DG1_Diagnosis DG1_03_DiagnosisCode DG1_03_DiagnosisCode PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_13_OutlierCost DG1_13_OutlierCost PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_16_DiagnosingClinician DG1_16_DiagnosingClinician PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_04_DiagnosisDescription DG1_04_DiagnosisDescription PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_06_DiagnosisDRGtype DG1_06_DiagnosisDRGtype PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_12_OutlierDays DG1_12_OutlierDays PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_08_DiagnosticRelatedGroup DG1_08_DiagnosticRelatedGroup PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_14_GrouperVersionAndType DG1_14_GrouperVersionAndType PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_01_SetID DG1_01_SetID PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_10_DRGGrouperReviewCode DG1_10_DRGGrouperReviewCode PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_07_MajorDiagnosticCategory DG1_07_MajorDiagnosticCategory PegaHL7PegaHC-HL7-Data-DG1_Diagnosis DG1_09_DRGApprovalIndicator DG1_09_DRGApprovalIndicator PegaHL7PegaHC-HL7-Data-Doctor DOC_04_MiddleInitialOrName DOC_04_MiddleInitialOrName PegaHL7PegaHC-HL7-Data-Doctor DOC_01_IdNumber DOC_01_IdNumber PegaHL7PegaHC-HL7-Data-Doctor DOC_13_IdentifierTypeCode DOC_13_IdentifierTypeCode PegaHL7PegaHC-HL7-Data-Doctor DOC_11_IdentifierCheckDigit DOC_11_IdentifierCheckDigit PegaHL7PegaHC-HL7-Data-Doctor DOC_14_AssigningFacilityId DOC_14_AssigningFacilityId PegaHL7PegaHC-HL7-Data-Doctor DOC_12_CheckDigitScheme DOC_12_CheckDigitScheme PegaHL7PegaHC-HL7-Data-Doctor DOC_07_Degree DOC_07_Degree PegaHL7PegaHC-HL7-Data-Doctor DOC_06_Prefix DOC_06_Prefix PegaHL7PegaHC-HL7-Data-Doctor DOC_05_Suffix DOC_05_Suffix PegaHL7PegaHC-HL7-Data-Doctor DOC_03_GivenName DOC_03_GivenName PegaHL7PegaHC-HL7-Data-Doctor DOC_02_FamilyName DOC_02_FamilyName PegaHL7PegaHC-HL7-Data-Doctor DOC_09_AssigningAuthority DOC_09_AssigningAuthority PegaHL7PegaHC-HL7-Data-Doctor DOC_10_NameTypeCode DOC_10_NameTypeCode PegaHL7PegaHC-HL7-Data-Doctor DOC_08_SourceTable DOC_08_SourceTable PegaHL7PegaHC-HL7-Data-

DSC_ContinuationPointer DSC_01_ContinuationPointer DSC_01_ContinuationPointer PegaHL7PegaHC-HL7-Data-

ERR_01_ErrorCodeAndLocation ERR_01_03_FieldPosition ERR_01_03_FieldPosition PegaHL7PegaHC-HL7-Data-

ERR_01_ErrorCodeAndLocation ERR_01_02_Sequence ERR_01_02_Sequence PegaHL7PegaHC-HL7-Data-

ERR_01_ErrorCodeAndLocation ERR_01_01_SegmentID ERR_01_01_SegmentID PegaHL7PegaHC-HL7-Data-

ERR_01_ErrorCodeAndLocation ERR_01_04_CodeIdentifyingError ERR_01_04_CodeIdentifyingError PegaHL7

PegaHC-HL7-Data-ERR_ErrorInformation ERR_01_ErrorCodeAndLocation ERR_01_ErrorCodeAndLocation PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_05_Suffix EVN_23_05_05_Suffix PegaHL7

PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_02_FamilyName EVN_23_05_02_FamilyName PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_01_IDNumber EVN_23_05_01_IDNumber PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_16_IdentifierTypeCode EVN_23_05_16_IdentifierTypeCode PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID

EVN_23_05_15_CodeIdentifyingCheckDigitS

cheme

EVN_23_05_15_CodeIdentifyingCheckDigitSc

heme PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_06_Prefix EVN_23_05_06_Prefix PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_17_AssigningFacilityID EVN_23_05_17_AssigningFacilityID PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_13_NameTypeCode EVN_23_05_13_NameTypeCode PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_04_MiddleInitialOrName EVN_23_05_04_MiddleInitialOrName PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_03_GivenName EVN_23_05_03_GivenName PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_14_IdentifierCheckDigit EVN_23_05_14_IdentifierCheckDigit PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_08_SourceTable EVN_23_05_08_SourceTable PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_09_AssigningAuthority EVN_23_05_09_AssigningAuthority PegaHL7PegaHC-HL7-Data-

EVN_23_05_OperatorID EVN_23_05_07_Degree EVN_23_05_07_Degree PegaHL7PegaHC-HL7-Data-EVN_EventType EVN_01_EventType EVN_01_EventType PegaHL7PegaHC-HL7-Data-EVN_EventType EVN_04_EventReasonCode EVN_04_EventReasonCode PegaHL7PegaHC-HL7-Data-EVN_EventType EVN_05_OperatorID EVN_05_OperatorID PegaHL7PegaHC-HL7-Data-EVN_EventType EVN_03_DateTimeOfPlannedEvent EVN_03_DateTimeOfPlannedEvent PegaHL7PegaHC-HL7-Data-EVN_EventType EVN_02_DateTimeOfEvent EVN_02_DateTimeOfEvent PegaHL7PegaHC-HL7-Data-EVN_EventType-V23 EVN_23_05_OperatorID EVN_23_05_OperatorID PegaHL7PegaHC-HL7-Data-EVN_EventType-V23 EVN_23_06_EventOccurred EVN_23_06_EventOccurred PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_03_FileSendingApplication FHS_03_FileSendingApplication PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_10_FileHeaderComment FHS_10_FileHeaderComment PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_11_FileControlID FHS_11_FileControlID PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_04_FileSendingFacility FHS_04_FileSendingFacility PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_07_FileCreationDateTime FHS_07_FileCreationDateTime PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_01_FileFieldSeparator FHS_01_FileFieldSeparator PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_05_FileReceivingApplication FHS_05_FileReceivingApplication PegaHL7

PegaHC-HL7-Data-FHS_FileHeader FHS_12_ReferenceFileControlID FHS_12_ReferenceFileControlID PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_08_FileSecurity FHS_08_FileSecurity PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_02_FileEncodingCharacters FHS_02_FileEncodingCharacters PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_06_FileReceivingFacility FHS_06_FileReceivingFacility PegaHL7PegaHC-HL7-Data-FHS_FileHeader FHS_09_FileNameOrID FHS_09_FileNameOrID PegaHL7

PegaHC-HL7-Data-FTS_FileTrailerSegment FTS_01_FileBatchCount FTS_01_FileBatchCount PegaHL7

PegaHC-HL7-Data-FTS_FileTrailerSegment FTS_02_FileTrailerComment FTS_02_FileTrailerComment PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_16_GuarantorEmployerName GT1_16_GuarantorEmployerName PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_17_GuarantorEmployerAddress GT1_17_GuarantorEmployerAddress PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_03_GuarantorName GT1_03_GuarantorName PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_09_GuarantorSex GT1_09_GuarantorSex PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_11_GuarantorRelationship GT1_11_GuarantorRelationship PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_12_GuarantorSSN GT1_12_GuarantorSSN PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_14_GuarantorDateEnd GT1_14_GuarantorDateEnd PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_01_SetID GT1_01_SetID PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_19_GuarantorEmployeeIDnum GT1_19_GuarantorEmployeeIDnum PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_20_GuarantorEmploymentStatus GT1_20_GuarantorEmploymentStatus PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_02_GuarantorNumber GT1_02_GuarantorNumber PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_08_GuarantorDateOfBirth GT1_08_GuarantorDateOfBirth PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_10_GuarantorType GT1_10_GuarantorType PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_05_GuarantorAddress GT1_05_GuarantorAddress PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_07_GuarantorPhNumBusiness GT1_07_GuarantorPhNumBusiness PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_18_GuarantorEmployPhoneNumber GT1_18_GuarantorEmployPhoneNumber PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_15_Guarantorpriority GT1_15_Guarantorpriority PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_04_GuarantorSpouseName GT1_04_GuarantorSpouseName PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_06_GuarantorPhNumHome GT1_06_GuarantorPhNumHome PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_13_GuarantorDateBegin GT1_13_GuarantorDateBegin PegaHL7PegaHC-HL7-Data-GT1_Guarantor GT1_21_GuarantorOrganization GT1_21_GuarantorOrganization PegaHL7PegaHC-HL7-Data-ID_23 ID_07_OrganizationName ID_07_OrganizationName PegaHL7PegaHC-HL7-Data-ID_23 ID_08_OrganizationNameTypeCode ID_08_OrganizationNameTypeCode PegaHL7PegaHC-HL7-Data-ID_23 ID_06_AssigningFacility ID_06_AssigningFacility PegaHL7PegaHC-HL7-Data-ID_23 ID_03_CheckDigitSchemeCode CheckDigitSchemeCode PegaHL7PegaHC-HL7-Data-ID_23 ID_02_CheckDigit CheckDigit PegaHL7PegaHC-HL7-Data-ID_23 ID_01_ID ID PegaHL7PegaHC-HL7-Data-ID_23 ID_04_AssigningAuthority ID_04_AssigningAuthority PegaHL7PegaHC-HL7-Data-ID_23 ID_05_IdentifierTypeCode ID_05_IdentifierTypeCode PegaHL7PegaHC-HL7-Data-IDExternal IDExternal_02_CheckDigit PID_02_02_CheckDigit PegaHL7PegaHC-HL7-Data-IDExternal IDExternal_01_PatientID PID_02_01_PatientID PegaHL7

PegaHC-HL7-Data-IDExternal IDExternal_04_AssigningFacilityID PID_02_04_AssigningFacilityID PegaHL7PegaHC-HL7-Data-IDExternal IDExternal_03_CheckDigitScheme PID_02_03_CheckDigitScheme PegaHL7PegaHC-HL7-Data-IN_InsuranceInfo IN2_InsuranceAdditionalInfo IN2_InsuranceAdditionalInfo PegaHL7PegaHC-HL7-Data-IN_InsuranceInfo IN1_Insurance IN1_Insurance PegaHL7PegaHC-HL7-Data-IN_InsuranceInfo IN3_InsuranceAdditionalCERT IN3_InsuranceAdditionalCERT PegaHL7PegaHC-HL7-Data-

IN1_14_AuthorizationInformation IN1_14_01_AuthorizationNumber IN1_14_01_AuthorizationNumber PegaHL7PegaHC-HL7-Data-

IN1_14_AuthorizationInformation IN1_14_03_Source IN1_14_03_Source PegaHL7PegaHC-HL7-Data-

IN1_14_AuthorizationInformation IN1_14_02_Date IN1_14_02_Date PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_06_InsuranceCoContactPers IN1_06_InsuranceCoContactPers PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_11_InsuredsGroupEmpName IN1_11_InsuredsGroupEmpName PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_16_NameOfInsured IN1_16_NameOfInsured PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_22_CoordOfBenPriority IN1_22_CoordOfBenPriority PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_30_VerificationBy IN1_30_VerificationBy PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_33_LifetimeReserveDays IN1_33_LifetimeReserveDays PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_08_GroupNumber IN1_08_GroupNumber PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_12_PlanEffectiveDate IN1_12_PlanEffectiveDate PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_21_CoordinationOfBenefits IN1_21_CoordinationOfBenefits PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_44_InsuredsEmployerAddress IN1_44_InsuredsEmployerAddress PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_24_NoticeOfAdmissionDate IN1_24_NoticeOfAdmissionDate PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_34_DelayBeforeLRDay IN1_34_DelayBeforeLRDay PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_39_PolicyLimitDays IN1_39_PolicyLimitDays PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_40_RoomRateSemiPrivate IN1_40_RoomRateSemiPrivate PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_02_InsurancePlanID IN1_02_InsurancePlanID PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_04_InsuranceCompanyName IN1_04_InsuranceCompanyName PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_13_PlanExpirationDate IN1_13_PlanExpirationDate PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_19_InsuredsAddress IN1_19_InsuredsAddress PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_20_AssignmentOfBenefits IN1_20_AssignmentOfBenefits PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_25_RptOfEligibilityCode IN1_25_RptOfEligibilityCode PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_29_VerificationDateTime IN1_29_VerificationDateTime PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_31_TypeOfAgreementCode IN1_31_TypeOfAgreementCode PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_32_BillingStatus IN1_32_BillingStatus PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_46_PriorInsurancePlanID IN1_46_PriorInsurancePlanID PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_38_PolicyLimitAmount IN1_38_PolicyLimitAmount PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_45_VerificationStatus IN1_45_VerificationStatus PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_09_GroupName IN1_09_GroupName PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_10_InsuredsGroupEmpID IN1_10_InsuredsGroupEmpID PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_26_RptOfEligibilityDate IN1_26_RptOfEligibilityDate PegaHL7

PegaHC-HL7-Data-IN1_Insurance IN1_03_InsuranceCompanyID IN1_03_InsuranceCompanyID PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_14_AuthorizationInformation IN1_14_AuthorizationInformation PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_42_InsuredsEmploymentStatus IN1_42_InsuredsEmploymentStatus PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_35_CompanyPlanCode IN1_35_CompanyPlanCode PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_36_PolicyNumber IN1_36_PolicyNumber PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_37_PolicyDeductible IN1_37_PolicyDeductible PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_41_RoomRatePrivate IN1_41_RoomRatePrivate PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_07_InsuranceCoPhoneNumber IN1_07_InsuranceCoPhoneNumber PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_15_PlanType IN1_15_PlanType PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_17_InsuredsRelationshiptopatient IN1_17_InsuredsRelationshiptopatient PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_18_InsuredsDateOfBirth IN1_18_InsuredsDateOfBirth PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_27_ReleaseInformationCode IN1_27_ReleaseInformationCode PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_01_SetID IN1_01_SetID PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_23_NoticeOfAdmissionCode IN1_23_NoticeOfAdmissionCode PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_28_PreAdmitCertPAC IN1_28_PreAdmitCertPAC PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_43_InsuredsSex IN1_43_InsuredsSex PegaHL7PegaHC-HL7-Data-IN1_Insurance IN1_05_InsuranceCompanyAddress IN1_05_InsuranceCompanyAddress PegaHL7PegaHC-HL7-Data-

IN2_28_RoomCoverageTypeAmount IN2_28_03_CoverageAmount IN2_28_03_CoverageAmount PegaHL7PegaHC-HL7-Data-

IN2_28_RoomCoverageTypeAmount IN2_28_02_AmountType IN2_28_02_AmountType PegaHL7PegaHC-HL7-Data-

IN2_28_RoomCoverageTypeAmount IN2_28_01_RoomType IN2_28_01_RoomType PegaHL7PegaHC-HL7-Data-

IN2_29_PolicyTypeAmount IN2_29_02_AmountClass IN2_29_02_AmountClass PegaHL7PegaHC-HL7-Data-

IN2_29_PolicyTypeAmount IN2_29_01_PolicyType IN2_29_01_PolicyType PegaHL7PegaHC-HL7-Data-

IN2_29_PolicyTypeAmount IN2_29_03_Amount IN2_29_03_Amount PegaHL7PegaHC-HL7-Data-

IN2_30_DailyDeductible IN2_30_03_NumberofDays IN2_30_03_NumberofDays PegaHL7PegaHC-HL7-Data-

IN2_30_DailyDeductible IN2_30_02_Amount IN2_30_02_Amount PegaHL7PegaHC-HL7-Data-

IN2_30_DailyDeductible IN2_30_01_DelayDays IN2_30_01_DelayDays PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_23_SpecialCoverageApprovalTitle IN2_23_SpecialCoverageApprovalTitle PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_26_PayorSubscriberId IN2_26_PayorSubscriberId PegaHL7

PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_06_MedicareHealthInsCardNumber IN2_06_MedicareHealthInsCardNumber PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_10_ChampusIdNumber IN2_10_ChampusIdNumber PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_22_SpecialCoverageApprovalName IN2_22_SpecialCoverageApprovalName PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_30_DailyDeductible IN2_30_DailyDeductible PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_07_MedicaidCaseName IN2_07_MedicaidCaseName PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_20_CombineBabyBill IN2_20_CombineBabyBill PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_25_PayorId IN2_25_PayorId PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_04_EmployerInformationData IN2_04_EmployerInformationData PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_05_MailClaimParty IN2_05_MailClaimParty PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_08_MedicaidCaseNumber IN2_08_MedicaidCaseNumber PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_15_ChampusRankGrade IN2_15_ChampusRankGrade PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_19_BabyCoverage IN2_19_BabyCoverage PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_21_BloodDeductible IN2_21_BloodDeductible PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_28_RoomCoverageTypeAmount IN2_28_RoomCoverageTypeAmount PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_03_InsuredsEmployerName IN2_03_InsuredsEmployerName PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_16_ChampusStatus IN2_16_ChampusStatus PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_24_NonCoveredInsuranceCode IN2_24_NonCoveredInsuranceCode PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_01_InsuredsEmployeeId IN2_01_InsuredsEmployeeId PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_13_ChampusStation IN2_13_ChampusStation PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_29_PolicyTypeAmount IN2_29_PolicyTypeAmount PegaHL7

PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_12_ChampusOrganization IN2_12_ChampusOrganization PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_09_ChampusSponsorName IN2_09_ChampusSponsorName PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_02_InsuredsSocialSecurityNumber IN2_02_InsuredsSocialSecurityNumber PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo PolicyTypeAmount RoomCoverageTypeAmount PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_27_EligibilitySource IN2_27_EligibilitySource PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_18_ChampusNonAvailCertOnFile IN2_18_ChampusNonAvailCertOnFile PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_17_ChampusRetireDate IN2_17_ChampusRetireDate PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_11_DependentOfChampusRecipient IN2_11_DependentOfChampusRecipient PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo RoomCoverageTypeAmount RoomCoverageTypeAmount PegaHL7PegaHC-HL7-Data-

IN2_InsuranceAdditionalInfo IN2_14_ChampusService IN2_14_ChampusService PegaHL7PegaHC-HL7-Data-IN3_05_Penalty IN3_05_02_PenaltyAmount IN3_05_02_PenaltyAmount PegaHL7PegaHC-HL7-Data-IN3_05_Penalty IN3_05_01_PenaltyType IN3_05_01_PenaltyType PegaHL7PegaHC-HL7-Data-IN3_11_Days IN3_11_02_NumberofDays IN3_11_02_NumberofDays PegaHL7PegaHC-HL7-Data-IN3_11_Days IN3_11_01_DayType IN3_11_01_DayType PegaHL7PegaHC-HL7-Data-

IN3_20_PreCertificationReqWindow IN3_20_01_PreCertPatientType IN3_20_01_PreCertPatientType PegaHL7PegaHC-HL7-Data-

IN3_20_PreCertificationReqWindow IN3_20_02_PreCertRequired IN3_20_02_PreCertRequired PegaHL7PegaHC-HL7-Data-

IN3_20_PreCertificationReqWindow IN3_20_03_PreCertWindow IN3_20_03_PreCertWindow PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_02_CertificationNumber IN3_02_CertificationNumber PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_04_CertificationRequired IN3_04_CertificationRequired PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT PreCertificationReqWindow PreCertificationReqWindow PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_05_Penalty IN3_05_Penalty PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_09_CertificationBeginDate IN3_09_CertificationBeginDate PegaHL7

PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_18_CertificationAgency IN3_18_CertificationAgency PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_22_SecondOpinionDate IN3_22_SecondOpinionDate PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_15_CertificationContact IN3_15_CertificationContact PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_21_CaseManager IN3_21_CaseManager PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_24_SecondOpinionDocReceived IN3_24_SecondOpinionDocReceived PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_03_CertifiedBy IN3_03_CertifiedBy PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_06_CertificationDateTime IN3_06_CertificationDateTime PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_10_CertificationEndDate IN3_10_CertificationEndDate PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_11_Days IN3_11_Days PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_13_NonConcurEffDateTime IN3_13_NonConcurEffDateTime PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_23_SecondOpinionStatus IN3_23_SecondOpinionStatus PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_25_SecondOpinionPractitioner IN3_25_SecondOpinionPractitioner PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_07_CertificationModifyDateTime IN3_07_CertificationModifyDateTime PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_08_Operator IN3_08_Operator PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_19_CertificationAgencyPhNum IN3_19_CertificationAgencyPhNum PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_12_NonConcurCodeDescription IN3_12_NonConcurCodeDescription PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_20_PreCertificationReqWindow IN3_20_PreCertificationReqWindow PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_16_CertificationContactPhNum IN3_16_CertificationContactPhNum PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_14_PhysicianReviewer IN3_14_PhysicianReviewer PegaHL7PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_17_AppealReason IN3_17_AppealReason PegaHL7

PegaHC-HL7-Data-

IN3_InsuranceAdditionalCERT IN3_01_SetID IN3_01_SetID PegaHL7PegaHC-HL7-Data-Location LOC_01_NurseUnit LOC_01_NurseUnit PegaHL7PegaHC-HL7-Data-Location LOC_03_Bed LOC_03_Bed PegaHL7PegaHC-HL7-Data-Location LOC_02_Room LOC_02_Room PegaHL7PegaHC-HL7-Data-Location LOC_04_FacilityID LOC_04_FacilityID PegaHL7PegaHC-HL7-Data-Location LOC_05_BedStatus LOC_05_BedStatus PegaHL7PegaHC-HL7-Data-Location23 LOC23_09_LocationDescription Location Description PegaHL7PegaHC-HL7-Data-Location23 LOC23_04_Facility Facility PegaHL7PegaHC-HL7-Data-Location23 LOC23_01_PointOfCare Point Of Care PegaHL7PegaHC-HL7-Data-Location23 LOC23_02_Room Room PegaHL7PegaHC-HL7-Data-Location23 LOC23_03_Bed Bed PegaHL7PegaHC-HL7-Data-Location23 LOC23_08_Floor Floor PegaHL7PegaHC-HL7-Data-Location23 LOC23_07_Building Building PegaHL7PegaHC-HL7-Data-Location23 LOC23_05_LocationStatus Location Status PegaHL7PegaHC-HL7-Data-Location23 LOC23_06_PersonLocationType Person Location Type PegaHL7PegaHC-HL7-Data-

MRG_03_PriorAlternatePatientID MRG_03_02_CheckDigit MRG_03_02_CheckDigit PegaHL7PegaHC-HL7-Data-

MRG_03_PriorAlternatePatientID MRG_03_01_AccountName MRG_03_01_AccountName PegaHL7PegaHC-HL7-Data-

MRG_03_PriorAlternatePatientID MRG_03_03_CheckDigitScheme MRG_03_03_CheckDigitScheme PegaHL7PegaHC-HL7-Data-

MRG_03_PriorAlternatePatientID MRG_03_04_AssigningFacilityID MRG_03_04_AssigningFacilityID PegaHL7PegaHC-HL7-Data-MRG_MergePatient MRG_04_PriorPatientIDExternal MRG_04_PriorPatientIDExternal PegaHL7PegaHC-HL7-Data-MRG_MergePatient MRG_02_PriorAlternatePatientID MRG_02_PriorAlternatePatientID PegaHL7

PegaHC-HL7-Data-MRG_MergePatient MRG_01_PriorPatientIDInternal

MRG_01_PriorPatientIDInternalMRG_01_Pri

orPatientIDInternal PegaHL7PegaHC-HL7-Data-MRG_MergePatient MRG_03_PriorAlternatePatientID MRG_03_PriorAlternatePatientID PegaHL7PegaHC-HL7-Data-

MSA_MessageAcknowledgement MSA_01_AcknowledgementCode MSA_01_AcknowledgementCode PegaHL7PegaHC-HL7-Data-

MSA_MessageAcknowledgement MSA_06_ErrorCondition MSA_06_ErrorCondition PegaHL7PegaHC-HL7-Data-

MSA_MessageAcknowledgement MSA_04_ExpectedSequenceNumber MSA_04_ExpectedSequenceNumber PegaHL7PegaHC-HL7-Data-

MSA_MessageAcknowledgement MSA_05_DelayedAcknowledgementType MSA_05_DelayedAcknowledgementType PegaHL7PegaHC-HL7-Data-

MSA_MessageAcknowledgement MSA_03_TextMessage MSA_03_TextMessage PegaHL7

PegaHC-HL7-Data-

MSA_MessageAcknowledgement MSA_02_MessageControlID MSA_02_MessageControlID PegaHL7PegaHC-HL7-Data-

MSH_23_11_ProcessingID MSH_23_11_02_ProcessingMode MSH_23_11_ProcessingMode PegaHL7PegaHC-HL7-Data-

MSH_23_11_ProcessingID MSH_23_11_01_ProcessingID MSH_23_11_ProcessingID PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_13_SequenceNumber MSH_13_SequenceNumber PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_01_FieldSeparator MSH_01_FieldSeparator PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_17_CountryCode MSH_17_CountryCode PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_14_ContinuationPointer MSH_14_ContinuationPointer PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_09_MessageType MSH_09_MessageType PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_08_Security MSH_08_Security PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_04_SendingFacility MSH_04_SendingFacility PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_03_SendingApplication MSH_03_SendingApplication PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_12_VersionID MSH_12_VersionID PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_15_AcceptAcknowledgementType MSH_15_AcceptAcknowledgementType PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader V23 V23 PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_11_ProcessingID MSH_11_ProcessingID PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_16_AppAcknowledgementType MSH_16_AppAcknowledgementType PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_06_ReceivingFacility MSH_06_ReceivingFacility PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_05_ReceivingApplication MSH_05_ReceivingApplication PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_10_MessageControlID MSH_10_MessageControlID PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_02_EncodingCharacters MSH_02_EncodingCharacters PegaHL7

PegaHC-HL7-Data-MSH_MessageHeader MSH_07_DateTimeOfMessage MSH_07_DateTimeOfMessage PegaHL7PegaHC-HL7-Data-MSH_MessageHeader-

V23 MSH_23_18_Characterset MSH_23_18_Characterset PegaHL7PegaHC-HL7-Data-MSH_MessageHeader-

V23 MSH_23_19_PrincipalLanguageofMessage MSH_23_19_PrincipalLanguageofMessage PegaHL7PegaHC-HL7-Data-MSH_MessageHeader-

V23 MSH_23_11_ProcessingID MSH_23_11_ProcessingID PegaHL7PegaHC-HL7-Data-MSH_MessageHeader-

V23 MSH_23_06_ReceivingFacility MSH_23_06_ReceivingFacility PegaHL7PegaHC-HL7-Data-MSH_MessageHeader-

V23 MSH_23_03_SendingApp MSH_23_03_SendingApp PegaHL7PegaHC-HL7-Data-MSH_MessageHeader-

V23 MSH_23_05_ReceivingApp MSH_23_05_ReceivingApp PegaHL7PegaHC-HL7-Data-MSH_MessageHeader-

V23 MSH_23_04_SendingFacility PegaHC-HL7-Data-MSH_MessageHeader PegaHL7

PegaHC-HL7-Data-MSH09_MessageType MSH_09_02_TriggerEvent MSH_09_02_TriggerEvent PegaHL7

PegaHC-HL7-Data-MSH09_MessageType MSH_09_01_MessageType MSH_09_01_MessageType PegaHL7PegaHC-HL7-Data-Name Name_06_Degree PID_05_06_Degree PegaHL7PegaHC-HL7-Data-Name Name_02_GivenName PID_05_02_GivenName PegaHL7PegaHC-HL7-Data-Name Name_01_FamilyName PID_05_01_FamilyName PegaHL7PegaHC-HL7-Data-Name Name_23_07_NameTypeCode Name_23_07_NameTypeCode PegaHL7PegaHC-HL7-Data-Name Name_05_Prefix PID_05_05_Prefix PegaHL7PegaHC-HL7-Data-Name Name_04_Suffix PID_05_04_Suffix PegaHL7PegaHC-HL7-Data-Name Name_03_MiddleInitialOrName PID_05_03_MiddleInitialOrName PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_11_NextofKinJobCodeClass NK1_11_NextofKinJobCodeClass PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_05_PhoneNumber NK1_05_PhoneNumber PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_01_SetID NK1_01_SetID PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_06_BusinessPhoneNumber NK1_06_BusinessPhoneNumber PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_10_NextofKinJobTitle NK1_10_NextofKinJobTitle PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_12_NextofKinEmployeeNumber NK1_12_NextofKinEmployeeNumber PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_04_Address NK1_04_Address PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_08_StartDate NK1_08_StartDate PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_03_Relationship NK1_03_Relationship PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_07_ContactRole NK1_07_ContactRole PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_09_EndDate NK1_09_EndDate PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_13_OrganizationName NK1_13_OrganizationName PegaHL7PegaHC-HL7-Data-NK1_NextofKin NK1_02_Name NK1_02_Name PegaHL7

PegaHC-HL7-Data-NK111_NextofKinJob NK1_11_02_EmpClassification NK1_11_02_EmpClassification PegaHL7

PegaHC-HL7-Data-NK111_NextofKinJob NK1_11_01_JobCode NK1_11_01_JobCode PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_06_Units OBX_06_Units PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_13_UserDefinedAccessChecks OBX_13_UserDefinedAccessChecks PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_05_ObservationValue OBX_05_ObservationValue PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_04_ObservationSubID OBX_04_ObservationSubID PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_02_ValueType OBX_02_ValueType PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_12_DateLastObsNormalValues OBX_12_DateLastObsNormalValues PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_11_ObservResultStatus OBX_11_ObservResultStatus PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_08_AbnormalFlags OBX_08_AbnormalFlags PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_01_SetID OBX_01_SetID PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_07_ReferencesRange OBX_07_ReferencesRange PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_10_NatureofAbnormalTest OBX_10_NatureofAbnormalTest PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_15_ProducersID OBX_15_ProducersID PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_09_Probability OBX_09_Probability PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_14_DateTimeoftheObservation OBX_14_DateTimeoftheObservation PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_16_ResponsibleObserver OBX_16_ResponsibleObserver PegaHL7PegaHC-HL7-Data-OBX_Observation OBX_03_ObservationIdentifier OBX_03_ObservationIdentifier PegaHL7

PegaHC-HL7-Data-OBX_Observation-V23 OBX_23_10_NatureOfAbnormalTest OBX_23_10_NatureOfAbnormalTest PegaHL7

PegaHC-HL7-Data-OBX_Observation-V23 OBX_23_16_ResponsibleObserver OBX_23_16_ResponsibleObserver PegaHL7

PegaHC-HL7-Data-OBX_Observation-V23 OBX_23_05_ObservationValue OBX_23_05_ObservationValue PegaHL7

PegaHC-HL7-Data-OBX_Observation-V23 ObservationMethod ObservationMethod PegaHL7

PegaHC-HL7-Data-OBX_Observation-V23 OBX_23_17_ObservationMethod OBX_23P_17_ObservationMethod PegaHL7PegaHC-HL7-Data-Occurrence Occurrence_02_OccurrenceDate UB2_07_02_OccurrenceDate PegaHL7PegaHC-HL7-Data-Occurrence Occurrence_01_OccurrenceCode UB2_07_01_OccurrenceCode PegaHL7PegaHC-HL7-Data-PatientID ID_04_AssigningFacilityID ID_04_AssigningFacilityID PegaHL7PegaHC-HL7-Data-PatientID ID_01_PatientID ID_01_PatientID PegaHL7PegaHC-HL7-Data-PatientID ID_03_CheckDigitScheme ID_03_CheckDigitScheme PegaHL7PegaHC-HL7-Data-PatientID ID_02_CheckDigit ID_02_CheckDigit PegaHL7PegaHC-HL7-Data-PatientID ID_05_VisitIDType ID_05_VisitIDType PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic DuplicatePatient DuplicatePatient PegaHL7

PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_03_PatientPrimaryFacility PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_10_DuplicatePatient PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_11_PublicityIndicator PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PatientPrimaryFacility PatientPrimaryFacility PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PrimaryCareProviderName PrimaryCareProviderName PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_12_ProtectionIndicator PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_08_OrganDonor PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_07_LivingWill PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_02_LivingArrangement PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_01_LivingDependency PD1_01_LivingDependency PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_06_Handicap PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_04_PrimaryCareProviderName PD1_04_PrimaryCareProviderName PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_09_SeparateBill PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-

PD1_PatientAddDemographic PD1_05_StudentIndicator PD1_02_LivingArrangement PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_04_EmailAddress Phone_04_EmailAddress PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_01_PhoneNumberText PhoneNumber PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_07_PhoneNumber Phone_07_PhoneNumber PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_05_CountryCode Phone_05_CountryCode PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_09_Text Phone_09_Text PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_06_AreaCityCode Phone_06_AreaCityCode PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_02_TelecommunicationUseCode Phone_02_TelecommunicationUseCode PegaHL7PegaHC-HL7-Data-PhoneNumber Phone_08_Extension Phone_08_Extension PegaHL7

PegaHC-HL7-Data-PhoneNumber

Phone_03_TelecommunicationEquipmentTy

pe

Phone_03_TelecommunicationEquipmentTy

pe PegaHL7PegaHC-HL7-Data-Physician PHYS_05_Suffix PHYS_05_Suffix PegaHL7PegaHC-HL7-Data-Physician PHYS_03_GivenName PHYS_03_GivenName PegaHL7

PegaHC-HL7-Data-Physician PHYS_01_PhysicianID PHYS_01_PhysicianID PegaHL7PegaHC-HL7-Data-Physician PHYS_08_SourceTable PHYS_08_SourceTable PegaHL7PegaHC-HL7-Data-Physician PHYS_07_Degree PHYS_07_Degree PegaHL7PegaHC-HL7-Data-Physician PHYS_04_MiddleInitialOrName PHYS_04_MiddleInitialOrName PegaHL7PegaHC-HL7-Data-Physician PHYS_02_FamilyName PHYS_02_FamilyName PegaHL7PegaHC-HL7-Data-Physician PHYS_06_Prefix PHYS_06_Prefix PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_24_MultipleBirthIndicator PID_24_MultipleBirthIndicator PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PatientIDInternal PatientInternalList PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_08_Sex PID_08_Sex PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_09_PatientAlias PID_09_PatientAlias PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_14_PhoneNumberBusiness PID_14_PhoneNumberBusiness PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_23_BirthPlace PID_23_BirthPlace PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_06_MothersMaidenName PID_06_MothersMaidenName PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_12_CountyCode PID_12_CountyCode PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_27_VeteransMilitaryStatus PID_27_VeteransMilitaryStatus PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_05_PatientName PID_05_PatientName PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_10_Race PID_10_Race PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_19_SSN PID_19_SSN PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_17_Religion PID_17_Religion PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_16_MaritalStatus PID_16_MaritalStatus PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_11_PatientAddress PID_11_PatientAddress PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_02_PatientIDExternal PID_02_PatientIDExternal PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_26_Citizenship PID_26_Citizenship PegaHL7

PegaHC-HL7-Data-

PID_PatientIdentification PID_03_PatientIDInternal PID_03_PatientIDInternal PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_21_MothersIdentifier PID_21_MothersIdentifier PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_20_DriverLicenceNumber PID_20_DriverLicenceNumber PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_22_EthnicGroup PID_22_EthnicGroup PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_15_PatientLanguage PID_15_PatientLanguage PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_01_SetID PID_01_SetID PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PatientAlias PatientInternalList PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PatientAddress PatientInternalList PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_25_BirthOrder PID_25_BirthOrder PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_18_PatientAccountNumber PID_18_PatientAccountNumber PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_13_PhoneNumberHome PID_13_PhoneNumberHome PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_04_AlternatePatientID PID_04_AlternatePatientID PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification PID_07_DateOfBirth PID_07_DateOfBirth PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PatientName PatientName PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_14_BusinessPhone PID_23_13_BusinessPhone PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 BusinessPhone BusinessPhone PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PatientIDAlternate PatientIDAlternate PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_02_ExternalPatientID PID_23_02_ExternalPatientID PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_05_PatientName PID_23_05_PatientName PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_30_PatientDeathIndicator PID_23_30_PatientDeathIndicator PegaHL7

PegaHC-HL7-Data-

PID_PatientIdentification-V23 HomePhone HomePhone PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 MothersIdentifier MothersIdentifier PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_03_InternalPatientID PID_23_02_PatientID PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_18_PatientAccountNumber PID_23_18_PatientAccountNumber PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_04_AlternatePatientID PID_23_04_AlternatePatientID PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_21_MothersIdentifier PID_23_21_MothersIdentifier PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_06_MotherMaidenName PID_23_06_MotherMaidenName PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_28_Nationality PID_23_28_Nationality PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_29_PatientDeathDateTime PID_23_29_PatientDeathDateTime PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_07_DateTimeOfBirth PID_23_07_DateTimeOfBirth PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_13_HomePhone PID_23_13_BusinessPhone PegaHL7PegaHC-HL7-Data-

PID_PatientIdentification-V23 PID_23_15_PrimaryLanguage PID_23_15_PrimaryLanguage PegaHL7PegaHC-HL7-Data-

PID20_DriverLicenseNumber PID_20_01_LicenseNumber PID_20_01_LicenseNumber PegaHL7PegaHC-HL7-Data-

PID20_DriverLicenseNumber PID_20_23_03_ExpirationDate PID_20_23_03_ExpirationDate PegaHL7PegaHC-HL7-Data-

PID20_DriverLicenseNumber PID_20_02_IssuingStateProvinceCountry PID_20_02_IssuingStateProvinceCountry PegaHL7PegaHC-HL7-Data-

PR1_12_ProcedurePractitioner PR1_12_01_ProcPractitionerID PR1_12_01_ProcPractitionerID PegaHL7PegaHC-HL7-Data-

PR1_12_ProcedurePractitioner PR1_12_02_ProcPractitionerType PR1_12_02_ProcPractitionerType PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_02_ProcedureCodingMethod PR1_02_ProcedureCodingMethod PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_13_ConsentCode PR1_13_ConsentCode PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_03_ProcedureCode PR1_03_ProcedureCode PegaHL7PegaHC-HL7-Data-PR1_Procedures ProcedurePractitioner ProcedurePractitioner PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_10_AnesthesiaMinutes PR1_10_AnesthesiaMinutes PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_07_ProcedureMinutes PR1_07_ProcedureMinutes PegaHL7

PegaHC-HL7-Data-PR1_Procedures PR1_14_ProcedurePriority PR1_14_ProcedurePriority PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_08_Anesthesiologist PR1_08_Anesthesiologist PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_05_ProcedureDateTime PR1_05_ProcedureDateTime PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_09_AnesthesiaCode PR1_09_AnesthesiaCode PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_11_Surgeon PR1_11_Surgeon PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_12_ProcedurePractitioner PR1_12_ProcedurePractitioner PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_01_SetID PR1_01_SetID PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_06_ProcedureType PR1_06_ProcedureType PegaHL7PegaHC-HL7-Data-PR1_Procedures PR1_04_ProcedureDescription PR1_04_ProcedureDescription PegaHL7

PegaHC-HL7-Data-PV1_20_FinancialClass PV1_20_01_FinancialClass PV1_20_01_FinancialClass PegaHL7

PegaHC-HL7-Data-PV1_20_FinancialClass PV1_20_02_EffectiveDate PV1_20_01_EffectiveDate PegaHL7PegaHC-HL7-Data-

PV1_23_37_DischargedtoLocation PV1_37_02_EffectiveDate PV1_37_02_EffectiveDate PegaHL7PegaHC-HL7-Data-

PV1_23_37_DischargedtoLocation PV1_37_01_DischargeLocation PV1_37_01_DischargeLocation PegaHL7PegaHC-HL7-Data-

PV1_37_DischargedtoLocation PV1_37_02_Description PV1_37_02_Description PegaHL7PegaHC-HL7-Data-

PV1_37_DischargedtoLocation PV1_37_01_Code PV1_37_01_Code PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_17_AdmittingDoctor PV1_17_AdmittingDoctor PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_28_InterestCode PV1_28_InterestCode PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_38_DietType PV1_38_DietType PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_40_BedStatus PV1_40_BedStatus PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_46_CurrentPatientBalance PV1_46_CurrentPatientBalance PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit PV1_47_TotalChargesPV147TotalCharges PV1_47_TotalCharges PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_48_TotalAdjustments PV1_48_TotalAdjustments PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_List PV1_List PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_01_SetID PV1_01_SetID PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_30_TransfertoBadDebtDate PV1_30_TransfertoBadDebtDate PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_23_CreditRating PV1_23_CreditRating PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_32_BadDebtTransferAmount PV1_32_BadDebtTransferAmount PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_37_DischargedtoLocation PV1_37_DischargedtoLocation PegaHL7PegaHC-HL7-Data-PV1_PatientVisit ConsultingDoctor ConsultingDoctor PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_03_AssignedPatientLocation PV1_03_AssignedPatientLocation PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_06_PriorPatientLocation PV1_06_PriorPatientLocation PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_15_AmbulatoryStatus PV1_15_AmbulatoryStatus PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_19_VisitNumber PV1_19_VisitNumber PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit PV1_25_ContractEffectiveDate PV1_25_ContractEffectiveDate PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_26_ContractAmount PV1_26_ContractAmount PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_36_DischargeDisposition PV1_36_DischargeDisposition PegaHL7PegaHC-HL7-Data-PV1_PatientVisit FinancialClass FinancialClass PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_04_AdmissionType PV1_04_AdmissionType PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_05_PreadmitNumber PV1_05_PreadmitNumber PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_21_ChargePriceIndicator PV1_21_ChargePriceIndicator PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_24_ContractCode PV1_24_ContractCode PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_29_TransfertoBadDebtCode PV1_29_TransfertoBadDebtCode PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_31_BadDebtAgencyCode PV1_31_BadDebtAgencyCode PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_35_DeleteAccountDate PV1_35_DeleteAccountDate PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_42_PendingLocation PV1_42_PendingLocation PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_50_AlternateVisitID PV1_50_AlternateVisitID PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_07_AttendingDoctor PV1_07_AttendingDoctor PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_08_ReferringDoctor PV1_08_ReferringDoctor PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_10_HospitalService PV1_10_HospitalService PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_20_FinancialClass PV1_20_FinancialClass PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_09_ConsultingDoctor PV1_09_ConsultingDoctor PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_11_TemporaryLocation PV1_11_TemporaryLocation PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_27_ContractPeriod PV1_27_ContractPeriod PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_33_BadDebtRecoveryAmount PV1_33_BadDebtRecoveryAmount PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_45_DischargeDateTime PV1_45_DischargeDateTime PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_02_PatientClass PV1_02_PatientClass PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_12_PreadmitTestIndicator PV1_12_PreadmitTestIndicator PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_13_ReadmissionIndicator PV1_13_ReadmissionIndicator PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_14_AdmitSource PV1_14_AdmitSource PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_18_PatientType PV1_18_PatientType PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_34_DeleteAccountIndicator PV1_34_DeleteAccountIndicator PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_43_PriorTemporaryLocation PV1_43_PriorTemporaryLocation PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_39_ServicingFacility PV1_39_ServicingFacility PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_41_AccountStatus PV1_41_AccountStatus PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_44_AdmitDateTime PV1_44_AdmitDateTime PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_49_TotalPayments PV1_49_TotalPayments PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_16_VIPIndicator PV1_16_VIPIndicator PegaHL7PegaHC-HL7-Data-PV1_PatientVisit PV1_22_CourtesyCode PV1_22_CourtesyCode PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_37_DischargedtoLocation PV1_23_37_DischargedtoLocation PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_51_VisitIndicator PV1_23_51_VisitIndicator PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_03_AssignedPatientLocation PV1_03_AssignedPatientLocation PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_50_AlternateVisitID PV1_23_50_AlternateVisitID PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_43_PriorTemporaryLocation PV1_23_43_PriorTemporaryLocation PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_19_VisitNumber PV1_23_19_VisitNumber PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_17_AdmittingDoctor PV1_23_17_AdmittingDoctor PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_11_TemporaryLocation PV1_23_11_TemporaryLocation PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_08_ReferringDoctor PV1_23_08_ReferringDoctor PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 ConsultingDoctor23 Consulting Doctor 23 PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_06_PriorPatientLocation PV1_23_06_PriorPatientLocation PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_05_PreadmitNumber PV1_23_05_PreadmitNumber PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_07_AttendingDoctor PV1_23_07_AttendingDoctor PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 AttendingDoctor Attending Doctor PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_42_PendingLocation PV1_23_42_PendingLocation PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_09_ConsultingDoctor PV1_23_09_ConsultingDoctor PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 AdmittingDoctor Admitting Doctor PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 OtherHealthcareProvider Other Healthcare Provider PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 ReferringDoctor Referring Doctor PegaHL7

PegaHC-HL7-Data-PV1_PatientVisit-V23 PV1_23_52_OtherHealthcareProvider PV1_23_52_OtherHealthcareProvider PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_07_VisitUserCode PV2_07_VisitUserCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_09_ExpectedDischargeDate PV2_09_ExpectedDischargeDate PegaHL7

PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_03_AdmitReason PV2_03_AdmitReason PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_04_TransferReason PV2_04_TransferReason PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_06_PatientValuablesLocation PV2_06_PatientValuablesLocation PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_08_ExpectedAdmitDate PV2_08_ExpectedAdmitDate PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_02_AccommodationCode PV2_02_AccommodationCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_05_PatientValuables PV2_05_PatientValuables PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo PV2_01_PriorPendingLocation PV2_01_PriorPendingLocation PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_23_ClinicOrganizationName PV2_23_23_ClinicOrganizationName PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_15_EmpIllnessRelatedIndicator PV2_23_15_EmpIllnessRelatedIndicator PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_09_ExpectedDischargeDate PV2_23_09_ExpectedDischargeDate PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_17_PurgeStatusDate PV2_23_17_PurgeStatusDate PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_18_SpecialProgramCode PV2_23_18_SpecialProgramCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_19_RetentionIndicator PV2_23_19_RetentionIndicator PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_26_PreviousTreatmentDate PV2_23_26_PreviousTreatmentDate PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_36_NewbornBabyIndicator PV2_23_36_NewbornBabyIndicator PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_27_ExpectedDischargeDisposition PV2_23_27_ExpectedDischargeDisposition PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_31_RecurringServiceCode PV2_23_31_RecurringServiceCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_13_ReferralSourceCode PV2_23_13_ReferralSourceCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_11_ActualLengthofInpatientStay PV2_23_11_ActualLengthofInpatientStay PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_35_MilitaryNonAvailabilityCode PV2_23_35_MilitaryNon-AvailabilityCode PegaHL7

PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_37_BabyDetainedIndicator PV2_23_37_BabyDetainedIndicator PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_28_SignatureonFileDate PV2_23_28_SignatureonFileDate PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_33_ExpectedSurgeryDateTime PV2_23_33_ExpectedSurgeryDate&Time PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_30_PatientChargeAdjustmentCode PV2_23_30_PatientChargeAdjustmentCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_29_FirstSimilarIllnessDate PV2_23_29_FirstSimilarIllnessDate PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_25_VisitPriorityCode PV2_23_25_VisitPriorityCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_16_PurgeStatusCode PV2_23_16_PurgeStatusCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_12_VisitDescription PV2_23_12_VisitDescription PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_34_MilitaryPartnershipCode PV2_23_34_MilitaryPartnershipCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_21_VisitPublicityCode PV2_23_21_VisitPublicityCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_14_PreviousServiceDate PV2_23_14_PreviousServiceDate PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_10_EstimtdLengthofInpatientStay PV2_23_10_EstimtdLengthofInpatientStay PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 ClinicOrganizationName ClinicOrganizationName PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_32_BillingMediaCode PV2_23_32_BillingMediaCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_24_PatientStatusCode PV2_23_24_PatientStatusCode PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_20_ExpectedNoOfInsurancePlans PV2_23_20_ExpectedNoOfInsurancePlans PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_22_VisitProtectionIndicator PV2_23_22_VisitProtectionIndicator PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_01_PriorPendingLocation PV2_23_01_PriorPendingLocation PegaHL7PegaHC-HL7-Data-

PV2_PatientVisitAddtionalInfo-V23 PV2_23_08_ExpectedAdmitDate PV2_23_08_ExpectedAdmitDate PegaHL7PegaHC-HL7-Data-

QRD_11_WhatDataCodeValueQual QRD_11_01_FirstDataCodeValue QRD_11_01_FirstDataCodeValue PegaHL7

PegaHC-HL7-Data-

QRD_11_WhatDataCodeValueQual QRD_11_02_LastDataCodeValue QRD_11_02_LastDataCodeValue PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_05_DeferredResponseType QRD_05_DeferredResponseType PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_10_WhatDepartmentDataCode QRD_10_WhatDepartmentDataCode PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_03_QueryPriority QRD_03_QueryPriority PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_08_WhoSubjectFilter QRD_08_WhoSubjectFilter PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_04_QueryID QRD_04_QueryID PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition WhatDataCodeValue QRD_List PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_06_DeferredResponseDateTime QRD_06_DeferredResponseDateTime PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_01_QueryDateTime QRD_01_QueryDateTime PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_12_QueryResultsLevel QRD_12_QueryResultsLevel PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_11_WhatDataCodeValueQual QRD_11_WhatDataCodeValueQual. PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_02_QueryFormatCode QRD_02_QueryFormatCode PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_09_WhatSubjectFilter QRD_09_WhatSubjectFilter PegaHL7

PegaHC-HL7-Data-QRD_QueryDefinition QRD_07_QuantityLimitedRequest QRD_07_QuantityLimitedRequest PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_02_WhenDataStartDateTime QRF_02_WhenDataStartDateTime PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_08_DateTimeSelectionQualifier QRF_08_DateTimeSelectionQualifier PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_04_WhatUserQualifier QRF_04_WhatUserQualifier PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_03_WhenDataEndDateTime QRF_03_WhenDataEndDateTime PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_07_WhichDateTimeStatusQualifier QRF_07_WhichDateTimeStatusQualifier PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_05_OtherQRYSubjectFilter QRF_05_OtherQRYSubjectFilter PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_01_WhereSubjectFilter QRF_01_WhereSubjectFilter PegaHL7PegaHC-HL7-Data-QRF_QueryFilter QRF_06_WhichDateTimeQualifier QRF_06_WhichDateTimeQualifier PegaHL7PegaHC-HL7-Data-Relation REL_05_AlternateText NK1_03_05_AlternateText PegaHL7PegaHC-HL7-Data-Relation REL_04_AlternateIdentifier NK1_03_04_AlternateIdentifier PegaHL7PegaHC-HL7-Data-Relation REL_02_Text NK1_03_02_Text PegaHL7PegaHC-HL7-Data-Relation REL_06_NameOfAltCodingSys NK1_03_06_NameOfAltCodingSys PegaHL7

PegaHC-HL7-Data-Relation REL_03_NameOfCodingSystem NK1_03_03_NameOfCodingSystem PegaHL7PegaHC-HL7-Data-Relation REL_01_Identifier NK1_03_01_Identifier PegaHL7PegaHC-HL7-Data-Settings FileListener FileListener PegaHL7PegaHC-HL7-Data-Technician TECH_05_Suffix DG1_16_05_Suffix PegaHL7PegaHC-HL7-Data-Technician TECH_06_Prefix DG1_16_06_Prefix PegaHL7PegaHC-HL7-Data-Technician TECH_08_SourceTable DG1_16_08_SourceTable PegaHL7PegaHC-HL7-Data-Technician TECH_04_MiddleInitialOrName DG1_16_04_MiddleInitialOrName PegaHL7PegaHC-HL7-Data-Technician TECH_07_Degree DG1_16_07_Degree PegaHL7PegaHC-HL7-Data-Technician TECH_03_GivenName DG1_16_03_GivenName PegaHL7PegaHC-HL7-Data-Technician TECH_01_IDNumber DG1_16_01_IDNumber PegaHL7PegaHC-HL7-Data-Technician TECH_02_FamilyName DG1_16_02_FamilyName PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_21_UB82Locator UB1_21_UB82Locator PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_10_ValueAmountAndCode UB1_10_ValueAmountAndCode PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_16_Occurrence UB1_16_Occurrence PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_23_UB82Locator UB1_23_UB82Locator PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_04_BloodReplacedPints UB1_04_BloodReplacedPints PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_12_SpecProgramIndicator UB1_12_SpecProgramIndicator PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_15_PSROURAprvdStayTo UB1_15_PSROURAprvdStayTo PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_05_BloodNotRplcdPints UB1_05_BloodNotRplcdPints PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_09_NonCoveredDays UB1_09_NonCoveredDays PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_13_PSROURApprovalIndicator UB1_13_PSROURApprovalIndicator PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_20_UB82Locator UB1_20_UB82Locator PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_18_OccurSpanStartDate UB1_18_OccurSpanStartDate PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_03_BloodFurnPintsOf UB1_03_BloodFurnPintsOf PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_07_ConditionCode UB1_07_ConditionCode PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_01_SetID UB1_01_SetID PegaHL7PegaHC-HL7-Data-UB1_UB82Data Occurence ValueAmountAndCode PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_06_CoInsuranceDays UB1_06_CoInsuranceDays PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_08_CoveredDays UB1_08_CoveredDays PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_14_PSROURAprvdStayFm UB1_14_PSROURAprvdStayFm PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_19_OccurSpanEndDate UB1_19_OccurSpanEndDate PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_02_BloodDeductible UB1_02_BloodDeductible PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_11_NumberOfGraceDays UB1_11_NumberOfGraceDays PegaHL7PegaHC-HL7-Data-UB1_UB82Data ValueAmountAndCode ValueAmountAndCode PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_17_OccurrenceSpan UB1_17_OccurrenceSpan PegaHL7PegaHC-HL7-Data-UB1_UB82Data UB1_22_UB82Locator UB1_22_UB82Locator PegaHL7PegaHC-HL7-Data-

UB2_08_OccurrenceSpanCodeDates UB2_08_01_OccurrenceCode UB2_08_01_OccurrenceCode PegaHL7PegaHC-HL7-Data-

UB2_08_OccurrenceSpanCodeDates UB2_08_02_OccSpanStartDate UB2_08_02_OccSpanStartDate PegaHL7

PegaHC-HL7-Data-

UB2_08_OccurrenceSpanCodeDates UB2_08_03_OccSpanStopDate UB2_08_03_OccSpanStopDate PegaHL7PegaHC-HL7-Data-UB2_UB92Data OccurenceSpanCodeDates UB2_01_SetID PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_05_NonCoveredDays UB2_05_NonCoveredDays PegaHL7PegaHC-HL7-Data-UB2_UB92Data OccurenceCodeAndDate UB2_01_SetID PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_04_CoveredDays UB2_04_CoveredDays PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_16_UB92Locator78State UB2_16_UB92Locator78State PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_10_UB92Locator11State UB2_10_UB92Locator11State PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_09_UB92Locator2State UB2_09_UB92Locator2State PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_07_OccurrenceCodeAndDate UB2_07_OccurrenceCodeAndDate PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_02_CoInsuranceDays UB2_02_CoInsuranceDays PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_14_UB92Locator56State UB2_14_UB92Locator56State PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_13_UB92Locator49National UB2_13_UB92Locator49National PegaHL7PegaHC-HL7-Data-UB2_UB92Data ValueAmountAndCode UB2_01_SetID PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_11_UB92Locator31National UB2_11_UB92Locator31National PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_03_ConditionCode UB2_03_ConditionCode PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_15_UB92Locator57National UB2_15_UB92Locator57National PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_08_OccurrenceSpanCodeDates UB2_08_OccurrenceSpanCodeDates PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_06_ValueAmountAndCode UB2_06_ValueAmountAndCode PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_01_SetID UB2_01_SetID PegaHL7PegaHC-HL7-Data-UB2_UB92Data UB2_12_DocumentControlNumber UB2_12_DocumentControlNumber PegaHL7PegaHC-HL7-Data-UniversalID UID_01_NamespaceID NamespaceID PegaHL7PegaHC-HL7-Data-UniversalID UID_03_UniversalIdType Universal Id Type PegaHL7PegaHC-HL7-Data-UniversalID UID_02_UniversalID Universal ID PegaHL7PegaHC-HL7-Data-Value Value_02_ValueAmount Value_02_ValueAmount PegaHL7PegaHC-HL7-Data-Value Value_01_ValueCode Value_01_ValueCode PegaHL7PegaHC-HL7-Work HL7Message HL7Message PegaHL7PegaHC-HL7-Work FileName FileName PegaHL7PegaHC-HL7-Work EventType EventType PegaHL7PegaHC-HL7-Work Delimiters ADT_A01 PegaHL7PegaHC-HL7-Work PropVersion PropVersion PegaHL7PegaHC-HL7-Work createDate createDate PegaHL7PegaHC-HL7-Work Trigger_Event Trigger_Event PegaHL7PegaHC-HL7-Work BatchID BatchID PegaHL7PegaHC-HL7-Work ACK_Acknowledgement ACK_Acknowledgement PegaHL7Code-Pega-Requestor BenefitSet BenefitSet PegaPCS-FoundationCode-Pega-Requestor FromLinkBenefits FromLinkBenefits PegaPCS-FoundationEmbed-PCS-MappingConfiguration- CodeGroupCategory CodeGroupCategory PegaPCS-FoundationEmbed-PCS-MappingConfiguration- CodeGroupName CodeGroupName PegaPCS-FoundationEmbed-PCS-MappingConfiguration- Type Type PegaPCS-Foundation

Embed-PCS-MappingConfiguration- CodeGroupLabel CodeGroupLabel PegaPCS-FoundationEmbed-PCS-MappingConfiguration- IsOverrideCodeGroup IsOverrideCodeGroup PegaPCS-FoundationEmbed-PCS-MappingConfiguration- CodeSetClass CodeSetClass PegaPCS-FoundationEmbed-PCS-Method Type Type PegaPCS-FoundationPegaPCS-Data-Config BenefitSetMode Benefit Set Mode PegaPCS-FoundationPegaPCS-Data-Config BenefitMappingMode Benefit Mapping Mode PegaPCS-FoundationPegaPCS-Data-Dictionary DictionaryType DictionaryType PegaPCS-FoundationPegaPCS-Data-Setting RuleSetVersion RuleSetVersion PegaPCS-FoundationPegaPCS-Data-Setting ApplicationVersion ApplicationVersion PegaPCS-FoundationPegaPCS-Data-Setting RuleSet RuleSet PegaPCS-FoundationPegaPCS-Data-Setting Application Application PegaPCS-FoundationPegaPCS-Data-Setting ClaimSystems ClaimSystems PegaPCS-FoundationPegaPCS-Data-Setting BenefitMappingConfiguration BenefitMappingConfiguration PegaPCS-FoundationPegaPCS-Data-Setting BenefitMappingMode DefaultOffering PegaPCS-FoundationPegaPCS-Data-Setting BenefitSetMode DefaultOffering PegaPCS-FoundationPegaPCS-Data-Setting DefaultOffering DefaultOffering PegaPCS-FoundationPegaPCS-Data-Setting DefaultClass DefaultClass PegaPCS-FoundationPegaPCS-Data-Setting RunMode DefaultOffering PegaPCS-FoundationRule-PCS- State State PegaPCS-FoundationRule-PCS- CurrentEffectiveDate Current EffectiveDate PegaPCS-FoundationRule-PCS- CurrentTermDate CurrentTermDate PegaPCS-FoundationRule-PCS- EffectiveDate EffectiveDate PegaPCS-FoundationRule-PCS- LOBOffering LOBOffering PegaPCS-FoundationRule-PCS- ProductCategory ProductCategory PegaPCS-FoundationRule-PCS- TermDate TermDate PegaPCS-FoundationRule-PCS- MandateID Name PegaPCS-FoundationRule-PCS- Name Name PegaPCS-Foundation


PegaX12-Data- IsFromRDC IsFromRDC PegaX12

PegaX12-Data-GS_FunctionalGroupHeader

GS08_VersionReleaseIndustryIdentifierCo

de Version Release Industry Identifier Code PegaX12PegaX12-Data-N276 HealthCareClaimStatusRequest HealthCareClaimStatusRequest PegaX12PegaX12-Data-N276-

HealthCareClaimStatusRequest FunctionalGroupHeader Functional Group Header PegaX12PegaX12-Data-N278 .GroupID Group ID PegaX12PegaX12-Data- GroupID GroupID PegaX124010PegaX12-Data- ISA_InterchangeControlHeader ISA_InterchangeControlHeader PegaX124010PegaX12-Data- X12Pre X12Pre PegaX124010PegaX12-Data- IsFromRDC IsFromRDC PegaX124010PegaX12-Data- MultClaimX12Body MultClaimX12Body PegaX124010PegaX12-Data- IEA_InterchangeControlTrailer IEA_InterchangeControlTrailer PegaX124010PegaX12-Data- Message X12 Message PegaX124010PegaX12-Data- X12Post X12Post PegaX124010PegaX12-Data- STCount STCount PegaX124010

PegaX12-Data-AAA_RequestValidation AAA01_YesNoConditionorResponseCode AAA01_YesNoConditionorResponseCode PegaX124010PegaX12-Data-AAA_RequestValidation AAA04_FollowupActionCode Followup Action Code PegaX124010PegaX12-Data-AAA_RequestValidation AAA03_RejectReasonCode Reject Reason Code PegaX124010PegaX12-Data-AAA_RequestValidation AAA02_AgencyQualifierCode AAA02_AgencyQualifierCode PegaX124010PegaX12-Data-ACT_AccountIdentification ACT02_Name Name PegaX124010PegaX12-Data-ACT_AccountIdentification ACT03_IdentificationCodeQualifier Identification Code Qualifier PegaX124010PegaX12-Data-ACT_AccountIdentification ACT05_AccountNumberQualifier Account Number Qualifier PegaX124010PegaX12-Data-ACT_AccountIdentification ACT04_IdentificationCode Identification Code PegaX124010PegaX12-Data-ACT_AccountIdentification ACT06_AccountNumber Account Number PegaX124010PegaX12-Data-ACT_AccountIdentification ACT08_PaymentMethodCode Payment Method Code PegaX124010PegaX12-Data-ACT_AccountIdentification ACT07_Description Description PegaX124010PegaX12-Data-ACT_AccountIdentification ACT01_AccountNumber Account Number PegaX124010PegaX12-Data-AMT_MonetaryAmount AMT02_MonetaryAmount AMT02_Monetary Amount PegaX124010PegaX12-Data-AMT_MonetaryAmount AMT01_AmountQualifierCode AMT01_Amount Qualifier Code PegaX124010PegaX12-Data-AMT_MonetaryAmount AMT03_CreditDebitFlagCode AMT03_Credit/Debit Flag Code PegaX124010PegaX12-Data-BGN_BeginningSegment BGN08_ActionCode Action Code PegaX124010PegaX12-Data-BGN_BeginningSegment BGN06_ReferenceIdentification Reference Identification PegaX124010PegaX12-Data-BGN_BeginningSegment BGN09_SecurityLevelCode Security Level Code PegaX124010PegaX12-Data-BGN_BeginningSegment BGN05_TimeCode Time Code PegaX124010PegaX12-Data-BGN_BeginningSegment BGN03_Date Date PegaX124010PegaX12-Data-BGN_BeginningSegment BGN04_Time Time PegaX124010PegaX12-Data-BGN_BeginningSegment BGN01_TransactionSetPurposeCode Transaction Set Purpose Code PegaX124010

PegaX12-Data-BGN_BeginningSegment BGN02_ReferenceIdentification Reference Identification PegaX124010PegaX12-Data-BGN_BeginningSegment BGN07_TransactionTypeCode Transaction Type Code PegaX124010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT06_TransactionTypeCode Transaction Type Code PegaX124010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT03_ReferenceIdentification Reference Identification PegaX124010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT02_TransactionSetPurposeCode Transaction Set Purpose Code PegaX124010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT05_Time Time PegaX124010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT04_Date Date PegaX124010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT01_HierarchicalStructureCode Hierarchical Structure Code PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS19_Quantity CAS19_Quantity PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS17_ReasonCode CAS17_ReasonCode PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS15_MonetaryAmount CAS15_MonetaryAmount PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS14_ReasonCode CAS14_ReasonCode PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS07_Quantity CAS07_Quantity PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS16_Quantity CAS16_Quantity PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS12_MonetaryAmount CAS12_MonetaryAmount PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS11_ReasonCode CAS11_ReasonCode PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS09_MonetaryAmount CAS09_MonetaryAmount PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS08_ReasonCode CAS08_ReasonCode PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS06_MonetaryAmount CAS06_MonetaryAmount PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS05_ReasonCode CAS05_ReasonCode PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS04_Quantity CAS04_Quantity PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS13_Quantity CAS13_Quantity PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS03_MonetaryAmount CAS03_MonetaryAmount PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS10_Quantity CAS10_Quantity PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS02_ReasonCode CAS02_ReasonCode PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS18_MonetaryAmount CAS18_MonetaryAmount PegaX124010PegaX12-Data-CAS_ClaimsAdjustment CAS01_ClaimAdjustmentGroupCode CAS01_Claim Adjustment Group Code PegaX124010PegaX12-Data-CL1_ClaimCodes CL102_AdmissionSourceCode CL102_AdmissionSourceCode PegaX124010

PegaX12-Data-CL1_ClaimCodes

CL104_NursingHomeResidentialStatusCod

e

CL104_NursingHomeResidentialStatusCo

de PegaX124010PegaX12-Data-CL1_ClaimCodes CL101_AdmissionTypeCode CL101_AdmissionTypeCode PegaX124010PegaX12-Data-CL1_ClaimCodes CL103_PatientStatusCode CL103_PatientStatusCode PegaX124010PegaX12-Data-CLM_HealthClaim CLM01_ClaimSubmittersIdentifier Claim Submitter's Identifier PegaX124010

PegaX12-Data-CLM_HealthClaim CLM07_ProviderAcceptAssignmentCode

Code indicating whether the provider

accepts assignment PegaX124010PegaX12-Data-CLM_HealthClaim CLM09_ReleaseOfInformationCode Release of Information Code PegaX124010

PegaX12-Data-CLM_HealthClaim CLM13_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX124010PegaX12-Data-CLM_HealthClaim CLM20_DelayReasonCode Delay Reason Code PegaX124010PegaX12-Data-CLM_HealthClaim CLM11_RelatedCausesInformation Related Causes Information PegaX124010PegaX12-Data-CLM_HealthClaim CLM16_ProviderAgreementCode Provider Agreement Code PegaX124010

PegaX12-Data-CLM_HealthClaim CLM18_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX124010


PegaX12-Data-CLM_HealthClaim CLM08_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX124010PegaX12-Data-CLM_HealthClaim CLM17_ClaimStatusCode Claim Status Code PegaX124010PegaX12-Data-CLM_HealthClaim CLM03_ClaimFilingIndicatorCode Claim Filing Indicator Code PegaX124010

PegaX12-Data-CLM_HealthClaim

CLM05_HealthCareServiceLocationInform

ation Health Care Service Location Information PegaX124010PegaX12-Data-CLM_HealthClaim CLM02_MonetaryAmount Monetary Amount PegaX124010

PegaX12-Data-CLM_HealthClaim CLM04_NonInstitutionalClaimTypeCode Non-Institutional Claim Type Code PegaX124010PegaX12-Data-CLM_HealthClaim CLM12_SpecialProgramCode Special Program Code PegaX124010PegaX12-Data-CLM_HealthClaim CLM19_ClaimSubmissionReasonCode Claim Submission Reason Code PegaX124010PegaX12-Data-CLM_HealthClaim CLM14_LevelOfService Level of Service PegaX124010PegaX12-Data-CLM_HealthClaim CLM10_PatientSignatureSourceCode Patient Signature Source Code PegaX124010

PegaX12-Data-CLM_HealthClaim CLM15_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX124010PegaX12-Data-

CLM05_HealthCareServiceLocationInfo CLM05_3_ClaimFrequencyTypeCode Code specifying frequency of the claim PegaX124010PegaX12-Data-

CLM05_HealthCareServiceLocationInfo CLM05_2_FacilityCodeQualifier Facility Code Qualifier PegaX124010PegaX12-Data-

CLM05_HealthCareServiceLocationInfo CLM05_1_FacilityCodeValue Facility Code Value PegaX124010

PegaX12-Data-CLM11_RelatedCausesInformation CLM11_1_RelatedCausesCode Related Causes Code PegaX124010

PegaX12-Data-CLM11_RelatedCausesInformation CLM11_4_StateOrProvinceCode State or Province Code PegaX124010

PegaX12-Data-CLM11_RelatedCausesInformation CLM11_5_CountryCode Country Code PegaX124010


PegaX12-Data-CLM11_RelatedCausesInformation CLM11_2_RelatedCausesCode Related Causes Code PegaX124010PegaX12-Data-CN1_ContractInformation CN104_ReferenceIdentification CN104_Reference Identification PegaX124010PegaX12-Data-CN1_ContractInformation CN101_ContractTypeCode CN101_Contract Type Code PegaX124010PegaX12-Data-CN1_ContractInformation CN103_Percent CN103_Percent PegaX124010PegaX12-Data-CN1_ContractInformation CN105_TermsDiscountPercent CN105_Terms Discount Percent PegaX124010PegaX12-Data-CN1_ContractInformation CN106_VersionIdentifier CN106_Version Identifier PegaX124010PegaX12-Data-CN1_ContractInformation CN102_MonetaryAmount CN102_Monetary Amount PegaX124010PegaX12-Data-COB_CoordinationOfBenefits COB03_CoordinationOfBenefitsCode Coordination OfBenefits Code PegaX124010

PegaX12-Data-COB_CoordinationOfBenefits

COB01_PayerResponsibilitySequenceNum

berCode

Payer Responsibility Sequence Number

Code PegaX124010PegaX12-Data-COB_CoordinationOfBenefits COB02_ReferenceIdentification COB02_ReferenceIdentification PegaX124010

PegaX12-Data-CR1_AmbulanceCertification CR104_AmbulanceTransportReasonCode

CR104_Ambulance Transport Reason

Code PegaX124010PegaX12-Data-CR1_AmbulanceCertification CR110_Description CR110_Description PegaX124010PegaX12-Data-CR1_AmbulanceCertification CR109_Description CR109_Description PegaX124010PegaX12-Data-CR1_AmbulanceCertification CR107_AddressInformation CR107_Address Information PegaX124010PegaX12-Data-CR1_AmbulanceCertification CR108_AddressInformation CR108_Address Information PegaX124010

PegaX12-Data-CR1_AmbulanceCertification CR105_UnitOrBasisForMeasurementCode

CR105_Unit Or Basis For Measurement

Code PegaX124010PegaX12-Data-CR1_AmbulanceCertification CR102_Weight CR102_Weight PegaX124010PegaX12-Data-CR1_AmbulanceCertification CR106_Quantity CR106_Quantity PegaX124010PegaX12-Data-CR1_AmbulanceCertification CR103_AmbulanceTransportCode CR103_Ambulance Transport Code PegaX124010



Code PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR206_Quantity CR206_Quantity PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR201_Count CR201_Count PegaX124010

PegaX12-Data-CR2_ChiropracticCertification CR205_UnitOrBasisForMeasurementCode


Code PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR210_Description CR210_Description PegaX124010

PegaX12-Data-CR2_ChiropracticCertification CR212_YesNoConditionOrResponseCode

CR212_Yes/No Condition Or Response

Code PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR208_NatureOfConditionCode CR208_Nature Of Condition Code PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR204_SubluxationLevelCode CR204_Subluxation Level Code PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR202_Quantity CR202_Quantity PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR203_SubluxationLevelCode CR203_Subluxation Level Code PegaX124010



Code PegaX124010

PegaX12-Data-CR2_ChiropracticCertification CR211_Description CR211_Description PegaX124010PegaX12-Data-CR2_ChiropracticCertification CR207_Quantity CR207_Quantity PegaX124010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR304_InsulinDependentCode CR304_Insulin Dependent Code PegaX124010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR302_UnitOrBasisForMeasurementCode


Code PegaX124010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR301_CertificationTypeCode CR301_Certification Type Code PegaX124010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR303_Quantity CR303_Quantity PegaX124010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR305_Description CR305_Description PegaX124010

PegaX12-Data-CR5_OxygenTherapyCertification CR517_OxygenDeliverySystemCode CR517_Oxygen Delivery System Code PegaX124010

PegaX12-Data-CR5_OxygenTherapyCertification CR502_Quantity CR502_Quantity PegaX124010

PegaX12-Data-CR5_OxygenTherapyCertification CR504_OxygenEquipmentTypeCode CR504_Oxygen Equipment Type Code PegaX124010



PegaX12-Data-CR5_OxygenTherapyCertification CR505_Description CR505_Description PegaX124010

PegaX12-Data-CR5_OxygenTherapyCertification CR515_OxygenTestFindingsCode CR515_Oxygen Test Findings Code PegaX124010


PegaX12-Data-CR5_OxygenTherapyCertification CR501_CertificationTypeCode CR501_Certification Type Code PegaX124010





PegaX12-Data-CR5_OxygenTherapyCertification CR512_OxygenTestConditionCode CR512_Oxygen Test Condition Code PegaX124010





PegaX12-Data-CR6_HomeHealthCareCertification CR601_PrognosisCode CR601_PrognosisCode PegaX124010

PegaX12-Data-CR6_HomeHealthCareCertification CR621_Date CR621_Date PegaX124010

PegaX12-Data-CR6_HomeHealthCareCertification CR611_MedicalCodeValue CR611_MedicalCodeValue PegaX124010


PegaX12-Data-CR6_HomeHealthCareCertification CR615_DateTimePeriodFormatQualifier CR615_DateTimePeriodFormatQualifier PegaX124010



PegaX12-Data-CR6_HomeHealthCareCertification CR607_YesNoConditionorResponseCode CR607_YesNoConditionorResponseCode PegaX124010

PegaX12-Data-CR6_HomeHealthCareCertification CR608_CertificationTypeCode CR608_CertificationTypeCode PegaX124010


PegaX12-Data-CR6_HomeHealthCareCertification CR616_DateTimePeriod CR616_DateTimePeriod PegaX124010

PegaX12-Data-CR6_HomeHealthCareCertification CR617_PatientLocationCode CR617_PatientLocationCode PegaX124010




PegaX12-Data-CR6_HomeHealthCareCertification CR610_ProductServiceIDQualifier CR610_ProductServiceIDQualifier PegaX124010





PegaX12-Data-CR6_HomeHealthCareCertification CR620_Date CR620_Date PegaX124010PegaX12-Data-

CR7_HomeHealthTreatmentPlanCertification CR703_Number CR703_Number PegaX124010PegaX12-Data-


CR7_HomeHealthTreatmentPlanCertification CR701_DisciplineTypeCode CR701_DisciplineTypeCode PegaX124010

PegaX12-Data-CRC_ConditionsIndicator CRC02_YesNoConditionOrResponseCode

CRC02_Yes/No Condition Or Response

Code PegaX124010PegaX12-Data-CRC_ConditionsIndicator CRC05_ConditionIndicator CRC05_Condition Indicator PegaX124010PegaX12-Data-CRC_ConditionsIndicator CRC07_ConditionIndicator CRC07_Condition Indicator PegaX124010PegaX12-Data-CRC_ConditionsIndicator CRC06_ConditionIndicator CRC06_Condition Indicator PegaX124010PegaX12-Data-CRC_ConditionsIndicator CRC04_ConditionIndicator CRC04_Condition Indicator PegaX124010PegaX12-Data-CRC_ConditionsIndicator CRC03_ConditionIndicator CRC03_Condition Indicator PegaX124010PegaX12-Data-CRC_ConditionsIndicator CRC01_CodeCategory CRC01_Code Category PegaX124010PegaX12-Data-CTP_PricingInformation CTP10_ConditionValue CTP10_ConditionValue PegaX124010PegaX12-Data-CTP_PricingInformation CTP09_BasisOfUnitPriceCode CTP09_BasisOfUnitPriceCode PegaX124010PegaX12-Data-CTP_PricingInformation CTP04_Quantity CTP04_Quantity PegaX124010PegaX12-Data-CTP_PricingInformation CTP05_CompositeUnitOfMeasure CTP05_CompositeUnitOfMeasure PegaX124010PegaX12-Data-CTP_PricingInformation CTP02_PriceIdentifierCode CTP02_Price Identifier Code PegaX124010PegaX12-Data-CTP_PricingInformation CTP11_MultiplePriceQuantity CTP11_MultiplePriceQuantity PegaX124010PegaX12-Data-CTP_PricingInformation CTP07_Multiplier CTP07_Multiplier PegaX124010PegaX12-Data-CTP_PricingInformation CTP08_MonetaryAmount CTP08_MonetaryAmount PegaX124010PegaX12-Data-CTP_PricingInformation CTP03_UnitPrice CTP03_UnitPrice PegaX124010PegaX12-Data-CTP_PricingInformation CTP06_PriceMultiplierQualifier CTP06_PriceMultiplierQualifier PegaX124010PegaX12-Data-CTP_PricingInformation CTP01_ClassOfTradeCode CTP01_Class Of Trade Code PegaX124010

PegaX12-Data-CTP05_CompositeUnitOfMeasure CTP05_12_Multiplier Multiplier PegaX124010

PegaX12-Data-CTP05_CompositeUnitOfMeasure CTP05_8_Exponent Exponent PegaX124010



PegaX12-Data-CTP05_CompositeUnitOfMeasure

CTP05_7_UnitOrBasisForMeasurementCo

de Unit Or Basis For Measurement Code PegaX124010







de


de PegaX124010




CTP05_13_UnitOrBasisForMeasurementC

ode Unit Or Basis For Measurement Code PegaX124010






PegaX12-Data-CTP05_CompositeUnitOfMeasure CTP05_5_Exponent Exponent PegaX124010PegaX12-Data-CUR_Currency CUR14_Date CUR14_Date PegaX124010PegaX12-Data-CUR_Currency CUR05_CurrencyCode CUR05_Currency Code PegaX124010PegaX12-Data-CUR_Currency CUR07_DateTimeQualifier CUR07_Date Time Qualifier PegaX124010PegaX12-Data-CUR_Currency CUR17_Date CUR17_Date PegaX124010PegaX12-Data-CUR_Currency CUR01_EntityIdentifierCode CUR01_Entity Identifier Code PegaX124010PegaX12-Data-CUR_Currency CUR02_CurrencyCode CUR02_Currency Code PegaX124010PegaX12-Data-CUR_Currency CUR10_DateTimeQualifier CUR10_DateTimeQualifier PegaX124010PegaX12-Data-CUR_Currency CUR11_Date CUR11_Date PegaX124010PegaX12-Data-CUR_Currency CUR13_DateTimeQualifier CUR13_DateTimeQualifier PegaX124010PegaX12-Data-CUR_Currency CUR12_Time CUR12_Time PegaX124010PegaX12-Data-CUR_Currency CUR19_DateTimeQualifier CUR19_DateTimeQualifier PegaX124010PegaX12-Data-CUR_Currency CUR20_Date CUR20_Date PegaX124010PegaX12-Data-CUR_Currency CUR21_Time CUR21_Time PegaX124010

PegaX12-Data-CUR_Currency CUR06_CurrencyMarketExchangeCode CUR06_Currency Market Exchange Code PegaX124010PegaX12-Data-CUR_Currency CUR09_Time CUR09_Time PegaX124010PegaX12-Data-CUR_Currency CUR18_Time CUR18_Time PegaX124010PegaX12-Data-CUR_Currency CUR03_ExchangeRate CUR03_Exchange Rate PegaX124010PegaX12-Data-CUR_Currency CUR04_EntityIdentifierCode CUR04_Entity Identifier Code PegaX124010PegaX12-Data-CUR_Currency CUR15_Time CUR15_Time PegaX124010PegaX12-Data-CUR_Currency CUR16_DateTimeQualifier CUR16_DateTimeQualifier PegaX124010PegaX12-Data-CUR_Currency CUR08_Date CUR08_Date PegaX124010PegaX12-Data-DMG_DemographicInformation DMG06_CitizenshipStatusCode Code indicating citizenship status PegaX124010PegaX12-Data-DMG_DemographicInformation DMG09_Quantity Quantity PegaX124010

PegaX12-Data-DMG_DemographicInformation DMG03_GenderCode Code indicating the sex of the individual PegaX124010PegaX12-Data-DMG_DemographicInformation DMG05_RaceOrEthnicityCode Code indicating race or ethnicity PegaX124010

PegaX12-Data-DMG_DemographicInformation DMG01_DateTimePeriodFormatQualifier Code indicating date and/or time format PegaX124010PegaX12-Data-DMG_DemographicInformation DMG07_CountryCode Code indicating country PegaX124010

PegaX12-Data-DMG_DemographicInformation DMG02_DateTimePeriod

Date and/or time or range of dates

and/or times PegaX124010PegaX12-Data-DMG_DemographicInformation DMG04_MaritalStatusCode Code indicating marital status PegaX124010PegaX12-Data-DMG_DemographicInformation DMG08_BasisOfVerificationCode Code indicating basis of verification PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB05_ProductOptionCode Product Option Code PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB08_MedicalCodeValue Medical Code Value PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB03_OccupationCode Occupation Code PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB01_DisabilityTypeCode Disability Type Code PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB07_ProductServiceIDQualifier Product/Service ID Qualifier PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB04_WorkIntensityCode Work Intensity Code PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB02_Quantity Quantity PegaX124010PegaX12-Data-DSB_DisabilityInformation DSB06_MonetaryAmount Monetary Amount PegaX124010

PegaX12-Data-DTP_DateOrTimeOrPeriod DTP02_DateTimePeriodFormatQualifier DTP02_Date Time Period Format Qualifier PegaX124010PegaX12-Data-DTP_DateOrTimeOrPeriod DTP01_DateTimeQualifier DTP01_Date/Time Qualifier PegaX124010PegaX12-Data-DTP_DateOrTimeOrPeriod DTP03_DateTimePeriod DTP03_Date Time Period PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB01_EligibilityorBenefitInformation Eligibility or Benefit Information PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB05_PlanCoverageDescription Plan Coverage Description PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB13_CompositeMedicalProcedure Composite Medical Procedure PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB11_YesNoConditionorResponseCode Yes/No Condition or Response Code PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB04_InsuranceTypeCode Insurance Type Code PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB03_ServiceTypeCode Service Type Code PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB02_CoverageLevelCode Coverage Level Code PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB08_Percent Percent PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB07_MonetaryAmount Monetary Amount PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB09_QuantityQualifier Quantity Qualifier PegaX124010

PegaX12-Data-EB_EligibilityorBenefitInformation EB06_TimePeriodQualifier Time Period Qualifier PegaX124010


PegaX12-Data-EB_EligibilityorBenefitInformation EB10_Quantity Quantity PegaX124010

PegaX12-Data-EB13_CompositeMedicalProcedure EB13_2_ProductServiceID Product/Service ID PegaX124010

PegaX12-Data-EB13_CompositeMedicalProcedure EB13_7_Description Description PegaX124010

PegaX12-Data-EB13_CompositeMedicalProcedure EB13_3_ProcedureModifier Procedure Modifier PegaX124010




PegaX12-Data-EB13_CompositeMedicalProcedure EB13_1_ProductServiceIDQualifier Product/Service ID Qualifier PegaX124010PegaX12-Data-EQ_EligibilityorBenefitInquiry EQ01_ServiceTypeCode Service Type Code PegaX124010PegaX12-Data-EQ_EligibilityorBenefitInquiry EQ04_InsuranceTypeCode Insurance Type Code PegaX124010

PegaX12-Data-EQ_EligibilityorBenefitInquiry

EQ02_CompositeMedicalProcedureIdentifi

er Composite Medical Procedure Identifier PegaX124010PegaX12-Data-EQ_EligibilityorBenefitInquiry EQ03_CoverageLevelCode Coverage Level Code PegaX124010

PegaX12-Data-

EQ02_CompositeMedicalProcedureIdentifier EQ02_2_ProductServiceID Product/Service ID PegaX124010PegaX12-Data-

EQ02_CompositeMedicalProcedureIdentifier EQ02_7_Description Description PegaX124010PegaX12-Data-

EQ02_CompositeMedicalProcedureIdentifier EQ02_1_ProductServiceIDQualifier Product/Service ID Qualifier PegaX124010PegaX12-Data-

EQ02_CompositeMedicalProcedureIdentifier EQ02_4_ProcedureModifier Procedure Modifier PegaX124010PegaX12-Data-



EQ02_CompositeMedicalProcedureIdentifier EQ02_5_ProcedureModifier Procedure Modifier PegaX124010PegaX12-Data-FRM_SupportingDocumentation FRM04_Date FRM04_Date PegaX124010PegaX12-Data-FRM_SupportingDocumentation FRM03_ReferenceIdentification FRM03_Reference Identification PegaX124010

PegaX12-Data-FRM_SupportingDocumentation FRM02_YesNoConditionOrResponseCode

FRM02_Yes/No Condition Or Response

Code PegaX124010PegaX12-Data-FRM_SupportingDocumentation FRM05_Percent FRM05_Percent PegaX124010PegaX12-Data-FRM_SupportingDocumentation FRM01_AssignedIdentification FRM01_Assigned Identification PegaX124010PegaX12-Data-GE_FunctionalGroupTrailer GE02_GroupControlNumber Group Control Number PegaX124010

PegaX12-Data-GE_FunctionalGroupTrailer GE01_NumberofTransactionSetsIncluded Number of Transaction Sets Included PegaX124010PegaX12-Data-GS_FunctionalGroupHeader GS02_ApplicationSendersCode Application Senders Code PegaX124010PegaX12-Data-GS_FunctionalGroupHeader GS06_GroupControlNumber Group Control Number PegaX124010PegaX12-Data-GS_FunctionalGroupHeader GS07_ResponsibleAgencyCode Responsible Agency Code PegaX124010PegaX12-Data-GS_FunctionalGroupHeader GS05_Time Time PegaX124010PegaX12-Data-GS_FunctionalGroupHeader GS04_Date Date PegaX124010PegaX12-Data-GS_FunctionalGroupHeader GS03_ApplicationReceiversCode Application Receivers Code PegaX124010



de Version Release Industry Identifier Code PegaX124010PegaX12-Data-GS_FunctionalGroupHeader GS01_FunctionalIdentifierCode Functional Identifier Code PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP15_ExceptionCode HCP15_Exception Code PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP05_Rate HCP05_Rate PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP14_PolicyComplianceCode HCP14_Policy Compliance Code PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP12_Quantity HCP12_Quantity PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP02_MonetaryAmount HCP02_Monetary Amount PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP04_ReferenceIdentification HCP04_Reference Identification PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP13_RejectReasonCode HCP13_Reject Reason Code PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP10_ProductServiceId HCP10_Product/Service Id PegaX124010

PegaX12-Data-HCP_HealthCarePricing HCP11_UnitOrBasisForMeasurementCode

HCP11_Unit Or Basis For Measurement

Code PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP01_PricingMethodology HCP01_Pricing Methodology PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP09_ProductServiceIdQualifier HCP09_Product/Service Id Qualifier PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP07_MonetaryAmount HCP07_Monetary Amount PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP08_ProductServiceId HCP08_Product/Service Id PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP03_MonetaryAmount HCP03_Monetary Amount PegaX124010PegaX12-Data-HCP_HealthCarePricing HCP06_ReferenceIdentification HCP06_Reference Identification PegaX124010PegaX12-Data-HCR_HealthCareServicesReview HCR01_ActionCode HCR01_ActionCode PegaX124010

PegaX12-Data-HCR_HealthCareServicesReview HCR04_YesNoConditionorResponseCode HCR04_YesNoConditionorResponseCode PegaX124010PegaX12-Data-HCR_HealthCareServicesReview HCR03_RejectReasonCode Reject Reason Code PegaX124010PegaX12-Data-HCR_HealthCareServicesReview HCR02_ReferenceIdentification HCR02_ReferenceIdentification PegaX124010

PegaX12-Data-HD_HealthCoverage HD09_YesNoConditionOrResponseCode Yes/No Condition Or Response Code PegaX124010PegaX12-Data-HD_HealthCoverage HD05_CoverageLevelCode Coverage Level Code PegaX124010PegaX12-Data-HD_HealthCoverage HD06_Count Count PegaX124010PegaX12-Data-HD_HealthCoverage HD10_DrugHouseCode Drug House Code PegaX124010PegaX12-Data-HD_HealthCoverage HD04_PlanCoverageDescription Plan Coverage Description PegaX124010

PegaX12-Data-HD_HealthCoverage HD11_YesNoConditionOrResponseCode Yes/No Condition Or Response Code PegaX124010PegaX12-Data-HD_HealthCoverage HD02_MaintenanceReasonCode Maintenance Reason Code PegaX124010PegaX12-Data-HD_HealthCoverage HD01_MaintenanceTypeCode Maintenance Type Code PegaX124010PegaX12-Data-HD_HealthCoverage HD07_Count Count PegaX124010PegaX12-Data-HD_HealthCoverage HD08_UnderwritingDecisionCode Underwriting Decision Code PegaX124010PegaX12-Data-HD_HealthCoverage HD03_InsuranceLineCode Insurance Line Code PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI05_HealthCareCodeInformation HI05_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI02_HealthCareCodeInformation HI02_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI03_HealthCareCodeInformation HI03_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI06_HealthCareCodeInformation HI06_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI07_HealthCareCodeInformation HI07_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI09_HealthCareCodeInformation HI09_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI04_HealthCareCodeInformation HI04_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI11_HealthCareCodeInformation HI11_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI10_HealthCareCodeInformation HI10_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI08_HealthCareCodeInformation HI08_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI12_HealthCareCodeInformation HI12_Health Care Code Information PegaX124010PegaX12-Data-HI_HealthCareInfoCodes HI01_HealthCareCodeInformation HI01_Health Care Code Information PegaX124010

PegaX12-Data-HI_HealthCareInformationCodes HI01_HealthCareCodeInformation HI01_Health Care Code Information PegaX124010

PegaX12-Data-HI01_HealthCareCodeInformation HI01_2_IndustryCode HI01_2_Industry Code PegaX124010

PegaX12-Data-HI01_HealthCareCodeInformation HI01_7_VersionIdentifier HI01_7_Version Identifier PegaX124010

PegaX12-Data-HI01_HealthCareCodeInformation HI01_4_DateTimePeriod HI01_4_Date Time Period PegaX124010

PegaX12-Data-HI01_HealthCareCodeInformation HI01_3_DateTimePeriodFormatQualifier

HI01_3_Date Time Period Format

Qualifier PegaX124010

PegaX12-Data-HI01_HealthCareCodeInformation HI01_5_MonetaryAmount HI01_5_Monetary Amount PegaX124010

PegaX12-Data-HI01_HealthCareCodeInformation HI01_1_CodeListQualifierCode HI01_1_Code List Qualifier Code PegaX124010

PegaX12-Data-HI01_HealthCareCodeInformation HI01_6_Quantity HI01_6_Quantity PegaX124010





















PegaX12-Data-HI12_HealthCareCodeInformation HI12_7_VersionIdentifier HI12_7_Version Identifier PegaX124010PegaX12-Data-HL_HierarchicalLevel HL02_HierarchicalParentIDNumber HL02_Hierarchical Parent ID Number PegaX124010PegaX12-Data-HL_HierarchicalLevel HL01_HierarchicalIDNumber HL01_Hierarchical ID Number PegaX124010PegaX12-Data-HL_HierarchicalLevel HL04_HierarchicalChildCode HL04_Hierarchical Child Code PegaX124010PegaX12-Data-HL_HierarchicalLevel HL03_HierarchicalLevelCode HL03_Hierarchical Level Code PegaX124010PegaX12-Data-HLH_HealthInformation HLH06_CurrentHealthConditionCode Current Health Condition Code PegaX124010PegaX12-Data-HLH_HealthInformation HLH02_Height Height PegaX124010PegaX12-Data-HLH_HealthInformation HLH03_Weight Weight PegaX124010PegaX12-Data-HLH_HealthInformation HLH05_Description Description PegaX124010PegaX12-Data-HLH_HealthInformation HLH07_Description Description PegaX124010PegaX12-Data-HLH_HealthInformation HLH04_Weight Weight PegaX124010PegaX12-Data-HLH_HealthInformation HLH01_HealthRelatedCode Health-Related Code PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery

HSD07_ShipDeliveryOrCalendarPatternCo

de

HSD07_Ship/Delivery Or Calendar Pattern

Code PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD08_ShipDeliveryPatternTimeCode HSD08_Ship/Delivery Pattern Time Code PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD01_QuantityQualifier HSD01_QuantityQualifier PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD05_TimePeriodQualifier HSD05_Time Period Qualifier PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD03_UnitForBasisOrMeasurementCode

HSD03_Unit For Basis Or Measurement

Code PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD06_NumberOfPeriods HSD06_Number Of Periods PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD02_Quantity HSD02_Quantity PegaX124010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD04_SampleSelectionModulus HSD04_Sample Selection Modulus PegaX124010PegaX12-Data-ICM_IndividualIncome ICM01_FrequencyCode Frequency Code PegaX124010PegaX12-Data-ICM_IndividualIncome ICM02_MonetaryAmount Monetary Amount PegaX124010PegaX12-Data-ICM_IndividualIncome ICM06_CurrencyCode Currency Code PegaX124010PegaX12-Data-ICM_IndividualIncome ICM04_LocationIdentifier Location Identifier PegaX124010PegaX12-Data-ICM_IndividualIncome ICM05_SalaryGrade Salary Grade PegaX124010

PegaX12-Data-ICM_IndividualIncome ICM03_Quantity ICM03_Quantity PegaX124010PegaX12-Data-IDC_IdentificationCard IDC01_PlanCoverageDescription Plan Coverage Description PegaX124010PegaX12-Data-IDC_IdentificationCard IDC03_Quantity Quantity PegaX124010PegaX12-Data-IDC_IdentificationCard IDC02_IdentificationCardTypeCode Identification Card Type Code PegaX124010PegaX12-Data-IDC_IdentificationCard IDC04_ActionCode Action Code PegaX124010

PegaX12-Data-IEA_InterchangeControlTrailer

IEA01_NumberofIncludedFunctionalGroup

s Number of Included Functional Groups PegaX124010PegaX12-Data-IEA_InterchangeControlTrailer IEA02_InterchangeControlNumber Interchange Control Number PegaX124010PegaX12-Data-III_Information III03_CodeCategory Code Category PegaX124010PegaX12-Data-III_Information III05_Quantity Quantity PegaX124010PegaX12-Data-III_Information III07_SurfaceLayerPositionCode Surface/Layer/Position Code PegaX124010PegaX12-Data-III_Information III02_IndustryCode Industry Code PegaX124010PegaX12-Data-III_Information III08_SurfaceLayerPositionCode Surface/Layer/Position Code PegaX124010PegaX12-Data-III_Information III09_SurfaceLayerPositionCode Surface/Layer/Position Code PegaX124010PegaX12-Data-III_Information III06_CompositeUnitOfMeasure Composite Unit Of Measure PegaX124010PegaX12-Data-III_Information III01_CodeListQualifierCode Code List Qualifier Code PegaX124010PegaX12-Data-III_Information III04_FreeFormMessageText Free-Form Message Text PegaX124010PegaX12-Data-INS_InsuredBenefit INS09_StudentStatusCode Student Status Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS03_MaintenanceTypeCode Maintenance Type Code PegaX124010

PegaX12-Data-INS_InsuredBenefit INS11_DateTimePeriodFormatQualifier Date Time Period Format Qualifier PegaX124010PegaX12-Data-INS_InsuredBenefit INS15_StateOrProvinceCode State or Province Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS10_YesNoConditionOrReponseCode Yes/No Condition or Reponse Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS12_DateTimePeriod Date Time Period PegaX124010PegaX12-Data-INS_InsuredBenefit INS06_MedicarePlanCode Medicare Plan Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS04_MaintenanceReasonCode Maintenance Reason Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS16_CountryCode Country Code PegaX124010

PegaX12-Data-INS_InsuredBenefit INS07_COBRAQualifying

Consolidation Omnibus Budget Recon.

Act (COBRA) Qualifying PegaX124010PegaX12-Data-INS_InsuredBenefit INS05_BenefitStatusCode Benefit Status Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS14_CityName City Name PegaX124010PegaX12-Data-INS_InsuredBenefit INS13_ConfidentialityCode Confidentiality Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS17_Number Number PegaX124010PegaX12-Data-INS_InsuredBenefit INS08_EmploymentStatusCode Employment Status Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS02_IndividualRelationshipCode Individual Relationship Code PegaX124010PegaX12-Data-INS_InsuredBenefit INS01_YesNoConditionOrReponseCode Yes/No Condition or Reponse Code PegaX124010

PegaX12-Data-ISA_InterchangeControlHeader ISA12_InterchangeControlVersionNumber InterchangeControlVersionNumber PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA07_InterchangeReceiverIDQualifier InterchangeReceiverIDQualifier PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA15_UsageIndicator UsageIndicator PegaX124010

PegaX12-Data-ISA_InterchangeControlHeader ISA04_SecurityInformation SecurityInformation PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA08_InterchangeReceiverID InterchangeReceiverID PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA16_ComponentElementSeparator ComponentElementSeparator PegaX124010

PegaX12-Data-ISA_InterchangeControlHeader ISA01_AuthorizationInformationQualifier AuthorizationInformationQualifier PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA02_AuthorizationInformation AuthorizationInformation PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA03_SecurityInformationQualifier SecurityInformationQualifier PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA10_InterchangeTime InterchangeTime PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA13_InterchangeControlNumber InterchangeControlNumber PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA14_AcknowledgmentRequested AcknowledgmentRequested PegaX124010

PegaX12-Data-ISA_InterchangeControlHeader

ISA11_InterchangeControlStandardsIdenti

fier InterchangeControlStandardsIdentifier PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA05_InterchangeSenderIDQualifier InterchangeSenderIDQualifier PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA06_InterchangeSenderID InterchangeSenderID PegaX124010PegaX12-Data-ISA_InterchangeControlHeader ISA09_InterchangeDate InterchangeDate PegaX124010PegaX12-Data-K3_FileInformation K301_FixedFormatInformation K301_Fixed Format Information PegaX124010PegaX12-Data-K3_FileInformation K303_CompositeUnitOfMeasure K303_Composite Unit Of Measure PegaX124010PegaX12-Data-K3_FileInformation K302_RecordFormatCode K302_Record Format Code PegaX124010PegaX12-Data-LE_LoopTrailer LE01_LoopIdentifierCode Loop Identifier Code PegaX124010PegaX12-Data-LIN_ItemIdentification LIN10_ProductServiceIDQualifier LIN10_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN25_ProductServiceID LIN25_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN01_AssignedIdentification LIN01_AssignedIdentification PegaX124010PegaX12-Data-LIN_ItemIdentification LIN05_ProductServiceID LIN05_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN09_ProductServiceID LIN09_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN18_ProductServiceIDQualifier LIN18_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN24_ProductServiceIDQualifier LIN24_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN31_ProductServiceID LIN31_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN12_ProductServiceIDQualifier LIN12_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN08_ProductServiceIDQualifier LIN08_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN22_ProductServiceIDQualifier LIN22_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN29_ProductServiceID LIN29_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN04_ProductServiceIDQualifier LIN04_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN06_ProductServiceIDQualifier LIN06_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN11_ProductServiceID LIN11_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN13_ProductServiceID LIN13_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN16_ProductServiceIDQualifier LIN16_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN21_ProductServiceID LIN21_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN23_ProductServiceID LIN23_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN30_ProductServiceIDQualifier LIN30_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN07_ProductServiceID LIN07_ProductServiceID PegaX124010

PegaX12-Data-LIN_ItemIdentification LIN19_ProductServiceID LIN19_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN28_ProductServiceIDQualifier LIN28_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN26_ProductServiceIDQualifier LIN26_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN27_ProductServiceID LIN27_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN14_ProductServiceIDQualifier LIN14_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN15_ProductServiceID LIN15_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN20_ProductServiceIDQualifier LIN20_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN02_ProductServiceIDQualifier LIN02_ProductServiceIDQualifier PegaX124010PegaX12-Data-LIN_ItemIdentification LIN03_ProductServiceID LIN03_ProductServiceID PegaX124010PegaX12-Data-LIN_ItemIdentification LIN17_ProductServiceID LIN17_ProductServiceID PegaX124010PegaX12-Data-LQ_IndustryCode LQ02_IndustryCode LQ02_Industry Code PegaX124010PegaX12-Data-LQ_IndustryCode LQ01_CodeListQualifierCode LQ01_Code List Qualifier Code PegaX124010PegaX12-Data-LS_LoopHeader LS01_LoopIdentifierCode Loop Identifier Code PegaX124010PegaX12-Data-LUI_LanguageUse LUI02_IdentificationCode Identification Code PegaX124010PegaX12-Data-LUI_LanguageUse LUI05_LanguageProficiencyIndicator Language Proficiency Indicator PegaX124010PegaX12-Data-LUI_LanguageUse LUI04_UseofLanguageIndicator Use of Language Indicator PegaX124010PegaX12-Data-LUI_LanguageUse LUI03_Description Description PegaX124010PegaX12-Data-LUI_LanguageUse LUI01_IdentificationCodeQualifier Identification Code Qualifier PegaX124010PegaX12-Data-LX_AssignedNumber LX01_AssignedNumber LX01 Assigned Number PegaX124010PegaX12-Data-MEA_Measurements MEA05_RangeMinimum MEA05_Range Minimum PegaX124010PegaX12-Data-MEA_Measurements MEA08_MeasurementAttributeCode MEA08_Measurement Attribute Code PegaX124010PegaX12-Data-MEA_Measurements MEA04_CompositeUnitOfMeasure MEA04_Composite Unit Of Measure PegaX124010PegaX12-Data-MEA_Measurements MEA09_SurfaceLayerPositionCode MEA09_Surface/Layer/Position Code PegaX124010

PegaX12-Data-MEA_Measurements MEA10_MeasurementMethodOrDevice MEA10_Measurement Method Or Device PegaX124010

PegaX12-Data-MEA_Measurements MEA01_MeasurementReferenceIDCode MEA01_MeasurementReferenceIDCode PegaX124010

PegaX12-Data-MEA_Measurements MEA07_MeasurementSignificanceCode MEA07_Measurement Significance Code PegaX124010PegaX12-Data-MEA_Measurements MEA03_MeasurementValue MEA03_Measurement Value PegaX124010PegaX12-Data-MEA_Measurements MEA06_RangeMaximum MEA06_Range Maximum PegaX124010PegaX12-Data-MEA_Measurements MEA02_MeasurementQualifier MEA02_Measurement Qualifier PegaX124010

PegaX12-Data-MIA_MedicareInpatientAdjudication MIA12_MonetaryAmount MIA12_Monetary Amount PegaX124010


PegaX12-Data-MIA_MedicareInpatientAdjudication MIA22_ReferenceIdentification MIA22_Reference Identification PegaX124010

PegaX12-Data-MIA_MedicareInpatientAdjudication MIA06_MonetaryAmount MIA06_MonetaryAmount PegaX124010





PegaX12-Data-MIA_MedicareInpatientAdjudication MIA01_Quantity MIA01_Quantity PegaX124010













PegaX12-Data-MIA_MedicareInpatientAdjudication MIA05_ReferenceIdentification MIA05_ReferenceIdentification PegaX124010



PegaX12-Data-

MOA_MedicareOutpatientAdjudication MOA01_Percent MOA01_Percent PegaX124010PegaX12-Data-

MOA_MedicareOutpatientAdjudication MOA06_ReferenceIdentification MOA06_Reference Identification PegaX124010PegaX12-Data-

MOA_MedicareOutpatientAdjudication MOA09_MonetaryAmount MOA09_Monetary Amount PegaX124010PegaX12-Data-






MOA_MedicareOutpatientAdjudication MOA03_ReferenceIdentification MOA03_Reference Identification PegaX124010PegaX12-Data-MSG_MessageText MSG02_PrinterCarriageControlCode MSG02_PrintercarriageControlCode PegaX124010PegaX12-Data-MSG_MessageText MSG03_Number MSG03_Number PegaX124010PegaX12-Data-MSG_MessageText MSG01_FreeFormMessageText MSG01_FreeFormMessageText PegaX124010PegaX12-Data-N1_Name N104_IdentificationCode Identification Code PegaX124010PegaX12-Data-N1_Name N105_EntityRelationshipCode Entity Relationship Code PegaX124010PegaX12-Data-N1_Name N106_EntityIdentifierCode Entity Identifier Code PegaX124010PegaX12-Data-N1_Name N101_EntityIdentifierCode Entity Identifier Code PegaX124010PegaX12-Data-N1_Name N102_Name Name PegaX124010PegaX12-Data-N1_Name N103_IdentificationQualifierCode Identification Qualifier Code PegaX124010

PegaX12-Data-N2_AdditionalNameInformation N201_Name Name PegaX124010

PegaX12-Data-N2_AdditionalNameInformation N202_Name Name PegaX124010PegaX12-Data-N270 MaximumEQLimit MaximumEQLimit PegaX124010PegaX12-Data-N270 EligibilityCoverageOrBenefitInquiry Eligibility, Coverage or Benefit Inquiry PegaX124010PegaX12-Data-N270 EQNumber MaximumEQLimit PegaX124010PegaX12-Data-N270-Dependent Loop2000DDependantLevel LOOP ID - 2000D DEPENDENT LEVEL PegaX124010PegaX12-Data-N270-

EligibilityCoverageOrBenefitInquiry FunctionalGroupHeader Functional Group Header PegaX124010PegaX12-Data-N270-

EligibilityCoverageOrBenefitInquiry Transaction Transaction PegaX124010

PegaX12-Data-N270-

EligibilityCoverageOrBenefitInquiry FunctionalGroupTrailer Functional Group Trailer PegaX124010PegaX12-Data-N270-Header TransactionSetHeader Transaction Set Header PegaX124010PegaX12-Data-N270-Header BeginningOfHierarchicalTransaction Beginning of Hierarchical Transaction PegaX124010

PegaX12-Data-N270-InformationReceiverLevel Loop2000BInformationReceiverLevel

LOOP ID - 2000B INFORMATION RECEIVER

LEVEL PegaX124010PegaX12-Data-N270-InformationSourceLevel Loop2000AInformationSourceLevel Loop 2000A Information Source Level PegaX124010PegaX12-Data-N270-

Loop2000AInformationSourceLevel InformationSourceLevel Information Source Level PegaX124010PegaX12-Data-N270-

Loop2000AInformationSourceLevel InformationReceiverLevel Information Receiver Level PegaX124010PegaX12-Data-N270-

Loop2000AInformationSourceLevel Loop2100AInformationSourceName

LOOP ID - 2100A INFORMATION SOURCE

NAME PegaX124010PegaX12-Data-N270-

Loop2000BInformationReceiverLevel Loop2100BInformationReceverName



Loop2000BInformationReceiverLevel Subscriber Subscriber PegaX124010PegaX12-Data-N270-

Loop2000BInformationReceiverLevel InformationReceiverLevel Information Receiver Level PegaX124010

PegaX12-Data-N270-Loop2000CSubscriberLevel Loop2100CSubscriberName LOOP ID - 2100C SUBSCRIBER NAME PegaX124010

PegaX12-Data-N270-Loop2000CSubscriberLevel SubscriberLevel Subscriber Level PegaX124010

PegaX12-Data-N270-Loop2000CSubscriberLevel SubscriberTraceNumber Subscriber Trace Number PegaX124010

PegaX12-Data-N270-Loop2000CSubscriberLevel Dependent Dependent PegaX124010

PegaX12-Data-N270-Loop2000DDependantLevel DependentLevel Dependent Level PegaX124010

PegaX12-Data-N270-Loop2000DDependantLevel DependentTraceNumber Dependent Trace Number PegaX124010

PegaX12-Data-N270-Loop2000DDependantLevel Loop2100DDependantName LOOP ID - 2100D DEPENDENT NAME PegaX124010PegaX12-Data-N270-

Loop2100AInformationSourceName InformationSourceName Information Source Name PegaX124010PegaX12-Data-N270-

Loop2100BInformationReceiverName InformationReceiverAddress Information Receiver Address PegaX124010PegaX12-Data-N270-

Loop2100BInformationReceiverName InformationReceiverContactInformation Information Receiver Contact Information PegaX124010

PegaX12-Data-N270-

Loop2100BInformationReceiverName InformationReceiverName Information Receiver Name PegaX124010PegaX12-Data-N270-

Loop2100BInformationReceiverName InformationReceiverProviderInformation

Information Receiver Provider

Information PegaX124010PegaX12-Data-N270-

Loop2100BInformationReceiverName

InformationReceiverAdditionalIdentificatio

n

Information Receiver Additional

Identification PegaX124010PegaX12-Data-N270-

Loop2100BInformationReceiverName InformationReceiverCityStateZIPCode Information Receiver City/State/ZIP Code PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName Loop2110CSubscriberOrBIInfo

LOOP ID - 2110C SUBSCRIBER ELIGIBILITY

OR BENEFIT INQUIRY INFORM PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName SubscriberAddress Subscriber Address PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName SubscriberAdditionalIdentification Subscriber Additional Identification PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName SubscriberDate Subscriber Date PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName ProviderInformation Provider Information PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName SubscriberName Subscriber Name PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName SubscriberCityStateZIPCode Subscriber City/State/ZIP Code PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName SubscriberDemographicInformation Subscriber Demographic Information PegaX124010

PegaX12-Data-N270-Loop2100CSubscriberName SubscriberRelationship Subscriber Relationship PegaX124010

PegaX12-Data-N270-Loop2100DDependantName DependentRelationship Dependent Relationship PegaX124010

PegaX12-Data-N270-Loop2100DDependantName DependentDate Dependent Date PegaX124010

PegaX12-Data-N270-Loop2100DDependantName DependentCityStateZIPCode Dependent City/State/ZIP Code PegaX124010

PegaX12-Data-N270-Loop2100DDependantName DependentDemographicInformation Dependent Demographic Information PegaX124010

PegaX12-Data-N270-Loop2100DDependantName DependentAddress Dependent Address PegaX124010

PegaX12-Data-N270-Loop2100DDependantName ProviderInformation Provider Information PegaX124010

PegaX12-Data-N270-Loop2100DDependantName DependentAdditionalIdentification Dependent Additional Identification PegaX124010

PegaX12-Data-N270-Loop2100DDependantName Loop2110DDependentEOrBIInfo

LOOP ID - 2110D DEPENDENT ELIGIBILITY

OR BENEFIT INQUIRY INFORMA PegaX124010

PegaX12-Data-N270-Loop2100DDependantName DependentName Dependent Name PegaX124010PegaX12-Data-N270-

Loop2110CSubscriberEOrBIInfo SubscriberEligibilityOrBenefitDate Subscriber Eligibility/Benefit Date PegaX124010PegaX12-Data-N270-

Loop2110CSubscriberEOrBIInfo SubscriberSpendDownAmount Subscriber Spend Down Amount PegaX124010PegaX12-Data-N270-

Loop2110CSubscriberEOrBIInfo SubscriberAdditionalInformation Subscriber Additional Information PegaX124010PegaX12-Data-N270-

Loop2110CSubscriberEOrBIInfo

SubscriberEligibilityOrBenefitInquiryInfor

mation

Subscriber Eligibility or Benefit Inquiry



SubscriberEligibilityOrBenefitAdditionalInq

uiryInformation

Subscriber Eligibility or Benefit Additional

Inquiry Information PegaX124010PegaX12-Data-N270-

Loop2110DDependentEOrBIInfo

DependentEligibilityOrBenefitAdditionalIn

quiryInformation

Dependent Eligibility or Benefit Additional



DependentEligibilityOrBenefitInquiryInfor

mation

Dependent Eligibility or Benefit Inquiry


Loop2110DDependentEOrBIInfo DependentEligibilityOrBenefitDate Dependent Eligibility/Benefit Date PegaX124010PegaX12-Data-N270-

Loop2110DDependentEOrBIInfo DependentAdditionalIdentification Dependent Additional Information PegaX124010PegaX12-Data-N270-Subscriber Loop2000CSubscriberLevel LOOP ID - 2000C SUBSCRIBER LEVEL PegaX124010PegaX12-Data-N270-Trailer TransactionSetTrailer Transaction Set Trailer PegaX124010PegaX12-Data-N270-Transaction InformationSourceLevel Information Source Level PegaX124010PegaX12-Data-N270-Transaction Trailer Transaction Trailer PegaX124010PegaX12-Data-N270-Transaction Header Header PegaX124010

PegaX12-Data-N271 EligibilityCoverageOrBeneInfor

Eligibility, Coverage or Benefit

Information PegaX124010PegaX12-Data-N271-DependentLevel Loop2000DDependentLevel LOOP ID - 2000D DEPENDENT LEVEL PegaX124010PegaX12-Data-N271-

EligibilityCoverageOrBeneInfor FunctionalGroupHeader Functional Group Header PegaX124010PegaX12-Data-N271-

EligibilityCoverageOrBeneInfor FunctionalGroupTrailer Functional Group Trailer PegaX124010PegaX12-Data-N271-

EligibilityCoverageOrBeneInfor Transaction Transaction PegaX124010PegaX12-Data-N271-Header TransactionSetHeader Transaction Set Header PegaX124010

PegaX12-Data-N271-Header BeginningOfHierarchicalTransaction Beginning of Hierarchical Transaction PegaX124010





Loop2000AInformationSourceLevel RequestValidation Request Validation PegaX124010PegaX12-Data-N271-





Loop2000BInformationReceiverLevel Loop2100BInformationReceiverName



Loop2000BInformationReceiverLevel SubscriberLevel Subscriber Level PegaX124010PegaX12-Data-N271-



PegaX12-Data-N271-Loop2000CSubscriberLevel DependentLevel Dependent Level PegaX124010



PegaX12-Data-N271-Loop2000DDependentLevel DependentLevel Dependent Level PegaX124010

PegaX12-Data-N271-Loop2000DDependentLevel DependentTraceNumber Dependent Trace Number PegaX124010

PegaX12-Data-N271-Loop2000DDependentLevel Loop2100DDependentName LOOP ID - 2100D DEPENDENT NAME PegaX124010PegaX12-Data-N271-

Loop2100AInformationSourceName InformationSourceAdditionalIdentification

Information Source Additional



Loop2100AInformationSourceName RequestValidation Request Validation PegaX124010PegaX12-Data-N271-

Loop2100AInformationSourceName InformationSourceContactInformation Information Source Contact Information PegaX124010

PegaX12-Data-N271-



n



Loop2100BInformationReceiverName InformationReceiverRequestValidation Information Receiver Request Validation PegaX124010PegaX12-Data-N271-

Loop2100BInformationReceiverName InformationReceiverName Information Receiver Name PegaX124010





PegaX12-Data-N271-Loop2100CSubscriberName SubscriberContactInformation Subscriber Contact Information PegaX124010

PegaX12-Data-N271-Loop2100CSubscriberName Loop2110CSubscriberEorBI


OR BENEFIT INFORMATION PegaX124010

PegaX12-Data-N271-Loop2100CSubscriberName SubscriberRequestValidation Subscriber Request Validation PegaX124010




PegaX12-Data-N271-Loop2100DDependentName DependentName Dependent Name PegaX124010

PegaX12-Data-N271-Loop2100DDependentName DependentCityStateZIPCode Dependent City/State/ZIP Code PegaX124010

PegaX12-Data-N271-Loop2100DDependentName DependentAdditionalIdentification Dependent Additional Identification PegaX124010

PegaX12-Data-N271-Loop2100DDependentName DependentDemographicInformation Dependent Demographic Information PegaX124010

PegaX12-Data-N271-Loop2100DDependentName DependentAddress Dependent Address PegaX124010

PegaX12-Data-N271-Loop2100DDependentName Loop2110DDependentEorBI



PegaX12-Data-N271-Loop2100DDependentName DependentContactInformation Dependent Contact Information PegaX124010

PegaX12-Data-N271-Loop2100DDependentName DependentRequestValidation Dependent Request Validation PegaX124010

PegaX12-Data-N271-Loop2100DDependentName DependentDate Dependent Date PegaX124010

PegaX12-Data-N271-Loop2100DDependentName DependentRelationship Dependent Relationship PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberAdditionalIdentification Subscriber Additional Identification PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberEligibilityorBenefitInformation

Subscriber Eligibility or Benefit

Information PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI LoopHeader Loop Header PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI HealthCareServicesDelivery Health Care Services Delivery PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI Loop2120CSubscriberBenefitREN

LOOP ID - 2120C SUBSCRIBER BENEFIT

RELATED ENTITY NAME PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberEligibilityBenefitDate Subscriber Eligibility/Benefit Date PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI LoopTrailer Loop Trailer PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI Loop2115CSubscriberEorBAI

Loop2115CSubscriberEligibilityorBenefitA

dditionalInformation PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI MessageText Message Text PegaX124010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberRequestValidation Subscriber Request Validation PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI DependentEligibilityorBenefitInformation

Dependent Eligibility or Benefit


PegaX12-Data-N271-Loop2110DDependentEorBI DependentAdditionalIdentification Dependent Additional Identification PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI LoopHeader Loop Header PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI MessageText Message Text PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI DependentRequestValidation Dependent Request Validation PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI DependentEligibilityBenefitDate Dependent Eligibility/Benefit Date PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI LoopTrailer Loop Trailer PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI HealthCareServicesDelivery Health Care Services Delivery PegaX124010

PegaX12-Data-N271-Loop2110DDependentEorBI Loop2120DDependentBenefitREN

LOOP ID - 2120D DEPENDENT BENEFIT


PegaX12-Data-N271-Loop2110DDependentEorBI Loop2115DDependentEorBAI


OR BENEFIT ADDITIONAL INFO PegaX124010

PegaX12-Data-N271-Loop2115CSubscriberEorBAI

SubscriberEligibilityorBenefitAdditionalInf

ormation



PegaX12-Data-N271-Loop2115DDependentEorBAI

DependentEligibilityorBenefitAdditionalInf

ormation



Loop2120CSubscriberBenefitREN SubscriberBenefitRelatedEntityAddress Subscriber Benefit Related Entity Address PegaX124010PegaX12-Data-N271-

Loop2120CSubscriberBenefitREN

SubscriberBenefitRelatedEntityContactInfo

rmation

Subscriber Benefit Related Entity Contact



SubscriberBenefitRelatedProviderInformat

ion

Subscriber Benefit Related Provider


Loop2120CSubscriberBenefitREN SubscriberBenefitRelatedEntityName Subscriber Benefit Related Entity Name PegaX124010PegaX12-Data-N271-

Loop2120CSubscriberBenefitREN SubscriberBenefitRelatedCityStateZIPCode

Subscriber Benefit Related City/State/ZIP

Code PegaX124010PegaX12-Data-N271-

Loop2120DDependentBenefitREN

DependentBenefitRelatedEntityCityStateZI

PCode

Dependent Benefit Related Entity

City/State/ZIP Code PegaX124010PegaX12-Data-N271-

Loop2120DDependentBenefitREN DependentBenefitRelatedEntityAddress


Address PegaX124010PegaX12-Data-N271-


DependentBenefitRelatedProviderInforma

tion

Dependent Benefit Related Provider



DependentBenefitRelatedEntityContactInf

ormation

Dependent Benefit Related Entity Contact


Loop2120DDependentBenefitREN DependentBenefitRelatedEntityName Dependent Benefit Related Entity Name PegaX124010PegaX12-Data-N271-SubscriberLevel Loop2000CSubscriberLevel LOOP ID - 2000C SUBSCRIBER LEVEL PegaX124010PegaX12-Data-N271-Trailer TransactionSetTrailer Transaction Set Trailer PegaX124010PegaX12-Data-N271-Transaction InformationSourceLevel Information Source Level PegaX124010PegaX12-Data-N271-Transaction Trailer Transaction Trailer PegaX124010PegaX12-Data-N271-Transaction Header Header PegaX124010PegaX12-Data-N276 HealthCareClaimStatusRequest HealthCareClaimStatusRequest PegaX124010PegaX12-Data-N276-DependentLevel Loop2000EDependentLevel LOOP ID - 2000E DEPENDENT LEVEL PegaX124010PegaX12-Data-N276-Header TransactionSetHeader Transaction Set Header PegaX124010PegaX12-Data-N276-Header BeginningOfHierarchicalTransaction Beginning of Hierarchical Transaction PegaX124010

PegaX12-Data-N276-

HealthCareClaimStatusRequest FunctionalGroupHeader Functional Group Header PegaX124010PegaX12-Data-N276-

HealthCareClaimStatusRequest FunctionalGroupTrailer Functional Group Trailer PegaX124010PegaX12-Data-N276-

HealthCareClaimStatusRequest Transaction Transaction PegaX124010




Loop2000AInformationSourceLevel Loop2100APayerName LOOP ID - 2100A PAYER NAME PegaX124010PegaX12-Data-N276-



Loop2000BInformationReceiverLevel ServiceProviderLevel Service Provider Level PegaX124010PegaX12-Data-N276-

Loop2000BInformationReceiverLevel InformationReceiverLevel Information Receiver Level PegaX124010PegaX12-Data-N276-




Loop2000CServiceProviderLevel ServiceProviderLevel Service Provider Level PegaX124010PegaX12-Data-N276-

Loop2000CServiceProviderLevel Loop2100CProviderName LOOP ID - 2100C PROVIDER NAME PegaX124010PegaX12-Data-N276-

Loop2000CServiceProviderLevel SubscriberLevel Subscriber Level PegaX124010

PegaX12-Data-N276-Loop2000DSubscriberLevel Loop2200DClaimSubmitterTraceNumber

LOOP ID - 2200D CLAIM SUBMITTER

TRACE NUMBER PegaX124010

PegaX12-Data-N276-Loop2000DSubscriberLevel Loop2000EDependentLevel LOOP ID - 2000E DEPENDENT LEVEL PegaX124010

PegaX12-Data-N276-Loop2000DSubscriberLevel SubscriberDemographicInformation Subscriber Demographic Information PegaX124010

PegaX12-Data-N276-Loop2000DSubscriberLevel Loop2100DSubscriberName LOOP ID - 2100D SUBSCRIBER NAME PegaX124010

PegaX12-Data-N276-Loop2000DSubscriberLevel SubscriberLevel Subscriber Level PegaX124010

PegaX12-Data-N276-Loop2000EDependentLevel DependentDemographicInformation Dependent Demographic Information PegaX124010

PegaX12-Data-N276-Loop2000EDependentLevel DependentLevel Dependent Level PegaX124010

PegaX12-Data-N276-Loop2000EDependentLevel Loop2100EDependentName LOOP ID - 2100E DEPENDENT NAME PegaX124010

PegaX12-Data-N276-Loop2000EDependentLevel Loop2200EClaimSubmitterTraceNumber

LOOP ID - 2200E CLAIM SUBMITTER

TRACE NUMBER PegaX124010PegaX12-Data-N276-Loop2100APayerName PayerContactInformation Payer Contact Information PegaX124010PegaX12-Data-N276-Loop2100APayerName PayerName Payer Name PegaX124010PegaX12-Data-N276-

Loop2100BInformationReceiverName InformationReceiverName Information Receiver Name PegaX124010PegaX12-Data-N276-Loop2100CProviderName ProviderName Provider Name PegaX124010

PegaX12-Data-N276-Loop2100DSubscriberName SubscriberName Subscriber Name PegaX124010

PegaX12-Data-N276-Loop2100EDependentName DependentName Dependent Name PegaX124010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber InstitutionalBillTypeIdentification Institutional Bill Type Identification PegaX124010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber ClaimSubmitterTraceNumber Claim Submitter Trace Number PegaX124010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber ClaimServiceDate Claim Service Date PegaX124010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber MedicalRecordIdentification Medical Record Identification PegaX124010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber ClaimSubmittedCharges Claim Submitted Charges PegaX124010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber Loop2210DServiceLineInformation

LOOP ID - 2210D SERVICE LINE

INFORMATION PegaX124010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber PayerClaimIdentificationNumber Payer Claim Identification Number PegaX124010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber InstitutionalBillTypeIdentification Institutional Bill Type Identification PegaX124010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber MedicalRecordIdentification Medical Record Identification PegaX124010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber ClaimSubmitterTraceNumber Claim Submitter Trace Number PegaX124010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber PayerClaimIdentificationNumber Payer Claim Identification Number PegaX124010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber ClaimSubmittedCharges Claim Submitted Charges PegaX124010

PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber ClaimServiceDate Claim Service Date PegaX124010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber Loop2210EServiceLineInformation

LOOP ID - 2210E SERVICE LINE


Loop2210DServiceLineInformation ServiceLineInformation Service Line Information PegaX124010PegaX12-Data-N276-

Loop2210DServiceLineInformation ServiceLineItemIdentification Service Line Item Identification PegaX124010PegaX12-Data-N276-

Loop2210DServiceLineInformation ServiceLineDate Service Line Date PegaX124010PegaX12-Data-N276-

Loop2210EServiceLineInformation ServiceLineInformation Service Line Information PegaX124010PegaX12-Data-N276-

Loop2210EServiceLineInformation ServiceLineItemIdentification Service Line Item Identification PegaX124010PegaX12-Data-N276-

Loop2210EServiceLineInformation ServiceLineDate Service Line Date PegaX124010

PegaX12-Data-N276-ServiceProviderLevel Loop2000CServiceProviderLevel

LOOP ID - 2000C SERVICE PROVIDER

LEVEL PegaX124010PegaX12-Data-N276-SubscriberLevel Loop2000DSubscriberLevel LOOP ID - 2000D SUBSCRIBER LEVEL PegaX124010PegaX12-Data-N276-Trailer TransactionSetTrailer Transaction Set Trailer PegaX124010PegaX12-Data-N276-Transaction InformationSourceLevel Information Source Level PegaX124010PegaX12-Data-N276-Transaction Trailer Transaction Trailer PegaX124010PegaX12-Data-N276-Transaction Header Header PegaX124010PegaX12-Data-N277 HealthCareClaimStatusNotification Health Care Claim Status Notification PegaX124010PegaX12-Data-N277-DependentLevel Loop2000EDependentLevel Loop2000E Dependent Level PegaX124010PegaX12-Data-N277-Header TransactionSetHeader Transaction Set Header PegaX124010

PegaX12-Data-N277-Header BeginningOfHierarchicalTransaction Beginning Of Hierarchical Transaction PegaX124010PegaX12-Data-N277-

HealthCareClaimStatusNotification FunctionalGroupHeader Functional Group Header PegaX124010PegaX12-Data-N277-

HealthCareClaimStatusNotification FunctionalGroupTrailer Functional Group Trailer PegaX124010PegaX12-Data-N277-

HealthCareClaimStatusNotification Transaction Transaction PegaX124010PegaX12-Data-N277-InformationReceiverLevel Loop2000BInformationReceiverLevel Loop2000B Information Receiver Level PegaX124010PegaX12-Data-N277-InformationSourceLevel Loop2000AInformationSourceLevel Loop2000A Information Source Level PegaX124010PegaX12-Data-N277-

Loop2000AInformationSourceLevel Loop2100APayerName Loop2100A Payer Name PegaX124010PegaX12-Data-N277-

Loop2000AInformationSourceLevel InformationReceiverLevel Information Receiver Level PegaX124010

PegaX12-Data-N277-



Loop2000BInformationReceiverLevel Loop2100BInformationReceiverName Loop2100B Information Receiver Name PegaX124010PegaX12-Data-N277-


Loop2000CServiceProviderLevel Loop2100CProviderName Loop2100C Provider Name PegaX124010PegaX12-Data-N277-


Loop2000CServiceProviderLevel Loop2000DSubscriberLevel Loop2000D Subscriber Level PegaX124010

PegaX12-Data-N277-Loop2000DSubscriberLevel Loop2200DClaimSubmitterTraceNumber

Loop2200D Claim Submitter Trace

Number PegaX124010



PegaX12-Data-N277-Loop2000DSubscriberLevel Loop2000EDependentLevel Loop2000E Dependent Level PegaX124010

PegaX12-Data-N277-Loop2000DSubscriberLevel Loop2100DSubscriberName Loop2100D Subscriber Name PegaX124010

PegaX12-Data-N277-Loop2000EDependentLevel Loop2200EClaimSubmitterTraceNumber

Loop2200E Claim Submitter Trace

Number PegaX124010

PegaX12-Data-N277-Loop2000EDependentLevel Loop2100EDependentName Loop2100E Dependent Name PegaX124010


PegaX12-Data-N277-Loop2000EDependentLevel DependentLevel Dependent Level PegaX124010PegaX12-Data-N277-Loop2100APayerName PayerName Payer Name PegaX124010PegaX12-Data-N277-Loop2100APayerName PayerContactInformation Payer Contact Information PegaX124010PegaX12-Data-N277-




Loop2200DClaimSubmitterTraceNumber InstitutionalBillTypeIdentification Institutional Bil lType Identification PegaX124010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber PayerClaimIdentificationNumber Payer Claim Identification Number PegaX124010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber ClaimSubmitterTraceNumber Claim Submitter Trace Number PegaX124010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber Loop2220DServiceLineInformation Loop2220D Service Line Information PegaX124010PegaX12-Data-N277-



Loop2200DClaimSubmitterTraceNumber ClaimLevelStatusInformation Claim Level Status Information PegaX124010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber PayerClaimIdentificationNumber Payer Claim Identification Number PegaX124010PegaX12-Data-N277-




Loop2200EClaimSubmitterTraceNumber ClaimLevelStatusInformation Claim Level Status Information PegaX124010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber Loop2220EServiceLineInformation Loop2220E Service Line Information PegaX124010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber ClaimSubmitterTraceNumber Claim Submitter Trace Number PegaX124010PegaX12-Data-N277-




Loop2220DServiceLineInformation ServiceLineStatusInformation Service Line Status Information PegaX124010PegaX12-Data-N277-

Loop2220EServiceLineInformation ServiceLineStatusInformation Service Line Status Information PegaX124010

PegaX12-Data-N277-

Loop2220EServiceLineInformation ServiceLineDate Service Line Date PegaX124010PegaX12-Data-N277-


Loop2220EServiceLineInformation ServiceLineItemIdentification Service Line Item Identification PegaX124010PegaX12-Data-N277-ServiceProviderLevel Loop2000CServiceProviderLevel Loop2000C Service Provider Level PegaX124010PegaX12-Data-N277-SubscriberLevel Loop2000DSubscriberLevel Loop2000D Subscriber Level PegaX124010PegaX12-Data-N277-Trailer TransactionSetTrailer Transaction Set Trailer PegaX124010PegaX12-Data-N277-Transaction Trailer Trailer PegaX124010PegaX12-Data-N277-Transaction Header Header PegaX124010PegaX12-Data-N277-Transaction InformationSourceLevel Information Source Level PegaX124010PegaX12-Data-N278 HealthcareServicesResponse Healthcare Services Response PegaX124010PegaX12-Data-N278 HealthcareServicesRequest Healthcare Services Request PegaX124010PegaX12-Data-N278-Header TransactionSetHeader Transaction Set Header PegaX124010

PegaX12-Data-N278-Header BeginningOfHierarchicalTransaction Beginning Of Hierarchical Transaction PegaX124010

PegaX12-Data-N278-HealthcareServicesRequest Transaction Transaction PegaX124010

PegaX12-Data-N278-HealthcareServicesRequest FunctionalGroupHeader Functional Group Header PegaX124010

PegaX12-Data-N278-HealthcareServicesRequest FunctionalGroupTrailer Functional Group Trailer PegaX124010

PegaX12-Data-N278-HealthcareServicesResponse FunctionalGroupTrailer Functional Group Trailer PegaX124010

PegaX12-Data-N278-HealthcareServicesResponse Transaction Transaction PegaX124010

PegaX12-Data-N278-HealthcareServicesResponse FunctionalGroupHeader Functional Group Header PegaX124010PegaX12-Data-N278-Loop2000AUMOLevel RequestValidation Request Validation PegaX124010

PegaX12-Data-N278-Loop2000AUMOLevel UMOLevel

Utilization Management Organization

Level PegaX124010PegaX12-Data-N278-Loop2000AUMOLevel Loop2000BRequesterLevel Loop 2000B - Requester Level PegaX124010PegaX12-Data-N278-Loop2000AUMOLevel Loop2010AUMOName Loop 2010A - UMO Name PegaX124010

PegaX12-Data-N278-Loop2000BRequesterLevel Loop2000CSubscriberLevel Loop 2000C - Subscriber Level PegaX124010

PegaX12-Data-N278-Loop2000BRequesterLevel RequesterLevel Requester Level PegaX124010

PegaX12-Data-N278-Loop2000BRequesterLevel Loop2010BRequesterName Loop 2010B - Requester Name PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel OnsetofCurrentSymptomsorIllnessDate

Onset of Current Symptoms or Illness

Date PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel AdditionalPatientInformation Additional Patient Information PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel LastMenstrualPeriodDate Last Menstrual Period Date PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2010CBContactName Loop 2010CB - Contact Name PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2010CASubscriberName Loop 2010CA - Subscriber Name PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel EstimatedDateofBirth Estimated Date of Birth PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel SubscriberDiagnosis Subscriber Diagnosis PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel AccidentDate Accident Date PegaX124010


PegaX12-Data-N278-Loop2000CSubscriberLevel PatientEventTrackingNumber Patient Event Tracking Number PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2000EServiceProviderLevel Loop 2000E - Service Provider Level PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2000DDependentLevel Loop 2000D - Dependent Level PegaX124010

PegaX12-Data-N278-Loop2000CSubscriberLevel SubscriberRequestValidation Subscriber Request Validation PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel AdditionalPatientInformation Additional Patient Information PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel Loop2000EServiceProviderLevel Loop 2000E - Service Provider Level PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel OnsetofCurrentSymptomsorIllnessDate


Date PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel AccidentDate Accident Date PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel DependentDiagnosis Dependent Diagnosis PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel EstimatedDateofBirth Estimated Date of Birth PegaX124010


PegaX12-Data-N278-Loop2000DDependentLevel Loop2010DBContactName Loop 2010DB - Contact Name PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel LastMenstrualPeriodDate LastMenstrualPeriodDate PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel Loop2010DADependentName Loop 2010DA - Dependent Name PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel PatientEventTrackingNumber Patient Event Tracking Number PegaX124010

PegaX12-Data-N278-Loop2000DDependentLevel DependentRequestValidation Dependent Request Validation PegaX124010PegaX12-Data-N278-

Loop2000EServiceProviderLevel Loop2010EServiceProviderName Loop 2010E - Service Provider Name PegaX124010PegaX12-Data-N278-

Loop2000EServiceProviderLevel Loop2000FServiceLevel Loop 2000F - Service Level PegaX124010PegaX12-Data-N278-

Loop2000EServiceProviderLevel ServiceProviderLevel Service Provider Level PegaX124010PegaX12-Data-N278-

Loop2000EServiceProviderLevel MessageText Message Text PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel DischargeDate Discharge Date PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel InstitutionalClaimCode Institutional Claim Code PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel MessageText Message Text PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel Procedures Procedures PegaX124010

PegaX12-Data-N278-Loop2000FServiceLevel SpinalManipulationServiceInformation Spinal Manipulation Service Information PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel PatientConditionInformation Patient Condition Information PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel SurgeryDate Surgery Date PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel HealthCareServicesDelivery HealthCareServicesDelivery PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel HealthCareServicesReview Health Care Services Review PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel HomeOxygenTherapyInformation Home Oxygen Therapy Information PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel PreviousCertificationIdentification Previous Certification Identification PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel ServiceLevel Service Level PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel ServiceTraceNumber Service Trace Number PegaX124010

PegaX12-Data-N278-Loop2000FServiceLevel HealthCareServicesReviewInformation Health Care Services Review Information PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel ServiceDate Service Date PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel AdditionalServiceInformation Additional Service Information PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel AdmissionDate Admission Date PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel CertificationEffectiveDate Certification Effective Date PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel Loop2010FContactName Loop 2010F - Contact Name PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel ServiceRequestValidation Service Request Validation PegaX124010

PegaX12-Data-N278-Loop2000FServiceLevel AmbulanceTransportInformation Ambulance Transport Information PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel CertificationIssueDate Certification Issue Date PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel HomeHealthCareInformation Home Health Care Information PegaX124010PegaX12-Data-N278-Loop2000FServiceLevel CertificationExpirationDate Certification Expiration Date PegaX124010

PegaX12-Data-N278-Loop2010AUMOName UMOName


Name PegaX124010PegaX12-Data-N278-Loop2010AUMOName UMOContact UMO Contact PegaX124010PegaX12-Data-N278-Loop2010AUMOName UMORequestValidation UMO Request Validation PegaX124010

PegaX12-Data-N278-Loop2010BRequesterName RequesterAddress Requester Address PegaX124010

PegaX12-Data-N278-Loop2010BRequesterName RequesterContactInformation Requester Contact Information PegaX124010

PegaX12-Data-N278-Loop2010BRequesterName RequesterRequestValidation Requester Request Validation PegaX124010

PegaX12-Data-N278-Loop2010BRequesterName RequesterSupplementalIdentification Requester Supplemental Identification PegaX124010

PegaX12-Data-N278-Loop2010BRequesterName RequesterProviderInformation Requester Provider Information PegaX124010

PegaX12-Data-N278-Loop2010BRequesterName RequesterName Requester Name PegaX124010

PegaX12-Data-N278-Loop2010BRequesterName RequesterCityStateZIPCode Requester City, State, ZIP Code PegaX124010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberRequestValidation Subscriber Request Validation PegaX124010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberSupplementalIdentification Subscriber Supplemental Identification PegaX124010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberName Subscriber Name PegaX124010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberDemographicInformation Subscriber Demographic Information PegaX124010PegaX12-Data-N278-Loop2010CBContactName ContactAddress ContactAddress PegaX124010PegaX12-Data-N278-Loop2010CBContactName ContactCityStateZipCode ContactCityStateZipCode PegaX124010PegaX12-Data-N278-Loop2010CBContactName ContactInformation ContactInformation PegaX124010PegaX12-Data-N278-Loop2010CBContactName ContactName ContactName PegaX124010

PegaX12-Data-N278-Loop2010DADependentName DependentSupplementalIdentification Dependent Supplemental Identification PegaX124010

PegaX12-Data-N278-Loop2010DADependentName DependentName Dependent Name PegaX124010

PegaX12-Data-N278-Loop2010DADependentName DependentRelationship Dependent Relationship PegaX124010

PegaX12-Data-N278-Loop2010DADependentName DependentRequestValidation Dependent Request Validation PegaX124010

PegaX12-Data-N278-Loop2010DADependentName DependentDemographicInformation Dependent Demographic Information PegaX124010

PegaX12-Data-N278-Loop2010DBContactName ContactCityStateZipCode ContactCityStateZipCode PegaX124010

PegaX12-Data-N278-Loop2010DBContactName ContactAddress ContactAddress PegaX124010

PegaX12-Data-N278-Loop2010DBContactName ContactInformation ContactInformation PegaX124010

PegaX12-Data-N278-Loop2010DBContactName ContactName ContactName PegaX124010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderCityStateZIPCode Service Provider City, State, ZIP Code PegaX124010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderAddress Service Provider Address PegaX124010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderRequestValidation Service Provider Request Validation PegaX124010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderInformation Service Provider Information PegaX124010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderName Service Provider Name PegaX124010PegaX12-Data-N278-

Loop2010EServiceProviderName Loop2000FServiceLevel Loop 2000F - Service Level PegaX124010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderSupplementalIdentification

Service Provider Supplemental


Loop2010EServiceProviderName ServiceProviderContactInformation Service Provider Contact Information PegaX124010PegaX12-Data-N278-Loop2010FContactName ContactCityStateZipCode ContactCityStateZipCode PegaX124010PegaX12-Data-N278-Loop2010FContactName ContactInformation ContactInformation PegaX124010PegaX12-Data-N278-Loop2010FContactName ContactName ContactName PegaX124010PegaX12-Data-N278-Loop2010FContactName ContactAddress ContactAddress PegaX124010PegaX12-Data-N278-Trailer TransactionSetTrailer Transaction Set Trailer PegaX124010

PegaX12-Data-N278-Transaction Loop2000AUMOLevel

Loop 2000A - Utilization Management

Organization Level PegaX124010PegaX12-Data-N278-Transaction Trailer Trailer PegaX124010PegaX12-Data-N278-Transaction Header Header PegaX124010PegaX12-Data-N3_AddressInformation N302_AddressInformation N302_Address Information PegaX124010PegaX12-Data-N3_AddressInformation N301_AddressInformation N301_Address Information PegaX124010PegaX12-Data-N4_GeographicLocation N401_CityName N401_City Name PegaX124010

PegaX12-Data-N4_GeographicLocation N406_LocationIdentifier N406_Location Identifier PegaX124010PegaX12-Data-N4_GeographicLocation N403_PostalCode N403_Postal Code PegaX124010PegaX12-Data-N4_GeographicLocation N402_StateOrProvinceCode N402_State Or Province Code PegaX124010PegaX12-Data-N4_GeographicLocation N405_LocationQualifier N405_Location Qualifier PegaX124010PegaX12-Data-N4_GeographicLocation N404_CountryCode N404_Country Code PegaX124010PegaX12-Data-N834 HealthcareEnrollment HealthcareEnrollment PegaX124010PegaX12-Data-N834-Header Loop1000BPayer Loop 1000B Payer PegaX124010PegaX12-Data-N834-Header BeginningSegment Beginning Segment PegaX124010PegaX12-Data-N834-Header TransactionSetHeader Transaction Set Header PegaX124010PegaX12-Data-N834-Header TransactionSetPolicyNumber Transaction Set Policy Number PegaX124010PegaX12-Data-N834-Header Loop1000CTPABrokerName Loop 1000C TPA/Broker Name PegaX124010PegaX12-Data-N834-Header FileEffectiveDate File Effective Date PegaX124010PegaX12-Data-N834-Header Loop1000ASponsorName Loop 1000A Sponsor Name PegaX124010PegaX12-Data-N834-HealthcareEnrollment FunctionalGroupHeader FunctionalGroupHeader PegaX124010PegaX12-Data-N834-HealthcareEnrollment Transaction Transaction PegaX124010PegaX12-Data-N834-HealthcareEnrollment FunctionalGroupTrailer FunctionalGroupTrailer PegaX124010PegaX12-Data-N834-Loop1000ASponsorName SponsorName Sponsor Name PegaX124010PegaX12-Data-N834-Loop1000BPayer Payer Payer PegaX124010

PegaX12-Data-N834-Loop1000CTPABrokerName Loop1100CTPABrokerAccountInformation TPA/Broker Account Information PegaX124010

PegaX12-Data-N834-Loop1000CTPABrokerName TPABrokerName TPABrokerName PegaX124010PegaX12-Data-N834-

Loop1100CTPABrokerAccountInfo TPABrokerAccountInformation TPA/Broker Account Information PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberPolicyNumber Member Policy Number PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail PriorCoverageMonths Prior Coverage Months PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2200DisabilityInformation Loop2200DisabilityInformation PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100DMemberEmployer Loop2100DMemberEmployer PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2300HealthCoverage Loop2300HealthCoverage PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100FCustodialParent Loop2100FCustodialParent PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberLevelDates Member Level Dates PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100BIncorrectMemberName Loop2100BIncorrectMemberName PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100GResponsiblePerson Loop2100GResponsiblePerson PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail SubscriberNumber Subscriber Number PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100CMemberMailingAddress Loop2100CMemberMailingAddress PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100EMemberSchool Loop2100EMemberSchool PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100AMemberName Loop 2100A - Member Name PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberLevelDetail Member Level Detail PegaX124010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberIdentificationNumber Member Identification Number PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberName Member Name PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberResidenceStreetAddress Member Residence Street Address PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberPolicyAmounts Member Policy Amounts PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberHealthInformation Member Health Information PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberCommunicationsNumbers Member Communications Numbers PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberIncome Member Income PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberResidenceCityStateZip Member Residence City State Zip PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberLanguage Member Language PegaX124010PegaX12-Data-N834-Loop2100AMemberName MemberDemographics Member Demographics PegaX124010PegaX12-Data-N834-

Loop2100BIncorrectMemberName IncorrectMemberName Incorrect Member Name PegaX124010PegaX12-Data-N834-

Loop2100BIncorrectMemberName IncorrectMemberDemographics Incorrect Member Demographics PegaX124010PegaX12-Data-N834-

Loop2100CMemberMailingAddress MemberMailingAddress Member Mailing Address PegaX124010PegaX12-Data-N834-

Loop2100CMemberMailingAddress MemberMailCityStateZip Member Mail City State Zip PegaX124010PegaX12-Data-N834-

Loop2100CMemberMailingAddress MemberMailStreetAddress Member Mail Street Address PegaX124010

PegaX12-Data-N834-Loop2100DMemberEmployer MemberEmployer Member Employer PegaX124010

PegaX12-Data-N834-Loop2100DMemberEmployer MemberEmployerCityStateZip Member Employer City State Zip PegaX124010

PegaX12-Data-N834-Loop2100DMemberEmployer MemberEmployerStreetAddress Member Employer Street Address PegaX124010

PegaX12-Data-N834-Loop2100DMemberEmployer

MemberEmployerCommunicationsNumbe

rs

MemberEmployerCommunicationsNumb

ers PegaX124010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchoolStreetAddress Member School Street Address PegaX124010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchoolCityStateZip Member School City State Zip PegaX124010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchool Member School PegaX124010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchoolCommunicationsNumbers

Member School Communications

Numbers PegaX124010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParentCommunicationsNumbers

Custodial Parent Communications

Numbers PegaX124010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParentStreetAddress Custodial Parent Street Address PegaX124010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParent Custodial Parent PegaX124010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParentCityStateZip Custodial Parent City State Zip PegaX124010

PegaX12-Data-N834-Loop2100GResponsiblePerson ResponsiblePersonStreetAddress Responsible Person Street Address PegaX124010

PegaX12-Data-N834-Loop2100GResponsiblePerson ResponsiblePerson Responsible Person PegaX124010

PegaX12-Data-N834-Loop2100GResponsiblePerson

ResponsiblePersonCommunicationsNumb

ers

Responsible Person Communications

Numbers PegaX124010

PegaX12-Data-N834-Loop2100GResponsiblePerson ResponsiblePersonCityStateZip Responsible Person City State Zip PegaX124010PegaX12-Data-N834-

Loop2200DisabilityInformation DisabilityEligibilityDates Disability Eligibility Dates PegaX124010PegaX12-Data-N834-

Loop2200DisabilityInformation DisabilityInformation Disability Information PegaX124010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoverage Health Coverage PegaX124010PegaX12-Data-N834-Loop2300HealthCoverage Loop2320CoordinationOfBenefits Loop2320CoordinationOfBenefits PegaX124010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoverageDates Health Coverage Dates PegaX124010PegaX12-Data-N834-Loop2300HealthCoverage Loop2310ProviderInformation Loop2310ProviderInformation PegaX124010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoveragePolicyNumber Health Coverage Policy Number PegaX124010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoveragePolicy Health Coverage Policy PegaX124010PegaX12-Data-N834-Loop2300HealthCoverage IdentificationCard Identification Card PegaX124010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderCityStateZip Provider City State Zip PegaX124010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderInformation Provider Information PegaX124010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderCommunicationsNumbers Provider Communications Numbers PegaX124010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderName Provider Name PegaX124010

PegaX12-Data-N834-Loop2310ProviderInformation PCPChangeReason PCP Change Reason PegaX124010PegaX12-Data-N834-

Loop2320CoordinationOfBenefits CoordinationOfBenefitsEligibilityDates Coordination Of Benefits Eligibility Dates PegaX124010PegaX12-Data-N834-

Loop2320CoordinationOfBenefits CoordinationOfBenefits Coordination Of Benefits PegaX124010PegaX12-Data-N834-

Loop2320CoordinationOfBenefits

AdditionalCoordinationOfBenefitsIdentifie

rs

Additional Coordination Of Benefits

Identifiers PegaX124010PegaX12-Data-N834-

Loop2320CoordinationOfBenefits OtherInsuranceCompanyName Other Insurance Company Name PegaX124010PegaX12-Data-N834-Trailer TransactionSetTrailer TransactionSetTrailer PegaX124010PegaX12-Data-N834-Transaction Header Header PegaX124010PegaX12-Data-N834-Transaction Loop2000MemberLevelDetail Loop2000MemberLevelDetail PegaX124010PegaX12-Data-N834-Transaction Trailer Trailer PegaX124010PegaX12-Data-N837 HealthcareClaim Healthcare Claim PegaX124010

PegaX12-Data-N837-BillingPayToProviderLevel Loop2000ABillingPayToProvider Loop2000ABillingPayToProvider PegaX124010PegaX12-Data-N837-Header TransmissionTypeIdentification Transmission Type Identification PegaX124010PegaX12-Data-N837-Header BeginningOfHierarchicalTransaction BeginningOfHierarchicalTransaction PegaX124010PegaX12-Data-N837-Header TransactionSetHeader TransactionSetHeader PegaX124010PegaX12-Data-N837-Header Loop1000ASubmitterName Loop1000ASubmitterName PegaX124010PegaX12-Data-N837-Header Loop1000BReceiverName Loop1000BReceiverName PegaX124010PegaX12-Data-N837-HealthcareClaim FunctionalGroupHeader Functional Group Header PegaX124010PegaX12-Data-N837-HealthcareClaim Transaction Transaction PegaX124010PegaX12-Data-N837-HealthcareClaim FunctionalGroupTrailer Functional Group Trailer PegaX124010

PegaX12-Data-N837-Loop1000ASubmitterName SubmitterName Submitter Name PegaX124010

PegaX12-Data-N837-Loop1000ASubmitterName SubmitterEDIContactInformation Submitter EDI Contact Information PegaX124010

PegaX12-Data-N837-Loop1000ASubmitterName AdditionalSubmitterName Additional Submitter Name PegaX124010PegaX12-Data-N837-Loop1000BReceiverName ReceiverName Receiver Name PegaX124010PegaX12-Data-N837-Loop1000BReceiverName AdditionalReceiverName Additional Receiver Name PegaX124010

PegaX12-Data-N837-

Loop2000ABillingPayToProvider BillingPayToProviderSpecialty Billing Pay To Provider Specialty PegaX124010PegaX12-Data-N837-

Loop2000ABillingPayToProvider BillingPayToProviderHierarchicalLevel Billing Pay To Provider Hierarchical Level PegaX124010PegaX12-Data-N837-

Loop2000ABillingPayToProvider ForeignCurrencyInformation Foreign Currency Information PegaX124010PegaX12-Data-N837-

Loop2000ABillingPayToProvider SubscriberLevel SubscriberLevel PegaX124010PegaX12-Data-N837-

Loop2000ABillingPayToProvider Loop2010ABPayToProviderName Loop2010ABPayToProviderName PegaX124010PegaX12-Data-N837-

Loop2000ABillingPayToProvider Loop2010AABillingProviderName Loop2010AABillingProviderName PegaX124010PegaX12-Data-N837-Loop2000BSubscriber PatientLevel PatientLevel PegaX124010PegaX12-Data-N837-Loop2000BSubscriber Loop2300ClaimInformation Loop 2300 Claim Information PegaX124010PegaX12-Data-N837-Loop2000BSubscriber SubscriberHierarchicalLevel Subscriber Hierarchical Level PegaX124010PegaX12-Data-N837-Loop2000BSubscriber PatientInformation Patient Information PegaX124010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BASubscriberName Loop2010BASubscriberName PegaX124010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BCResponsiblePartyName Loop2010BC Responsible Party Name PegaX124010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BDResponsiblePartyName Loop2010BD Responsible Party Name PegaX124010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BBPayerName Loop 2010BB Payer Name PegaX124010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BCPayerName Loop 2010BC Payer Name PegaX124010

PegaX12-Data-N837-Loop2000BSubscriber Loop2010BBCreditDebitCardHolderName

Loop2010BB Credit/Debit Card Holder

Name PegaX124010PegaX12-Data-N837-Loop2000BSubscriber SubscriberInformation Subscriber Information PegaX124010

PegaX12-Data-N837-Loop2000BSubscriber Loop2010BDCreditDebitCardHolderName

Loop2010BD Credit/Debit Card Holder

Name PegaX124010PegaX12-Data-N837-Loop2000CPatient PatientHierarchicalLevel Patient Hierarchical Level PegaX124010PegaX12-Data-N837-Loop2000CPatient Loop2010CAPatientName Loop 2010CA Patient Name PegaX124010PegaX12-Data-N837-Loop2000CPatient Loop2300ClaimInformation Loop 2300 Claim Information PegaX124010PegaX12-Data-N837-Loop2000CPatient PatientInformation Patient Information PegaX124010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingPayToProviderSpecialty Billing Pay To Provider Specialty PegaX124010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderContactInformation Billing Provider Contact Information PegaX124010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderName Billing Provider Name PegaX124010PegaX12-Data-N837-

Loop2010AABillingProviderName CreditDebitCardBillingInformation Credit Debit Card Billing Information PegaX124010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderSecondaryIdentification Billing Provider Secondary Identification PegaX124010

PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderAddress Billing Provider Address PegaX124010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderCityStateZipCode Billing Provider City State Zip Code PegaX124010PegaX12-Data-N837-

Loop2010ABPayToProviderName PayToProviderAddress Pay To Provider Address PegaX124010PegaX12-Data-N837-

Loop2010ABPayToProviderName PayToProviderSecondaryIdentification Pay To Provider Secondary Identification PegaX124010PegaX12-Data-N837-

Loop2010ABPayToProviderName PayToProviderName Pay To Provider Name PegaX124010PegaX12-Data-N837-

Loop2010ABPayToProviderName PayToProviderCityStateZipCode Pay To Provider City State Zip Code PegaX124010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberDemographicInformation Subscriber Demographic Information PegaX124010

PegaX12-Data-N837-Loop2010BASubscriberName PropertyAndCasualtyClaimNumber Property and Casualty Claim Number PegaX124010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberAddress Subscriber Address PegaX124010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberSecondaryIdentification Subscriber Secondary Identification PegaX124010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberName Subscriber Name PegaX124010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberCityStateZipCode Subscriber City State Zip Code PegaX124010PegaX12-Data-N837-

Loop2010BBCreditDebitCardHolderName CreditDebitCardInformation CreditDebitCardInformation PegaX124010PegaX12-Data-N837-

Loop2010BBCreditDebitCardHolderName CreditDebitCardHolderName Credit/Debit Card Holder Name PegaX124010PegaX12-Data-N837-Loop2010BBPayerName PayerName Payer Name PegaX124010PegaX12-Data-N837-Loop2010BBPayerName AdditionalNameInformation Additional Name Information PegaX124010PegaX12-Data-N837-Loop2010BBPayerName PayerAddress Payer Address PegaX124010PegaX12-Data-N837-Loop2010BBPayerName PayerSecondaryIdentification Payer Secondary Identification PegaX124010PegaX12-Data-N837-Loop2010BBPayerName PayerCityStateZipCode Payer City State Zip Code PegaX124010PegaX12-Data-N837-Loop2010BCPayerName AdditionalNameInformation Additional Name Information PegaX124010PegaX12-Data-N837-Loop2010BCPayerName PayerName Payer Name PegaX124010PegaX12-Data-N837-Loop2010BCPayerName PayerSecondaryIdentification Payer Secondary Identification PegaX124010PegaX12-Data-N837-Loop2010BCPayerName PayerCityStateZipCode Payer City State Zip Code PegaX124010PegaX12-Data-N837-Loop2010BCPayerName PayerAddress Payer Address PegaX124010PegaX12-Data-N837-

Loop2010BCResponsiblePartyName ResponsiblePartyName Responsible Party Name PegaX124010

PegaX12-Data-N837-

Loop2010BCResponsiblePartyName ResponsiblePartyCityStateZipCode ResponsiblePartyCityStateZipCode PegaX124010PegaX12-Data-N837-

Loop2010BCResponsiblePartyName ResponsiblePartyAddress Responsible Party Address PegaX124010PegaX12-Data-N837-

Loop2010BDCreditDebitCardHolderName CreditDebitCardInformation CreditDebitCardInformation PegaX124010PegaX12-Data-N837-

Loop2010BDCreditDebitCardHolderName CreditDebitCardHolderName Credit/Debit Card Holder Name PegaX124010PegaX12-Data-N837-

Loop2010BDResponsiblePartyName ResponsiblePartyAddress Responsible Party Address PegaX124010PegaX12-Data-N837-

Loop2010BDResponsiblePartyName ResponsiblePartyCityStateZipCode ResponsiblePartyCityStateZipCode PegaX124010PegaX12-Data-N837-

Loop2010BDResponsiblePartyName ResponsiblePartyName Responsible Party Name PegaX124010PegaX12-Data-N837-Loop2010CAPatientName PatientName Patient Name PegaX124010PegaX12-Data-N837-Loop2010CAPatientName PatientCityStateZipCode Patient City/State/Zip Code PegaX124010PegaX12-Data-N837-Loop2010CAPatientName PatientAddress Patient Address PegaX124010PegaX12-Data-N837-Loop2010CAPatientName PatientDemographicInformation Patient Demographic Information PegaX124010PegaX12-Data-N837-Loop2010CAPatientName PatientSecondaryInformation Patient Secondary Information PegaX124010PegaX12-Data-N837-Loop2010CAPatientName PropertyAndCasualtyClaimNumber Property And Casualty Claim Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateAccident Date - Accident PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateAssumedAndRelinquishedCareDates

Date - Assumed And Relinquished Care

Dates PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateDischarge DateDischarge PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation EPSDTReferral EPSDT Referral PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation HealthCareDiagnosisCode HealthCareDiagnosisCode PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation HomeHealthActivitiesPermitted HomeHealthActivitiesPermitted PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation MedicalRecordNumber Medical Record Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation OccurrenceSpanInformation Occurrence Span Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation OccurrenceSpanInformation2

Occurrence Span Information 2 - has type

of pagelist PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateAuthorizedReturnToWork Date - Authorized Return To Work PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastMenstrualPeriod Date - Last Menstrual Period PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastWorked Date - Last Worked PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateOrderDate

Date - Order Date - obsolete - deleted

from IG in Addendum PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateSimilarIllnessSymptomOnset Date - Similar Illness Symptom Onset PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DischargeHour Discharge Hour PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation AmbulanceCertification Ambulance Certification PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ConditionInformation2 Condition Information2 - type pagelist PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation CreditDebitCardMaximumAmount Credit/Debit Card Maximum Amount PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateHearingAndVisionPrescriptionDate

Date - Hearing And Vision Prescription

Date PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateReferralDate

Date - Referral Date - obsolete per the IG

Addendum PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation InvestigationalDeviceExemptionNumber Investigational Device Exemption Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation

Loop2310CPurchasedServiceProviderNam

e

Loop2310C Purchased Service Provider

Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2400ServiceLine Loop2400 Service Line PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation OtherDiagnosisInformation Other Diagnosis Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation PROApprovalNumber PRO Approval Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310AReferringProviderName Loop2310A Referring Provider Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310COtherProviderName Loop - 2310C Other Provider Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2320OtherSubscriberInformation Loop2320 Other Subscriber Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation MammographyCertificationNumber Mammography Certification Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation PriorAuthorizationOrReferralNumber Prior Authorization Or Referral Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ProcedureInformation Procedure Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ValueInformation2 Value Information2 - of type PageList PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimSupplementalInformation Claim Supplemental Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateDisabilityBegin Date - Disability Begin PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DiagnosisInformation DiagnosisInformation PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimQuantity Claim Quantity PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastXRay Date - Last X-Ray PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DemonstrationProjectIdentifier Demonstration Project Identifier PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation FileInformation File Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation HomeboundIndicator Homebound Indicator PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation HomeHealthFunctionalLimitations HomeHealthFunctionalLimitations PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310BOperatingPhysicianName Loop2310B Operating Physician Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ServiceAuthorizationExceptionCode Service Authorization Exception Code PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation OtherProcedureInformation Other Procedure Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ReasonForVisitDiagnosisInformation Reason For Visit Diagnosis Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation RepricedClaimNumber Repriced Claim Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DocumentIdentificationCode DocumentIdentificationCode PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation HomeHealthMentalStatus Home Health Mental Status PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation MandatoryMedicareCrossoverIndicator Mandatory Medicare Crossover Indicator PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation PatientEstimatedAmountDue Patient Estimated Amount Due PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation AdjustedRepricedClaimNumber Adjusted Repriced Claim Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation BillingNote Billing Note PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimPricingRepricingInformation Claim Pricing Repricing Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation AmbulanceTransportInformation Ambulance Transport Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimAmountDue Claim Amount Due PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimCode Claim Code PegaX124010


ClinicalLaboratoryImprovementAmendme

ntNumber


Amendment Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ContractInformation Contract Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateAdmission Date - Admission PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateDisabilityEnd Date - Disability End PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateOnsetOfCurrentIllnessSymptom Date - Onset Of Current Illness/Symptom PegaX124010


Loop2305HomeHealthCarePlanInformatio

n

Loop2305 Home Health Care Plan


PegaX12-Data-N837-Loop2300ClaimInformation Loop2310BRenderingProviderName Loop - 2310B Rendering Provider Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310DServiceFacilityLocation Loop - 2310D Service Facility Location PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation PatientConditionInformationVision Patient Condition Information: Vision PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation AmbulatoryPatientGroup Ambulatory Patient Group PegaX124010


ClaimIdentificationNumberForClearingHou

ses

Claim Identification Number For Clearing

Houses PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ConditionInformation Condition Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateEstimatedDateOfBirth

Date - Estimated Date Of Birth - obsolete

per the IG Addendum PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DiagnosisRelatedGroupInformation Diagnosis Related Group Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310AAttendingPhysicianName Loop2310A Attending Physician Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310ESupervisingProviderName Loop2310E Supervising Provider Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation OccurrenceInformation OccurrenceInformation PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation OccurrenceInformation2 OccurrenceInformation2 - pagelist PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation SpinalManipulationServiceInformation Spinal Manipulation Service Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation TotalPurchasedServiceAmount Total Purchased Service Amount PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateStatement Date - Statement PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DocumentIdentificationCode2 DocumentIdentificationCode2 PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation HomeHealthCareInformation Home Health Care Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310AOperatingPhysicianName Loop2310A Operating Physician Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310EServiceFacilityName Loop - 2310E Service Facility Name PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2330FOtherPayerOtherProvider Loop - 2330F Other Payer Other Provider PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation OriginalReferenceNumber Original Reference Number PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation PatientAmountDue Patient Amount Due PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation PatientAmountPaid Patient Amount Paid PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation PayerEstimatedAmountDue Payer Estimated Amount Due PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation TreatmentCodeInformation Treatment Code Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation TreatmentCodeInformation2

Treatment Code Information2 - type

PageList PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ValueInformation Value Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation AnesthesiaModifyingUnits Anesthesia Modifying Units PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimInformation Claim Information PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimNote Claim Note PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimNote2

Claim Note 2 - page list version of

ClaimNote PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateAcuteManifestation Date - Acute Manifestation PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateInitialTreatment Date - Initial Treatment PegaX124010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastSeen Date - Last Seen PegaX124010PegaX12-Data-N837-

Loop2305HomeHealthCarePlan HealthCareServicesDelivery Health Care Services Delivery PegaX124010PegaX12-Data-N837-

Loop2305HomeHealthCarePlan HomeHealthCarePlanInformation Home Health Care Plan Information PegaX124010PegaX12-Data-N837-

Loop2310AAttendingPhysicianName AttendingPhysicianName Attending Provider Name PegaX124010PegaX12-Data-N837-

Loop2310AAttendingPhysicianName AttendingPhysicianSpecialityInformation Referring Provider Speciality Information PegaX124010PegaX12-Data-N837-

Loop2310AAttendingPhysicianName

AttendingPhysicianSecondaryIdentificatio

n

Referring Provider Secondary


Loop2310AOperatingPhysicianName OperatingPhysicianSpecialityInformation Operating Provider Speciality Information PegaX124010PegaX12-Data-N837-

Loop2310AOperatingPhysicianName

OperatingPhysicianSecondaryIdentificatio

n

Operating Provider Secondary


Loop2310AOperatingPhysicianName OperatingPhysicianName Operating Provider Name PegaX124010PegaX12-Data-N837-

Loop2310AReferringProviderName ReferringProviderSecondaryIdentification



Loop2310AReferringProviderName ReferringProviderSpecialityInformation Referring Provider Speciality Information PegaX124010PegaX12-Data-N837-

Loop2310AReferringProviderName ReferringProviderName Referring Provider Name PegaX124010PegaX12-Data-N837-

Loop2310BOperatingPhysicianName OperatingPhysicianSpecialityInformation

Operating Physician Speciality Info -

obsolete per IG addendum PegaX124010PegaX12-Data-N837-

Loop2310BOperatingPhysicianName


n



Loop2310BOperatingPhysicianName OperatingPhysicianName Operating Provider Name PegaX124010

PegaX12-Data-N837-

Loop2310BRenderingProviderName RenderingProviderName Rendering Provider Name PegaX124010PegaX12-Data-N837-

Loop2310BRenderingProviderName RenderingProviderSpecialtyInformation Rendering Provider Specialty Information PegaX124010PegaX12-Data-N837-

Loop2310BRenderingProviderName RenderingProviderSecondaryIdentification

Rendering Provider Secondary


Loop2310COtherProviderName OtherProviderSpecialityInformation

Other Provider Speciality Information -


Loop2310COtherProviderName OtherProviderSecondaryIdentification



Loop2310COtherProviderName OtherProviderName Referring Provider Name PegaX124010PegaX12-Data-N837-

Loop2310CPurchasedServiceProviderNm PurchasedServiceProviderName Purchased Service Provider Name PegaX124010PegaX12-Data-N837-

Loop2310CPurchasedServiceProviderNm

PurchasedServiceProviderSecondaryIdenti

fication

Purchased Service Provider Secondary


Loop2310DReferringProviderName ReferringProviderSpecialityInformation

Referring Provider Speciality Info -

obsolete per IG Addendum PegaX124010PegaX12-Data-N837-

Loop2310DReferringProviderName ReferringProviderName

Referring Provider Name - obsolete per IG

addendum PegaX124010PegaX12-Data-N837-

Loop2310DReferringProviderName ReferringProviderSecondaryIdentification

Referring Provider Secondary Ident -


Loop2310DServiceFacilityLocation ServiceFacilityLocationAddress Service Facility Location Address PegaX124010PegaX12-Data-N837-

Loop2310DServiceFacilityLocation

ServiceFacilityLocationSecondaryIdentifica

tion

Service Facility Location Secondary


Loop2310DServiceFacilityLocation ServiceFacilityLocationCityStateZipCode

Service Facility Location City/State/Zip


Loop2310DServiceFacilityLocation ServiceFacilityLocation Service Facility Location PegaX124010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilityAddress Service Facility Location Address PegaX124010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilitySpecialtyInformation

Service Facility Specialty Info - obsolete

per IG Addendum PegaX124010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilityName ServiceFacilityName PegaX124010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilitySecondaryIdentification



Loop2310EServiceFacilityName ServiceFacilityCityStateZipCode


Code PegaX124010

PegaX12-Data-N837-

Loop2310ESupervisingProviderName SupervisingProviderName Supervising Provider Name PegaX124010PegaX12-Data-N837-

Loop2310ESupervisingProviderName

SupervisingProviderSecondaryIdentificatio

n

Supervising Provider Secondary


Loop2320OtherSubscriberInformation

CoordinationOfBenefitsPatientPaidAmoun

t

Coordination Of Benefits Patient Paid

Amount PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation DiagnosticRelatedGroupOutletAmount DiagnosticRelatedGroupOutletAmount PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330AOtherSubscriberName Loop2330A Other Subscriber Name PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330COtherPayerPatientInformation

Loop2330C Other Payer Patient


Loop2320OtherSubscriberInformation SubscriberDemographicInformation Subscriber Demographic Information PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation CoordinationOfBenefitsAllowedAmount

Coordination Of Benefits Allowed


Loop2320OtherSubscriberInformation OtherSubscriberDemographicInformation

Other Subscriber Demographic



CoordinationOfBenefitsMedicareBTrustFu

ndPaidAmount

CoordinationOfBenefitsMedicareBTrustFu

ndPaidAmount PegaX124010PegaX12-Data-N837-


CoordinationOfBenefitsPatientResponsibili

tyAmount

Coordination Of Benefits Patient

Responsibility Amount PegaX124010PegaX12-Data-N837-


CoordinationOfBenefitsTotalClaimBeforeT

axesAmount

Coordination Of Benefits Total Claim

Before Taxes Amount PegaX124010PegaX12-Data-N837-


CoordinationOfBenefitsTotalDeniedAmou

nt

CoordinationOfBenefitsTotalDeniedAmou

nt PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330DOtherPayerAttendingProvidr Loop2330DOtherPayerAttendingProvidr PegaX124010PegaX12-Data-N837-


Loop2330FOtherPayerPurchasedServicePr

ovider

Loop2330F Other Payer Purchased

Service Provider PegaX124010PegaX12-Data-N837-


MedicareInpatientAdjudicationInformatio

n


n PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation CoordinationOfBenefitsTaxAmount Coordination Of Benefits Tax Amount PegaX124010PegaX12-Data-N837-


CoordinationOfBenefitsTotalSubmittedCha

rges

CoordinationOfBenefitsTotalSubmittedCh

arges PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330FOtherPayerOtherProvider Loop2330FOtherPayerOtherProvider PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330EOtherPayerRenderingProvider

Loop2330E Other Payer Rendering

Provider PegaX124010

PegaX12-Data-N837-


MedicareOutpatientAdjudicationInformati

on

Medicare Outpatient Adjudication


Loop2320OtherSubscriberInformation MedicarePaidAmount MedicarePaidAmount PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330DOtherPayerReferringProvider

Loop2330D Other Payer Referring

Provider PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Medicarepaidamounteighty Medicarepaidamounteighty PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation ClaimLevelAdjustments Claim Level Adjustments PegaX124010PegaX12-Data-N837-


CoordinationOfBenefitsMedicareATrustFu

ndPaidAmount

CoordinationOfBenefitsMedicareATrustF

undPaidAmount PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330BOtherPayerName Loop2330B Other Payer Name PegaX124010PegaX12-Data-N837-


Loop2330HOtherPayerSupervisingProvide

r

Loop2330H Other Payer Supervising


Loop2320OtherSubscriberInformation Loop2330HOtherPayerSvcFacProvider Loop2330HOtherPayerSvcFacProvider PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation CoordinationOfBenefitsApprovedAmount

Coordination Of Benefits Approved


Loop2320OtherSubscriberInformation CoordinationOfBenefitsCoveredAmount

Coordination Of Benefits Covered


Loop2320OtherSubscriberInformation OtherInsuranceCoverageInformation Other Insurance Coverage Information PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation OtherSubscriberInformation Other Subscriber Information PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation CoordinationOfBenefitsPayerPaidAmount

Coordination Of Benefits Payer Paid



CoordinationOfBenefitsTotalMedicarePaid

Amount

CoordinationOfBenefitsTotalMedicarePai

dAmount PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330EOtherPayerOperatingProvidr Loop2330EOtherPayerOperatingProvidr PegaX124010PegaX12-Data-N837-


Loop2330GOtherPayerServiceFacilityLocat

ion

Loop2330G Other Payer Service Facility

Location PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation PayerPriorPayment PayerPriorPayment PegaX124010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation CoordinationOfBenefitsDiscountAmount

Coordination Of Benefits Discount



CoordinationOfBenefitsPerDayLimitAmou

nt

Coordination Of Benefits Per Day Limit

Amount PegaX124010

PegaX12-Data-N837-


CoordinationOfBenefitsTotalNonCoveredA

mount

CoordinationOfBenefitsTotalNonCovered


Loop2330AOtherSubscriberName OtherSubscriberCityStateZipCode Other Subscriber City/State/Zip Code PegaX124010PegaX12-Data-N837-

Loop2330AOtherSubscriberName OtherSubscriberDemographicInformation



Loop2330AOtherSubscriberName OtherSubscriberAddress Other Subscriber Address PegaX124010PegaX12-Data-N837-

Loop2330AOtherSubscriberName OtherSubscriberName Other Subscriber Name PegaX124010PegaX12-Data-N837-

Loop2330AOtherSubscriberName OtherSubscriberSecondaryIdentification Other Subscriber Secondary Identification PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerCityStateZipCode Other Payer City/State/Zip Code PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerName Other Payer Name PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerClaimAdjustmentIndicator Other Payer Claim Adjustment Indicator PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName ClaimAdjudicationDate Claim Adjudication Date PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerContactInformation Other Payer Contact Information PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerSecondaryIdentifier Other Payer Secondary Identifier PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName

OtherPayerPriorAuthorizationOrReferralN

umber2

Other Payer Prior Authorization Or

Referral Number - Page type PegaX124010



umber


Referral Number PegaX124010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerAddress Other Payer Address PegaX124010PegaX12-Data-N837-

Loop2330COtherPayerPatientInfo OtherPayerPatientIdentification Other Payer Patient Identification PegaX124010PegaX12-Data-N837-

Loop2330COtherPayerPatientInfo OtherPayerPatientInformation Other Payer Patient Information PegaX124010PegaX12-Data-N837-

Loop2330DOtherPayerAttendingProvidr

OtherPayerAttendingProviderIdentificatio

n

Other Payer Attending Provider


Loop2330DOtherPayerAttendingProvidr OtherPayerAttendingProvider Other Payer Attending Provider PegaX124010PegaX12-Data-N837-

Loop2330DOtherPayerReferringProvidr OtherPayerReferringProviderIdentification

Other Payer Referring Provider

Identification PegaX124010

PegaX12-Data-N837-

Loop2330DOtherPayerReferringProvidr OtherPayerReferringProvider Other Payer Referring Provider PegaX124010PegaX12-Data-N837-

Loop2330EOtherPayerOperatingProvidr OtherPayerOperatingProvider Other Payer Rendering Provider PegaX124010PegaX12-Data-N837-

Loop2330EOtherPayerOperatingProvidr

OtherPayerOperatingProviderIdentificatio

n

Other Payer Rendering Provider

Secondary Identification PegaX124010PegaX12-Data-N837-

Loop2330EOtherPayerRenderingProvidr

OtherPayerRenderingProviderSecondaryId

entification



Loop2330EOtherPayerRenderingProvidr OtherPayerRenderingProvider Other Payer Rendering Provider PegaX124010PegaX12-Data-N837-

Loop2330FOtherPayerOtherProvider OtherPayerOtherProviderIdentification



Loop2330FOtherPayerOtherProvider OtherPayerOtherProvider Other Payer Rendering Provider PegaX124010PegaX12-Data-N837-

Loop2330FOtherPayerPurchSvcProvider

OtherPayerPurchasedServiceProviderIdent

ification

Other Payer Purchased Service Provider


Loop2330FOtherPayerPurchSvcProvider OtherPayerPurchasedServiceProvider Other Payer Purchased Service Provider PegaX124010PegaX12-Data-N837-

Loop2330GOtherPayerReferringProvidr OtherPayerReferringProvider

Other Payer Rendering Provider -


Loop2330GOtherPayerReferringProvidr OtherPayerReferringProviderIdentification

OtherPayerReferringProviderIdent -


Loop2330GOtherPayerSvcFacilityLoc

OtherPayerServiceFacilityLocationIdentific

ation

Other Payer Service Facility Location


Loop2330GOtherPayerSvcFacilityLoc OtherPayerServiceFacilityLocation Other Payer Service Facility Location PegaX124010PegaX12-Data-N837-

Loop2330HOtherPayerSuperviseProvidr OtherPayerSupervisingProvider Other Payer Supervising Provider PegaX124010PegaX12-Data-N837-

Loop2330HOtherPayerSuperviseProvidr

OtherPayerSupervisingProviderIdentificati

on

Other Payer Supervising Provider


Loop2330HOtherPayerSvcFacProvider OtherPayerServiceFacilityProvider Other Payer Rendering Provider PegaX124010PegaX12-Data-N837-

Loop2330HOtherPayerSvcFacProvider

OtherPayerServiceFacilityProviderIdentific

ation


Secondary Identification PegaX124010PegaX12-Data-N837-Loop2400ServiceLine LineNote Line Note PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2410DrugIdentification Loop2410DrugIdentification PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420EOrderingProviderName Loop2420E Ordering Provider Name PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420FReferringProviderName Loop2420F Referring Provider Name PegaX124010PegaX12-Data-N837-Loop2400ServiceLine PostageClaimedAmount Postage Claimed Amount PegaX124010PegaX12-Data-N837-Loop2400ServiceLine ServiceTaxAmount ServiceTaxAmount PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine AmbulanceCertification Ambulance Certification PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_AcuteManifestation Date_Acute Manifestation PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine Date_OrderDate

Date_Order Date - obsolete per the IG

Addendum PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_Shipped Date_Shipped PegaX124010PegaX12-Data-N837-Loop2400ServiceLine FileInformation File Information PegaX124010PegaX12-Data-N837-Loop2400ServiceLine LineItemControlNumber Line Item Control Number PegaX124010PegaX12-Data-N837-Loop2400ServiceLine MammographyCertificationNumber Mammography Certification Number PegaX124010PegaX12-Data-N837-Loop2400ServiceLine OxygenFlowRate Oxygen Flow Rate PegaX124010PegaX12-Data-N837-Loop2400ServiceLine RepricedLineItemReferenceNumber Repriced Line Item Reference Number PegaX124010PegaX12-Data-N837-Loop2400ServiceLine ServiceLine Service Line PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine SpinalManipulationServiceInformation Spinal Manipulation Service Information PegaX124010PegaX12-Data-N837-Loop2400ServiceLine ContractInformation Contract Information PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_DateLastSeen Date_Date Last Seen PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_LastXRay Date_Last X-Ray PegaX124010PegaX12-Data-N837-Loop2400ServiceLine DMERCConditionIndicator DMERC Condition Indicator PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine DurableMedicalEquipmentCertification Durable Medical Equipment Certification PegaX124010PegaX12-Data-N837-Loop2400ServiceLine FacilityTaxAmount FacilityTaxAmount PegaX124010PegaX12-Data-N837-Loop2400ServiceLine HealthCareServicesDelivery Health Care Services Delivery PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420ARenderingProviderName Loop2420A Rendering Provider Name PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine PrescriptionNumber

Prescription Number - Obsolete (removed

from IG) PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine Loop2430LineAdjudicationInformation Loop2430 Line Adjudication Information PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine PriorAuthorizationOrReferralNumber Prior Authorization Or Referral Number PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine

ReferringClinicalLaboratoryImprovementA

mendmentFacilityIdent

Referring Clinical Laboratory

Improvement AmendmentFacilityIdent PegaX124010PegaX12-Data-N837-Loop2400ServiceLine SalesTaxAmount Sales Tax Amount PegaX124010PegaX12-Data-N837-Loop2400ServiceLine ServiceLineDate AssessmentDate PegaX124010PegaX12-Data-N837-Loop2400ServiceLine UniversalProductNumber Universal Product Number PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_BeginTherapyDate Date_Begin Therapy Date PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_InitialTreatment Date_Initial Treatment PegaX124010PegaX12-Data-N837-Loop2400ServiceLine TestResult Test Result PegaX124010PegaX12-Data-N837-Loop2400ServiceLine AmbulanceTransportInformation Ambulance Transport Information PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_LastCertificationDate Date_Last Certification Date PegaX124010


Date_OxygenSaturationArterialBloodGasT

estDate

Date_Oxygen Saturation/Arterial Blood

Gas Test Date - replacment PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine Date_ReferralDate

Date_Referral Date - obsolete per the IG

Addendum PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_ServiceDate Date - Service Date PegaX124010PegaX12-Data-N837-Loop2400ServiceLine DMERCCMNIndicator DMERC CMN Indicator PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine Loop2420DSupervisingProviderName Loop2420D Supervising Provider Name PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine Date_Test

Date_Test - obsolete - use Date_TestDate

instead. PegaX124010PegaX12-Data-N837-Loop2400ServiceLine AmbulatoryPatientGroup Ambulatory Patient Group PegaX124010PegaX12-Data-N837-Loop2400ServiceLine AssessmentDate AssessmentDate PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_TestDate Date_TestDate - Replaces Date_Test PegaX124010PegaX12-Data-N837-Loop2400ServiceLine DurableMedicalEquipmentService Durable Medical Equipment Service PegaX124010PegaX12-Data-N837-Loop2400ServiceLine LinePricingRepricingInformation Line Pricing/Repricing Information PegaX124010


AdjustedRepricedLineItemReferenceNumb

er

Adjusted Repriced Line Item Reference

Number PegaX124010



ntIdentification


Amendment Identification PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_SimilarIllnessSymptomOnset Date_Similar Illness/Symptom Onset PegaX124010PegaX12-Data-N837-Loop2400ServiceLine HomeOxygenTherapyInformation Home Oxygen Therapy Information PegaX124010PegaX12-Data-N837-Loop2400ServiceLine HospiceEmployeeIndicator Hospice Employee Indicator PegaX124010PegaX12-Data-N837-Loop2400ServiceLine ImmunizationBatchNumber Immunization Batch Number PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420AAttendingPhysicianName Loop2420AAttendingPhysicianName PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420COtherProviderName Loop2420COtherProviderName PegaX124010


Loop2420GOtherPayerPriorAuthorization

OrReferralNumber

Loop2420G Other Payer Prior

Authorization Or Referral Number PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2440FormIdentificationCode Loop2440 Form Identification Code PegaX124010PegaX12-Data-N837-Loop2400ServiceLine ProfessionalService Professional Service PegaX124010PegaX12-Data-N837-Loop2400ServiceLine PurchasedServiceInformation Purchased Service Information PegaX124010


Loop2420BPurchasedServiceProviderNam

e

Loop2420B Purchased Service Provider

Name PegaX124010PegaX12-Data-N837-Loop2400ServiceLine InstitutionalService Institutional Service PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420CServiceFacilityLocation Loop2420C Service Facility Location PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420DSupervisingProvierName Loop2420D Supervising Provier Name PegaX124010PegaX12-Data-N837-Loop2400ServiceLine ApprovedAmount Approved Amount PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Date_CertificationRevisionDate Date_Certification Revision Date PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine AnesthesiaModifyingUnits

Anesthesia Modifying Units - obsolete per

IG Addendum PegaX124010

PegaX12-Data-N837-Loop2400ServiceLine Date_OnsetOfCurrentSymptomIllness Date_Onset Of Current Symptom/Illness PegaX124010



est

Date_OxygenSaturation/ArterialBloodGas

Test -obsolete-see history PegaX124010PegaX12-Data-N837-Loop2400ServiceLine LineSupplementalInformation LineSupplementalInformation PegaX124010PegaX12-Data-N837-Loop2400ServiceLine Loop2420BOperatingPhysicianName Loop2420BOperatingPhysicianName PegaX124010

PegaX12-Data-N837-Loop2410DrugIdentification DrugPricing DrugPricing PegaX124010

PegaX12-Data-N837-Loop2410DrugIdentification PrescriptionNumber PrescriptionNumber PegaX124010

PegaX12-Data-N837-Loop2410DrugIdentification DrugIdentification DrugIdentification PegaX124010PegaX12-Data-N837-



n





n2



Loop2420AAttendingPhysicianName AttendingPhysicianSpecialityInformation

Attending Physician Speciality Info -


Loop2420AAttendingPhysicianName AttendingPhysicianName Rendering Provider Name PegaX124010PegaX12-Data-N837-

Loop2420ARenderingProviderName RenderingProviderSecondaryIdentification



Loop2420ARenderingProviderName RenderingProviderSpecialityInformation Rendering Provider Speciality Information PegaX124010PegaX12-Data-N837-

Loop2420ARenderingProviderName RenderingProviderName Rendering Provider Name PegaX124010PegaX12-Data-N837-

Loop2420BOperatingPhysicianName OperatingPhysicianName OperatingPhysicianName PegaX124010PegaX12-Data-N837-

Loop2420BOperatingPhysicianName OperatingPhysicianSpecialtyInformation

OperatingPhysicianSpecialtyInfo -




n



Loop2420BPurchasedServiceProviderNm PurchasedServiceProviderName Purchased Service Provider Name PegaX124010PegaX12-Data-N837-

Loop2420BPurchasedServiceProviderNm


fication



Loop2420COtherProviderName OtherProviderName Other Provider Name PegaX124010PegaX12-Data-N837-

Loop2420COtherProviderName OtherProviderSecondaryIdentification Other Provider Secondary Identification PegaX124010PegaX12-Data-N837-

Loop2420COtherProviderName OtherProviderSpecialtyInformation

OtherProviderSpecialtyInformation -

obsolete per IG addendum PegaX124010

PegaX12-Data-N837-

Loop2420CServiceFacilityLocation


tion



Loop2420CServiceFacilityLocation ServiceFacilityLocation Service Facility Location PegaX124010PegaX12-Data-N837-

Loop2420CServiceFacilityLocation ServiceFacilityLocationCityStateZip Service Facility Location City/State/Zip PegaX124010PegaX12-Data-N837-

Loop2420CServiceFacilityLocation ServiceFacilityLocationAddress Service Facility Location Address PegaX124010PegaX12-Data-N837-

Loop2420DReferringProviderName ReferringProviderSpecialtyInformation

Referring Provider Specialty Info -






ReferringProviderName - obsolete per IG


Loop2420DSupervisingProviderName


n



Loop2420DSupervisingProviderName SupervisingProviderName Supervising Provider Name PegaX124010PegaX12-Data-N837-

Loop2420EOrderingProviderName OrderingProviderContactInformation Ordering Provider Contact Information PegaX124010PegaX12-Data-N837-

Loop2420EOrderingProviderName OrderingProviderName Ordering Provider Name PegaX124010PegaX12-Data-N837-

Loop2420EOrderingProviderName OrderingProviderCityStateZip Ordering Provider City/State/Zip PegaX124010PegaX12-Data-N837-

Loop2420EOrderingProviderName OrderingProviderSecondaryIdentification

Ordering Provider Secondary


Loop2420EOrderingProviderName OrderingProviderAddress Ordering Provider Address PegaX124010PegaX12-Data-N837-

Loop2420FReferringProviderName ReferringProviderName Referring Provider Name PegaX124010PegaX12-Data-N837-

Loop2420FReferringProviderName ReferringProviderSecondaryIdentification



Loop2420FReferringProviderName ReferringProviderSpecialtyInformation Referring Provider Specialty Information PegaX124010PegaX12-Data-N837-

Loop2420GOtherPayrPriorAuthOrRefNbr


umberName


Referral Number Name PegaX124010PegaX12-Data-N837-


OtherPayerPriorAuthorizationorReferralN

umber

Other Payer Prior Authorization or

Referral Number PegaX124010PegaX12-Data-N837-

Loop2430LineAdjudicationInformation LineAdjudicationInformation Line Adjudication Information PegaX124010

PegaX12-Data-N837-

Loop2430LineAdjudicationInformation LineAdjustment Line Adjustment PegaX124010PegaX12-Data-N837-

Loop2430LineAdjudicationInformation LineAdjudicationDate Line Adjudication Date PegaX124010PegaX12-Data-N837-

Loop2440FormIdentificationCode SupportingDocumentation Supporting Documentation PegaX124010PegaX12-Data-N837-

Loop2440FormIdentificationCode FormIdentificationCode Form Identification Code PegaX124010PegaX12-Data-N837-PatientLevel Loop2000CPatient Loop2000CPatient PegaX124010PegaX12-Data-N837-SubscriberLevel Loop2000BSubscriber Loop2000BSubscriber PegaX124010PegaX12-Data-N837-Trailer TransactionSetTrailer Transaction Set Trailer PegaX124010PegaX12-Data-N837-Transaction BillingPayToProviderLevel BillingPayToProviderLevel PegaX124010PegaX12-Data-N837-Transaction Header Header PegaX124010PegaX12-Data-N837-Transaction Trailer Transaction Trailer PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM108_IdentificationCodeQualifier Identification Code Qualifier PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM107_NameSuffix Name Suffix PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM101_EntityIdentifierCode Entity Identifier Code PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM104_NameFirst Name First PegaX124010PegaX12-Data-


NM1_IndividualorOrganizationalName NM102_EntityTypeQualifier Entity Type Qualifier PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM105_NameMiddle Name Middle PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM103_NameLastorOrganizationName Name Last or Organization Name PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM110_EntityRelationshipCode EntityRelationshipCode PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM109_IdentificationCode Identification Code PegaX124010PegaX12-Data-

NM1_IndividualorOrganizationalName NM106_NamePrefix Name Prefix PegaX124010PegaX12-Data-NTE_NoteSpecialInstruction NTE01_NoteReferenceCode NTE01_Note Reference Code PegaX124010PegaX12-Data-NTE_NoteSpecialInstruction NTE02_Description NTE02_Description PegaX124010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI03_YesNoConditionOrResponseCode

OI03_Yes/No Condition Or Response

Code PegaX124010

PegaX12-Data-

OI_OtherHealthInsuranceInformation OI05_ProviderAgreementCode OI05_Provider Agreement Code PegaX124010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI06_ReleaseOfInformationCode OI06_Release Of Information Code PegaX124010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI01_ClaimFilingIndicatorCode OI01_Claim Filing Indicator Code PegaX124010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI04_PatientSignatureSourceCode OI04_Patient Signature Source Code PegaX124010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI02_ClaimSubmissionReasonCode OI02_Claim Submission Reason Code PegaX124010PegaX12-Data-PAT_PatientInformation PAT08_Weight Numeric value of weight PegaX124010

PegaX12-Data-PAT_PatientInformation PAT09_YesNoConditionOrResponseCode

Code indicating Yes/No Condition or

Response PegaX124010

PegaX12-Data-PAT_PatientInformation PAT05_DateTimePeriodFormatQualifier

Code indicating the date format and/or

time format PegaX124010PegaX12-Data-PAT_PatientInformation PAT04_StudentStatusCode Student Status Code PegaX124010

PegaX12-Data-PAT_PatientInformation PAT07_UnitOrBasisForMeasurementCode Code specifying units for weight PegaX124010PegaX12-Data-PAT_PatientInformation PAT03_EmploymentStatusCode Employment Status Code PegaX124010PegaX12-Data-PAT_PatientInformation PAT01_IndividualRelationshipCode Individual Relationship Code PegaX124010PegaX12-Data-PAT_PatientInformation PAT02_PatientLocationCode Patient Location Code PegaX124010

PegaX12-Data-PAT_PatientInformation PAT06_DateTimePeriod

Expression of a date, a time or a range of

dates and times PegaX124010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER06_CommunicationNumber Communication Number 1 PegaX124010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER02_Name Name PegaX124010PegaX12-Data-


PER_AdministrativeCommunicationsContact PER05_CommunicationNumberQualifier Communication Number Qualifier PegaX124010PegaX12-Data-


PER_AdministrativeCommunicationsContact PER09_ContactInquiryReference Contact Inquiry Reference PegaX124010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER01_ContactFunctionCode Contact Function Code PegaX124010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER07_CommunicationNumberQualifier Communication Number Qualifier PegaX124010

PegaX12-Data-

PER_AdministrativeCommunicationsContact PER03_CommunicationNumberQualifier Communication Number Qualifier PegaX124010PegaX12-Data-PLA_PlaceOrLocation PLA01_ActionCode Action Code PegaX124010PegaX12-Data-PLA_PlaceOrLocation PLA03_Date Date PegaX124010PegaX12-Data-PLA_PlaceOrLocation PLA05_MaintenanceReasonCode Maintenance Reason Code PegaX124010PegaX12-Data-PLA_PlaceOrLocation PLA02_EntityIdentifierCode Entity Identifier Code PegaX124010PegaX12-Data-PLA_PlaceOrLocation PLA04_Time Time PegaX124010PegaX12-Data-ProcessingStatistics NumberTransactionSetsTotal NumberTransactionSetsTotal PegaX124010PegaX12-Data-ProcessingStatistics RunDate RunDate PegaX124010PegaX12-Data-ProcessingStatistics NumberFunctionalGroupsSent NumberFunctionalGroupsSent PegaX124010PegaX12-Data-ProcessingStatistics NumberTransactionSetsPerType NumberTransactionSetsPerType PegaX124010PegaX12-Data-ProcessingStatistics testingGroup testingGroup PegaX124010PegaX12-Data-ProcessingStatistics NumberFunctionalGroups NumberFunctionalGroups PegaX124010PegaX12-Data-ProcessingStatistics StartTime Start Time PegaX124010PegaX12-Data-ProcessingStatistics EndTime End Time PegaX124010PegaX12-Data-ProcessingStatistics ErrorMsg ErrorMsg PegaX124010PegaX12-Data-ProcessingStatistics NumberTransactionSetsSent NumberTransactionSetsSent PegaX124010

PegaX12-Data-ProcessingStatisticsTransactionType FirstWorkID FirstWorkID PegaX124010

PegaX12-Data-ProcessingStatisticsTransactionType NumberWorkObjectsCreated Number Work Objects Created PegaX124010

PegaX12-Data-ProcessingStatisticsTransactionType LastWorkID LastWorkID PegaX124010

PegaX12-Data-ProcessingStatisticsTransactionType NumberTransactionSetsProcessed NumberTransactionSetsProcessed PegaX124010

PegaX12-Data-ProcessingStatisticsTransactionType NumberMessagesInError Number Messages In Error PegaX124010PegaX12-Data-PRV_ProviderInformation PRV06_ProviderOrganizationCode PRV06_Provider Organization Code PegaX124010PegaX12-Data-PRV_ProviderInformation PRV03_ReferenceIdentification PRV03_Reference Identification PegaX124010PegaX12-Data-PRV_ProviderInformation PRV01_ProviderCode PRV01_Provider Code PegaX124010

PegaX12-Data-PRV_ProviderInformation PRV05_ProviderSpecialtyInformation PRV05_Provider Specialty Information PegaX124010PegaX12-Data-PRV_ProviderInformation PRV04_StateorProvinceCode PRV04_State or Province Code PegaX124010

PegaX12-Data-PRV_ProviderInformation PRV02_ReferenceIdentificationQualifier PRV02_Reference Identification Qualifier PegaX124010PegaX12-Data-PS1_PurchaseService PS102_MonetaryAmount PS102_Monetary Amount PegaX124010PegaX12-Data-PS1_PurchaseService PS101_ReferenceIdentification PS101_Reference Identification PegaX124010PegaX12-Data-PS1_PurchaseService PS103_StateOrProvinceCode PS103_State Or Province Code PegaX124010PegaX12-Data-PWK_Paperwork PWK02_ReportTransmissionCode PWK02_Report Transmission Code PegaX124010PegaX12-Data-PWK_Paperwork PWK01_ReportTypeCode PWK01_Report Type Code PegaX124010

PegaX12-Data-PWK_Paperwork PWK08_ActionsIndicated PWK08_Actions Indicated PegaX124010PegaX12-Data-PWK_Paperwork PWK09_RequestCategoryCode PWK09_Request Category Code PegaX124010PegaX12-Data-PWK_Paperwork PWK06_IdentificationCode PWK06_Identification Code PegaX124010PegaX12-Data-PWK_Paperwork PWK04_EntityIdentifierCode PWK04_Entity Identifier Code PegaX124010PegaX12-Data-PWK_Paperwork PWK07_Description PWK07_Description PegaX124010PegaX12-Data-PWK_Paperwork PWK03_ReportCopiesNeeded PWK03_Report Copies Needed PegaX124010PegaX12-Data-PWK_Paperwork PWK05_IdentificationCodeQualifier PWK05_Identification Code Qualifier PegaX124010PegaX12-Data-QTY_Quantity QTY03_CompositeUnitOfMeasure QTY03_Composite Unit Of Measure PegaX124010PegaX12-Data-QTY_Quantity QTY01_QuantityQualifier QTY01_Quantity Qualifier PegaX124010PegaX12-Data-QTY_Quantity QTY04_FreeFormMessage QTY04_Free-Form Message PegaX124010PegaX12-Data-QTY_Quantity QTY02_Quantity QTY02_Quantity PegaX124010

PegaX12-Data-REF_ReferenceIdentification REF01_ReferenceIdentificationQualifier Reference Identification Qualifier PegaX124010PegaX12-Data-REF_ReferenceIdentification REF04_ReferenceIdentifier ReferenceIdentifier PegaX124010PegaX12-Data-REF_ReferenceIdentification REF03_Description Description PegaX124010PegaX12-Data-REF_ReferenceIdentification REF02_ReferenceIdentification Reference Identification PegaX124010

PegaX12-Data-SBR_SubscriberInformation

SBR01_PayerResponsibilitySequenceNumb

erCode


Code PegaX124010PegaX12-Data-SBR_SubscriberInformation SBR08_EmploymentStatusCode Employment Status Code PegaX124010PegaX12-Data-SBR_SubscriberInformation SBR05_InsuranceTypeCode Insurance Type Code PegaX124010PegaX12-Data-SBR_SubscriberInformation SBR09_ClaimFilingIndicatorCode Claim Filing Indicator Code PegaX124010PegaX12-Data-SBR_SubscriberInformation SBR02_IndividualRelationshipCode Individual Relationship Code PegaX124010

PegaX12-Data-SBR_SubscriberInformation SBR07_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX124010PegaX12-Data-SBR_SubscriberInformation SBR04_Name Name PegaX124010PegaX12-Data-SBR_SubscriberInformation SBR06_CoordinationOfBenefitsCode Coordination Of Benefits Code PegaX124010PegaX12-Data-SBR_SubscriberInformation SBR03_ReferenceIdentification Reference Identification PegaX124010PegaX12-Data-SE_TransactionSetTrailer SE02_TransactionSetControlNumber Transaction Set Control Number PegaX124010PegaX12-Data-SE_TransactionSetTrailer SE01_NumberofIncludedSegments Number of Included Segments PegaX124010PegaX12-Data-ST_TransactionSetHeader ST02_TransactionSetControlNumber TransactionSetControlNumber PegaX124010PegaX12-Data-ST_TransactionSetHeader ST01_TransactionSetIdentifierCode TransactionSetIdentifierCode PegaX124010PegaX12-Data-STC_StatusInformation STC12_FreeFormMessageText Free-Form Message Text PegaX124010PegaX12-Data-STC_StatusInformation STC02_Date Date PegaX124010PegaX12-Data-STC_StatusInformation STC01_HealthCareClaimStatus Health Care Claim Status PegaX124010PegaX12-Data-STC_StatusInformation STC08_Date Date PegaX124010PegaX12-Data-STC_StatusInformation STC05_MonetaryAmount Monetary Amount PegaX124010PegaX12-Data-STC_StatusInformation STC10_HealthCareClaimStatus Health Care Claim Status PegaX124010PegaX12-Data-STC_StatusInformation STC06_Date Date PegaX124010PegaX12-Data-STC_StatusInformation STC11_HealthCareClaimStatus Health Care Claim Status PegaX124010PegaX12-Data-STC_StatusInformation STC04_MonetaryAmount Monetary Amount PegaX124010

PegaX12-Data-STC_StatusInformation STC07_PaymentMethodCode Payment Method Code PegaX124010PegaX12-Data-STC_StatusInformation STC09_CheckNumber Check Number PegaX124010PegaX12-Data-STC_StatusInformation STC03_ActionCode Action Code PegaX124010PegaX12-Data-STC01_HealthCareClaimStatus STC01_3_EntityIdentifierCode Entity Identifier Code PegaX124010PegaX12-Data-STC01_HealthCareClaimStatus STC01_2_IndustryCode Industry Code PegaX124010PegaX12-Data-STC01_HealthCareClaimStatus STC01_1_IndustryCode Industry Code PegaX124010PegaX12-Data-STC10_HealthCareClaimStatus STC10_3_EntityIdentifierCode Entity Identifier Code PegaX124010PegaX12-Data-STC10_HealthCareClaimStatus STC10_2_IndustryCode Industry Code PegaX124010PegaX12-Data-STC10_HealthCareClaimStatus STC10_1_IndustryCode Industry Code PegaX124010PegaX12-Data-STC11_HealthCareClaimStatus STC11_3_EntityIdentifierCode Entity Identifier Code PegaX124010PegaX12-Data-STC11_HealthCareClaimStatus STC11_1_IndustryCode Industry Code PegaX124010PegaX12-Data-STC11_HealthCareClaimStatus STC11_2_IndustryCode Industry Code PegaX124010PegaX12-Data-SV1_ProfessionalService SV113_ReviewCode SV113 Review Code PegaX124010

PegaX12-Data-SV1_ProfessionalService

SV114_NationalOrLocalAssignedReviewVal

ue

SV114 National Or Local Assigned Review

Value PegaX124010


SV101_CompositeMedicalProcedureIdenti

fier

SV101_CompositeMedicalProcedureIdent

ifier PegaX124010PegaX12-Data-SV1_ProfessionalService SV105_FacilityCodeValue SV105 Facility Code Value PegaX124010PegaX12-Data-SV1_ProfessionalService SV121_ProviderAgreementCode SV121 Provider Agreement Code PegaX124010PegaX12-Data-SV1_ProfessionalService SV102_MonetaryAmount SV102 Monetary Amount PegaX124010

PegaX12-Data-SV1_ProfessionalService SV111_YesNoConditionOrResponseCode

SV111 Yes/No Condition Or Response

Code PegaX124010PegaX12-Data-SV1_ProfessionalService SV115_CopayStatusCode SV115_CopayStatusCode PegaX124010PegaX12-Data-SV1_ProfessionalService SV118_PostalCode SV118 Postal Code PegaX124010PegaX12-Data-SV1_ProfessionalService SV119_MonetaryAmount SV119 Monetary Amount PegaX124010PegaX12-Data-SV1_ProfessionalService SV106_ServiceTypeCode SV106 Service Type Code PegaX124010

PegaX12-Data-SV1_ProfessionalService SV107_CompositeDiagnosisCodePointer SV107_CompositeDiagnosisCodePointer PegaX124010PegaX12-Data-SV1_ProfessionalService SV117_ReferenceIdentification SV117 Reference Identification PegaX124010PegaX12-Data-SV1_ProfessionalService SV108_MonetaryAmount SV108 Monetary Amount PegaX124010PegaX12-Data-SV1_ProfessionalService SV110_MultipleProcedureCode SV110 Multiple Procedure Code PegaX124010


SV116_HealthCareProfessionalShortageAr

eaCode

SV116 HealthCare Professional Shortage

Area Code PegaX124010



Code PegaX124010PegaX12-Data-SV1_ProfessionalService SV120_LevelOfCareCode SV120 Level Of Care Code PegaX124010

PegaX12-Data-SV1_ProfessionalService SV103_UnitOrBasisForMeasurementCode

SV103 Unit Or Basis For Measurement

Code PegaX124010PegaX12-Data-SV1_ProfessionalService SV104_Quantity SV104 Quantity PegaX124010




SV101_CompositeMedicalProcedureIdent SV101_2_ProductServiceID SV101-2 Product/Service ID PegaX124010PegaX12-Data-

SV101_CompositeMedicalProcedureIdent SV101_6_ProcedureModifier SV101-6 Procedure Modifier PegaX124010PegaX12-Data-



SV101_CompositeMedicalProcedureIdent SV101_3_ProcedureModifier SV101_3_ProcedureModifier PegaX124010PegaX12-Data-

SV101_CompositeMedicalProcedureIdent SV101_1_ProductServiceIDQualifier SV101-1 Product/Service ID Qualifier PegaX124010PegaX12-Data-

SV101_CompositeMedicalProcedureIdent SV101_7_Description SV101-7 Description PegaX124010PegaX12-Data-

SV107_CompositeDiagnosisCodePointer SV107_4_DiagnosisCodePointer SV107-4 Diagnosis Code Pointer PegaX124010PegaX12-Data-



SV107_CompositeDiagnosisCodePointer SV107_2_DiagnosisCodePointer SV107-2 Diagnosis Code Pointer PegaX124010PegaX12-Data-SV2_InstitutionalService SV210_LevelOfCareCode SV210_LevelOfCareCode PegaX124010PegaX12-Data-SV2_InstitutionalService SV203_MonetaryAmount SV203_MonetaryAmount PegaX124010PegaX12-Data-SV2_InstitutionalService SV206_UnitRate SV206_UnitRate PegaX124010PegaX12-Data-SV2_InstitutionalService SV207_MonetaryAmount SV207_MonetaryAmount PegaX124010

PegaX12-Data-SV2_InstitutionalService SV208_YesNoConditionOrResponseCode SV208_YesNoConditionOrResponseCode PegaX124010

PegaX12-Data-SV2_InstitutionalService


fier


ifier PegaX124010PegaX12-Data-SV2_InstitutionalService SV201_ServiceID SV201_ServiceID PegaX124010PegaX12-Data-SV2_InstitutionalService SV205_Quantity SV205_Quantity PegaX124010

PegaX12-Data-SV2_InstitutionalService SV204_UnitOrBasisForMeasurementCode SV204_UnitOrBasisForMeasurementCode PegaX124010PegaX12-Data-SV2_InstitutionalService SV201_ServiceID2 SV201_ServiceID2 PegaX124010


SV209_NursingHomeResidentialStatusCod

e

SV209_NursingHomeResidentialStatusCo

de PegaX124010

PegaX12-Data-


SV202_CompositeMedicalProcedureIdent SV202_1_ProductServiceIDQualifier SV202-1 Product/Service ID Qualifier PegaX124010PegaX12-Data-





SV202_CompositeMedicalProcedureIdent SV202_5_ProcedureModifier SV202-5 Procedure Modifier PegaX124010PegaX12-Data-SV4_DrugService SV417_LevelOfCareCode SV417_Level Of Care Code PegaX124010PegaX12-Data-SV4_DrugService SV401_ReferenceIdentification SV401_Reference Identification PegaX124010

PegaX12-Data-SV4_DrugService SV409_YesNoConditionOrResponseCode

SV409_Yes/No Condition Or Response

Code PegaX124010



Code PegaX124010PegaX12-Data-SV4_DrugService SV418_PriorAuthorizationTypeCode SV418_Prior Authorization Type Code PegaX124010PegaX12-Data-SV4_DrugService SV403_ReferenceIdentification SV403_Reference Identification PegaX124010PegaX12-Data-SV4_DrugService SV406_LevelOfServiceCode SV406_Level Of Service Code PegaX124010

PegaX12-Data-SV4_DrugService SV412_BasisOfCostDeterminationCode SV412_Basis Of Cost Determination Code PegaX124010

PegaX12-Data-SV4_DrugService

SV413_BasisOfDaysSupplyDeterminationC

ode

SV413_Basis Of Days Supply

Determination Code PegaX124010PegaX12-Data-SV4_DrugService SV416_PatientLocationCode SV416_Patient Location Code PegaX124010PegaX12-Data-SV4_DrugService SV407_PrescriptionOriginCode SV407_Prescription Origin Code PegaX124010PegaX12-Data-SV4_DrugService SV411_UnitDoseCode SV411_Unit Dose Code PegaX124010PegaX12-Data-SV4_DrugService SV415_CoPayStatusCode SV415_CoPay Status Code PegaX124010PegaX12-Data-SV4_DrugService SV405_DispenseAsWrittenCode SV405_Dispense As Written Code PegaX124010PegaX12-Data-SV4_DrugService SV408_Description SV408_Description PegaX124010



fier


ifier PegaX124010



Code PegaX124010PegaX12-Data-SV4_DrugService SV414_DosageFormCode SV414_Dosage Form Code PegaX124010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV505_MonetaryAmount SV505_MonetaryAmount PegaX124010

PegaX12-Data-

SV5_DurableMedicalEquipmentService SV504_MonetaryAmount SV504_MonetaryAmount PegaX124010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV502_UnitOrBasisForMeasurementCode SV502_UnitOrBasisForMeasurementCode PegaX124010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV507_PrognosisCode SV507_PrognosisCode PegaX124010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV506_FrequencyCode SV506_FrequencyCode PegaX124010PegaX12-Data-

SV5_DurableMedicalEquipmentService


fier


ifier PegaX124010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV503_Quantity SV503_Quantity PegaX124010PegaX12-Data-



SV501_CompositeMedicalProcedureIdent SV501_2_ProductServiceID SV501_2_ProductServiceID PegaX124010PegaX12-Data-

SV501_CompositeMedicalProcedureIdent SV501_1_ProductServiceIDQualifier SV501_1_ProductServiceIDQualifier PegaX124010PegaX12-Data-

SV501_CompositeMedicalProcedureIdent SV501_7_Description SV501_7_Description PegaX124010PegaX12-Data-


SV501_CompositeMedicalProcedureIdent SV501_6_ProcedureModifier SV501_6_ProcedureModifier PegaX124010

PegaX12-Data-SVC_ServiceInformation

SVC01_CompositeMedicalProcedureIdenti

fier Composite Medical Procedure Identifier PegaX124010



fier Composite Medical Procedure Identifier PegaX124010PegaX12-Data-SVC_ServiceInformation SVC02_MonetaryAmount Monetary Amount PegaX124010PegaX12-Data-SVC_ServiceInformation SVC07_Quantity Quantity PegaX124010PegaX12-Data-SVC_ServiceInformation SVC03_MonetaryAmount Monetary Amount PegaX124010PegaX12-Data-SVC_ServiceInformation SVC04_ProductServiceID Product/Service ID PegaX124010PegaX12-Data-SVC_ServiceInformation SVC05_Quantity Quantity PegaX124010PegaX12-Data-

SVC01_CompositeMediProcedureIdentifier SVC01_6_ProcedureModifier Procedure Modifier PegaX124010PegaX12-Data-

SVC01_CompositeMediProcedureIdentifier SVC01_3_ProcedureModifier Procedure Modifier PegaX124010

PegaX12-Data-


SVC01_CompositeMediProcedureIdentifier SVC01_2_ProductServiceID Product/Service ID PegaX124010PegaX12-Data-


SVC01_CompositeMediProcedureIdentifier SVC01_7_Description Description PegaX124010PegaX12-Data-

SVC01_CompositeMediProcedureIdentifier SVC01_1_ProductServiceIDQualifier Product/Service ID Qualifier PegaX124010PegaX12-Data-SVD_ServiceLineAdjudication SVD05_Quantity SVD05_Quantity PegaX124010PegaX12-Data-SVD_ServiceLineAdjudication SVD02_MonetaryAmount SVD02_Monetary Amount PegaX124010

PegaX12-Data-SVD_ServiceLineAdjudication

SVD03_CompositeMedicalProcedureIdenti

fier

SVD03_Composite Medical Procedure

Identifier PegaX124010PegaX12-Data-SVD_ServiceLineAdjudication SVD04_ProductServiceId SVD04_Product/Service Id PegaX124010PegaX12-Data-SVD_ServiceLineAdjudication SVD01_IdentificationCode SVD01_Identification Code PegaX124010PegaX12-Data-SVD_ServiceLineAdjudication SVD06_AssignedNumber SVD06_Assigned Number PegaX124010PegaX12-Data-

SVD03_CompositeMedicalProcedureId SVD03_1_ProductServiceIdQualifier SVD03_1_Product/Service Id Qualifier PegaX124010PegaX12-Data-

SVD03_CompositeMedicalProcedureId SVD03_5_ProcedureModifier SVD03_5_Procedure Modifier PegaX124010PegaX12-Data-

SVD03_CompositeMedicalProcedureId SVD03_7_Description SVD03_7_Description PegaX124010PegaX12-Data-



SVD03_CompositeMedicalProcedureId SVD03_2_ProductServiceId SVD03_2_Product/Service Id PegaX124010PegaX12-Data-

SVD03_CompositeMedicalProcedureId SVD03_6_ProcedureModifier SVD03_6_Procedure Modifier PegaX124010PegaX12-Data-TRN_Trace TRN01_TraceTypeCode TRN01_TraceTypeCode PegaX124010PegaX12-Data-TRN_Trace TRN02_ReferenceIdentification TRN02_ReferenceIdentification PegaX124010PegaX12-Data-TRN_Trace TRN04_ReferenceIdentification TRN04_ReferenceIdentification PegaX124010PegaX12-Data-TRN_Trace TRN03_OriginatingCompanyIdentifier TRN03_OriginatingCompanyIdentifier PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation

UM04_HealthCareServiceLocationInforma

tion

UM04_HealthCareServiceLocationInform

ation PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM03_ServiceTypeCode UM03_ServiceTypeCode PegaX124010

PegaX12-Data-

UM_HealthCareServicesReviewInformation UM09_ReleaseofInformationCode UM09_ReleaseofInformationCode PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM08_PrognosisCode UM08_PrognosisCode PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM02_CertificationCode UM02_CertificationCode PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM07_CurrentHealthConditionCode UM07_CurrentHealthConditionCode PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM05_RelatedCausesInformation UM05_RelatedCausesInformation PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM01_RequestCategoryCode UM01_RequestCategoryCode PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM10_DelayReasonCode UM10_DelayReasonCode PegaX124010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM06_LevelofServiceCode UM06_LevelofServiceCode PegaX124010PegaX12-Data-

UM04_HealthCareServiceLocationInfo UM04_2_FacilityCodeQualifier UM04_2_FacilityCodeQualifier PegaX124010PegaX12-Data-

UM04_HealthCareServiceLocationInfo UM04_1_FacilityCodeValue UM04_1_FacilityCodeValue PegaX124010PegaX12-Data-

UM04_HealthCareServiceLocationInfo UM04_3_ClaimFrequencyTypeCode UM04_3_ClaimFrequencyTypeCode PegaX124010

PegaX12-Data-UM05_RelatedCausesInformation UM05_5_CountryCode UM05_5_CountryCode PegaX124010

PegaX12-Data-UM05_RelatedCausesInformation UM05_3_RelatedCausesCode UM05_3_RelatedCausesCode PegaX124010


PegaX12-Data-UM05_RelatedCausesInformation UM05_4_StateorProvinceCode UM05_4_StateorProvinceCode PegaX124010

PegaX12-Data-UM05_RelatedCausesInformation UM05_2_RelatedCausesCode UM05_2_RelatedCausesCode PegaX124010Index-CircumstanceDefinition pxUserIdentifier ID of current user PegaX125010PegaX12-Data- FileTypeSelected FileTypeSelected PegaX125010PegaX12-Data- Message X12 Message PegaX125010PegaX12-Data- IEA_InterchangeControlTrailer IEA_InterchangeControlTrailer PegaX125010PegaX12-Data- BatchID BatchID PegaX125010PegaX12-Data- ISA_InterchangeControlHeader ISA_InterchangeControlHeader PegaX125010PegaX12-Data- IsFromRDC IsFromRDC PegaX125010PegaX12-Data- X12Post X12Post PegaX125010

PegaX12-Data- X12Pre X12Pre PegaX125010PegaX12-Data- GroupID GroupID PegaX125010PegaX12-Data- MessageCorrelation Message Correlation PegaX125010PegaX12-Data- MultClaimX12Body MultClaimX12Body PegaX125010PegaX12-Data- STCount STCount PegaX125010PegaX12-Data-AAA_RequestValidation AAA02_AgencyQualifierCode AAA02_AgencyQualifierCode PegaX125010PegaX12-Data-AAA_RequestValidation AAA04_FollowupActionCode Followup Action Code PegaX125010

PegaX12-Data-AAA_RequestValidation AAA01_YesNoConditionorResponseCode AAA01_YesNoConditionorResponseCode PegaX125010PegaX12-Data-AAA_RequestValidation AAA03_RejectReasonCode Reject Reason Code PegaX125010PegaX12-Data-ACT_AccountIdentification ACT07_Description Description PegaX125010PegaX12-Data-ACT_AccountIdentification ACT08_PaymentMethodCode Payment Method Code PegaX125010PegaX12-Data-ACT_AccountIdentification ACT05_AccountNumberQualifier Account Number Qualifier PegaX125010PegaX12-Data-ACT_AccountIdentification ACT02_Name Name PegaX125010PegaX12-Data-ACT_AccountIdentification ACT06_AccountNumber Account Number PegaX125010PegaX12-Data-ACT_AccountIdentification ACT01_AccountNumber Account Number PegaX125010PegaX12-Data-ACT_AccountIdentification ACT03_IdentificationCodeQualifier Identification Code Qualifier PegaX125010PegaX12-Data-ACT_AccountIdentification ACT04_IdentificationCode Identification Code PegaX125010PegaX12-Data-AMT_MonetaryAmount AMT03_CreditDebitFlagCode AMT03_Credit/Debit Flag Code PegaX125010PegaX12-Data-AMT_MonetaryAmount AMT02_MonetaryAmount AMT02_Monetary Amount PegaX125010PegaX12-Data-AMT_MonetaryAmount AMT01_AmountQualifierCode AMT01_Amount Qualifier Code PegaX125010PegaX12-Data-BGN_BeginningSegment BGN08_ActionCode Action Code PegaX125010PegaX12-Data-BGN_BeginningSegment BGN06_ReferenceIdentification Reference Identification PegaX125010PegaX12-Data-BGN_BeginningSegment BGN05_TimeCode Time Code PegaX125010PegaX12-Data-BGN_BeginningSegment BGN01_TransactionSetPurposeCode Transaction Set Purpose Code PegaX125010PegaX12-Data-BGN_BeginningSegment BGN09_SecurityLevelCode Security Level Code PegaX125010PegaX12-Data-BGN_BeginningSegment BGN07_TransactionTypeCode Transaction Type Code PegaX125010PegaX12-Data-BGN_BeginningSegment BGN02_ReferenceIdentification Reference Identification PegaX125010PegaX12-Data-BGN_BeginningSegment BGN04_Time Time PegaX125010PegaX12-Data-BGN_BeginningSegment BGN03_Date Date PegaX125010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT03_ReferenceIdentification Reference Identification PegaX125010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT06_TransactionTypeCode Transaction Type Code PegaX125010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT04_Date Date PegaX125010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT02_TransactionSetPurposeCode Transaction Set Purpose Code PegaX125010PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT05_Time Time PegaX125010

PegaX12-Data-

BHT_BeginningOfHierarchicalTransaction BHT01_HierarchicalStructureCode Hierarchical Structure Code PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS04_Quantity CAS04_Quantity PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS10_Quantity CAS10_Quantity PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS19_Quantity CAS19_Quantity PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS08_ReasonCode CAS08_ReasonCode PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS01_ClaimAdjustmentGroupCode CAS01_Claim Adjustment Group Code PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS06_MonetaryAmount CAS06_MonetaryAmount PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS15_MonetaryAmount CAS15_MonetaryAmount PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS16_Quantity CAS16_Quantity PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS14_ReasonCode CAS14_ReasonCode PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS11_ReasonCode CAS11_ReasonCode PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS03_MonetaryAmount CAS03_MonetaryAmount PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS13_Quantity CAS13_Quantity PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS17_ReasonCode CAS17_ReasonCode PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS05_ReasonCode CAS05_ReasonCode PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS09_MonetaryAmount CAS09_MonetaryAmount PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS18_MonetaryAmount CAS18_MonetaryAmount PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS02_ReasonCode CAS02_ReasonCode PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS07_Quantity CAS07_Quantity PegaX125010PegaX12-Data-CAS_ClaimsAdjustment CAS12_MonetaryAmount CAS12_MonetaryAmount PegaX125010PegaX12-Data-CL1_ClaimCodes CL102_AdmissionSourceCode CL102_AdmissionSourceCode PegaX125010

PegaX12-Data-CL1_ClaimCodes

CL104_NursingHomeResidentialStatusCod

e

CL104_NursingHomeResidentialStatusCo

de PegaX125010PegaX12-Data-CL1_ClaimCodes CL103_PatientStatusCode CL103_PatientStatusCode PegaX125010PegaX12-Data-CL1_ClaimCodes CL101_AdmissionTypeCode CL101_AdmissionTypeCode PegaX125010PegaX12-Data-CLM_HealthClaim CLM12_SpecialProgramCode Special Program Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM11_RelatedCausesInformation Related Causes Information PegaX125010

PegaX12-Data-CLM_HealthClaim CLM18_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM02_MonetaryAmount Monetary Amount PegaX125010

PegaX12-Data-CLM_HealthClaim CLM13_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM16_ProviderAgreementCode Provider Agreement Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM20_DelayReasonCode Delay Reason Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM03_ClaimFilingIndicatorCode Claim Filing Indicator Code PegaX125010

PegaX12-Data-CLM_HealthClaim CLM07_ProviderAcceptAssignmentCode

Code indicating whether the provider

accepts assignment PegaX125010


PegaX12-Data-CLM_HealthClaim CLM15_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM19_ClaimSubmissionReasonCode Claim Submission Reason Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM10_PatientSignatureSourceCode Patient Signature Source Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM01_ClaimSubmittersIdentifier Claim Submitter's Identifier PegaX125010

PegaX12-Data-CLM_HealthClaim CLM06_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM17_ClaimStatusCode Claim Status Code PegaX125010

PegaX12-Data-CLM_HealthClaim

CLM05_HealthCareServiceLocationInform

ation Health Care Service Location Information PegaX125010PegaX12-Data-CLM_HealthClaim CLM14_LevelOfService Level of Service PegaX125010

PegaX12-Data-CLM_HealthClaim CLM04_NonInstitutionalClaimTypeCode Non-Institutional Claim Type Code PegaX125010PegaX12-Data-CLM_HealthClaim CLM09_ReleaseOfInformationCode Release of Information Code PegaX125010PegaX12-Data-

CLM05_HealthCareServiceLocationInfo CLM05_3_ClaimFrequencyTypeCode Code specifying frequency of the claim PegaX125010PegaX12-Data-

CLM05_HealthCareServiceLocationInfo CLM05_2_FacilityCodeQualifier Facility Code Qualifier PegaX125010PegaX12-Data-

CLM05_HealthCareServiceLocationInfo CLM05_1_FacilityCodeValue Facility Code Value PegaX125010


PegaX12-Data-CLM11_RelatedCausesInformation CLM11_5_CountryCode Country Code PegaX125010


PegaX12-Data-CLM11_RelatedCausesInformation CLM11_4_StateOrProvinceCode State or Province Code PegaX125010

PegaX12-Data-CLM11_RelatedCausesInformation CLM11_3_RelatedCausesCode Related Causes Code PegaX125010PegaX12-Data-CN1_ContractInformation CN101_ContractTypeCode CN101_Contract Type Code PegaX125010PegaX12-Data-CN1_ContractInformation CN103_Percent CN103_Percent PegaX125010PegaX12-Data-CN1_ContractInformation CN102_MonetaryAmount CN102_Monetary Amount PegaX125010PegaX12-Data-CN1_ContractInformation CN106_VersionIdentifier CN106_Version Identifier PegaX125010PegaX12-Data-CN1_ContractInformation CN105_TermsDiscountPercent CN105_Terms Discount Percent PegaX125010PegaX12-Data-CN1_ContractInformation CN104_ReferenceIdentification CN104_Reference Identification PegaX125010PegaX12-Data-COB_CoordinationOfBenefits COB03_CoordinationOfBenefitsCode Coordination OfBenefits Code PegaX125010

PegaX12-Data-COB_CoordinationOfBenefits

COB01_PayerResponsibilitySequenceNum

berCode


Code PegaX125010PegaX12-Data-COB_CoordinationOfBenefits COB04_ServiceTypeCode COB04_ServiceTypeCode PegaX125010

PegaX12-Data-COB_CoordinationOfBenefits COB02_ReferenceIdentification COB02_ReferenceIdentification PegaX125010PegaX12-Data-CR1_AmbulanceCertification CR110_Description CR110_Description PegaX125010PegaX12-Data-CR1_AmbulanceCertification CR108_AddressInformation CR108_Address Information PegaX125010



Code PegaX125010PegaX12-Data-CR1_AmbulanceCertification CR103_AmbulanceTransportCode CR103_Ambulance Transport Code PegaX125010



Code PegaX125010

PegaX12-Data-CR1_AmbulanceCertification CR104_AmbulanceTransportReasonCode

CR104_Ambulance Transport Reason

Code PegaX125010PegaX12-Data-CR1_AmbulanceCertification CR102_Weight CR102_Weight PegaX125010PegaX12-Data-CR1_AmbulanceCertification CR106_Quantity CR106_Quantity PegaX125010PegaX12-Data-CR1_AmbulanceCertification CR107_AddressInformation CR107_Address Information PegaX125010PegaX12-Data-CR1_AmbulanceCertification CR109_Description CR109_Description PegaX125010



Code PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR210_Description CR210_Description PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR203_SubluxationLevelCode CR203_Subluxation Level Code PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR208_NatureOfConditionCode CR208_Nature Of Condition Code PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR211_Description CR211_Description PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR204_SubluxationLevelCode CR204_Subluxation Level Code PegaX125010

PegaX12-Data-CR2_ChiropracticCertification CR205_UnitOrBasisForMeasurementCode


Code PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR201_Count CR201_Count PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR206_Quantity CR206_Quantity PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR207_Quantity CR207_Quantity PegaX125010PegaX12-Data-CR2_ChiropracticCertification CR202_Quantity CR202_Quantity PegaX125010




CR3_DurableMedicalEquipmentCertification CR303_Quantity CR303_Quantity PegaX125010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR302_UnitOrBasisForMeasurementCode



CR3_DurableMedicalEquipmentCertification CR301_CertificationTypeCode CR301_Certification Type Code PegaX125010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR305_Description CR305_Description PegaX125010PegaX12-Data-

CR3_DurableMedicalEquipmentCertification CR304_InsulinDependentCode CR304_Insulin Dependent Code PegaX125010








PegaX12-Data-CR5_OxygenTherapyCertification CR501_CertificationTypeCode CR501_Certification Type Code PegaX125010






PegaX12-Data-CR5_OxygenTherapyCertification CR517_OxygenDeliverySystemCode CR517_Oxygen Delivery System Code PegaX125010


PegaX12-Data-CR5_OxygenTherapyCertification CR512_OxygenTestConditionCode CR512_Oxygen Test Condition Code PegaX125010






PegaX12-Data-CR6_HomeHealthCareCertification CR601_PrognosisCode CR601_PrognosisCode PegaX125010


PegaX12-Data-CR6_HomeHealthCareCertification CR608_CertificationTypeCode CR608_CertificationTypeCode PegaX125010


PegaX12-Data-CR6_HomeHealthCareCertification CR617_PatientLocationCode CR617_PatientLocationCode PegaX125010










PegaX12-Data-CR6_HomeHealthCareCertification CR610_ProductServiceIDQualifier CR610_ProductServiceIDQualifier PegaX125010



PegaX12-Data-CR6_HomeHealthCareCertification CR611_MedicalCodeValue CR611_MedicalCodeValue PegaX125010PegaX12-Data-

CR7_HomeHealthTreatmentPlanCertification CR703_Number CR703_Number PegaX125010

PegaX12-Data-


CR7_HomeHealthTreatmentPlanCertification CR701_DisciplineTypeCode CR701_DisciplineTypeCode PegaX125010PegaX12-Data-CRC_ConditionsIndicator CRC01_CodeCategory CRC01_Code Category PegaX125010PegaX12-Data-CRC_ConditionsIndicator CRC07_ConditionIndicator CRC07_Condition Indicator PegaX125010PegaX12-Data-CRC_ConditionsIndicator CRC03_ConditionIndicator CRC03_Condition Indicator PegaX125010

PegaX12-Data-CRC_ConditionsIndicator CRC02_YesNoConditionOrResponseCode

CRC02_Yes/No Condition Or Response

Code PegaX125010PegaX12-Data-CRC_ConditionsIndicator CRC04_ConditionIndicator CRC04_Condition Indicator PegaX125010PegaX12-Data-CRC_ConditionsIndicator CRC05_ConditionIndicator CRC05_Condition Indicator PegaX125010PegaX12-Data-CRC_ConditionsIndicator CRC06_ConditionIndicator CRC06_Condition Indicator PegaX125010PegaX12-Data-CTP_PricingInformation CTP10_ConditionValue CTP10_ConditionValue PegaX125010PegaX12-Data-CTP_PricingInformation CTP02_PriceIdentifierCode CTP02_Price Identifier Code PegaX125010PegaX12-Data-CTP_PricingInformation CTP05_CompositeUnitOfMeasure CTP05_CompositeUnitOfMeasure PegaX125010PegaX12-Data-CTP_PricingInformation CTP01_ClassOfTradeCode CTP01_Class Of Trade Code PegaX125010PegaX12-Data-CTP_PricingInformation CTP07_Multiplier CTP07_Multiplier PegaX125010PegaX12-Data-CTP_PricingInformation CTP04_Quantity CTP04_Quantity PegaX125010PegaX12-Data-CTP_PricingInformation CTP09_BasisOfUnitPriceCode CTP09_BasisOfUnitPriceCode PegaX125010PegaX12-Data-CTP_PricingInformation CTP06_PriceMultiplierQualifier CTP06_PriceMultiplierQualifier PegaX125010PegaX12-Data-CTP_PricingInformation CTP03_UnitPrice CTP03_UnitPrice PegaX125010PegaX12-Data-CTP_PricingInformation CTP08_MonetaryAmount CTP08_MonetaryAmount PegaX125010PegaX12-Data-CTP_PricingInformation CTP11_MultiplePriceQuantity CTP11_MultiplePriceQuantity PegaX125010

















de


de PegaX125010








PegaX12-Data-CTP05_CompositeUnitOfMeasure CTP05_12_Multiplier Multiplier PegaX125010PegaX12-Data-CUR_Currency CUR10_DateTimeQualifier CUR10_DateTimeQualifier PegaX125010PegaX12-Data-CUR_Currency CUR17_Date CUR17_Date PegaX125010PegaX12-Data-CUR_Currency CUR18_Time CUR18_Time PegaX125010PegaX12-Data-CUR_Currency CUR19_DateTimeQualifier CUR19_DateTimeQualifier PegaX125010PegaX12-Data-CUR_Currency CUR21_Time CUR21_Time PegaX125010PegaX12-Data-CUR_Currency CUR02_CurrencyCode CUR02_Currency Code PegaX125010PegaX12-Data-CUR_Currency CUR12_Time CUR12_Time PegaX125010PegaX12-Data-CUR_Currency CUR20_Date CUR20_Date PegaX125010PegaX12-Data-CUR_Currency CUR07_DateTimeQualifier CUR07_Date Time Qualifier PegaX125010PegaX12-Data-CUR_Currency CUR13_DateTimeQualifier CUR13_DateTimeQualifier PegaX125010PegaX12-Data-CUR_Currency CUR15_Time CUR15_Time PegaX125010PegaX12-Data-CUR_Currency CUR09_Time CUR09_Time PegaX125010PegaX12-Data-CUR_Currency CUR05_CurrencyCode CUR05_Currency Code PegaX125010PegaX12-Data-CUR_Currency CUR11_Date CUR11_Date PegaX125010PegaX12-Data-CUR_Currency CUR14_Date CUR14_Date PegaX125010PegaX12-Data-CUR_Currency CUR16_DateTimeQualifier CUR16_DateTimeQualifier PegaX125010PegaX12-Data-CUR_Currency CUR01_EntityIdentifierCode CUR01_Entity Identifier Code PegaX125010PegaX12-Data-CUR_Currency CUR03_ExchangeRate CUR03_Exchange Rate PegaX125010PegaX12-Data-CUR_Currency CUR04_EntityIdentifierCode CUR04_Entity Identifier Code PegaX125010

PegaX12-Data-CUR_Currency CUR06_CurrencyMarketExchangeCode CUR06_Currency Market Exchange Code PegaX125010PegaX12-Data-CUR_Currency CUR08_Date CUR08_Date PegaX125010PegaX12-Data-DMG_DemographicInformation DMG04_MaritalStatusCode Code indicating marital status PegaX125010PegaX12-Data-DMG_DemographicInformation DMG09_Quantity Quantity PegaX125010

PegaX12-Data-DMG_DemographicInformation DMG05_CompositeRaceOrEthnicityCode DMG05_CompositeRaceOrEthnicityCode PegaX125010

PegaX12-Data-DMG_DemographicInformation DMG08_BasisOfVerificationCode Code indicating basis of verification PegaX125010PegaX12-Data-DMG_DemographicInformation CompositeRaceOrEthnicityCode CompositeRaceOrEthnicityCode PegaX125010PegaX12-Data-DMG_DemographicInformation DMG10_CodeListQualifierCode DMG10_CodeListQualifierCode PegaX125010

PegaX12-Data-DMG_DemographicInformation DMG03_GenderCode Code indicating the sex of the individual PegaX125010PegaX12-Data-DMG_DemographicInformation DMG07_CountryCode Code indicating country PegaX125010

PegaX12-Data-DMG_DemographicInformation DMG02_DateTimePeriod

Date and/or time or range of dates

and/or times PegaX125010

PegaX12-Data-DMG_DemographicInformation DMG01_DateTimePeriodFormatQualifier Code indicating date and/or time format PegaX125010PegaX12-Data-DMG_DemographicInformation DMG11_IndustryCode DMG11_IndustryCode PegaX125010PegaX12-Data-DMG_DemographicInformation DMG06_CitizenshipStatusCode Code indicating citizenship status PegaX125010PegaX12-Data-DMG05_RaceOrEthnicityCode DMG05_3_IndustryCode DMG05_3_IndustryCode PegaX125010PegaX12-Data-DMG05_RaceOrEthnicityCode DMG05_1_RaceOrEthnicityCode DMG05_1_RaceOrEthnicityCode PegaX125010PegaX12-Data-DMG05_RaceOrEthnicityCode DMG05_2_CodeListQualifierCode DMG05_2_CodeListQualifierCode PegaX125010PegaX12-Data-

DN1_OrthodonticTotalMonthsOfTreatment DN102_Quantity DN102_Quantity PegaX125010PegaX12-Data-

DN1_OrthodonticTotalMonthsOfTreatment DN104_Description DN104_Description PegaX125010PegaX12-Data-

DN1_OrthodonticTotalMonthsOfTreatment DN101_Quantity DN101_Quantity PegaX125010PegaX12-Data-

DN1_OrthodonticTotalMonthsOfTreatment DN103_YesNoConditionOrResponseCode DN103_YesNoConditionOrResponseCode PegaX125010PegaX12-Data-DN2_ToothStatus DN203_Quantity DN203_Quantity PegaX125010PegaX12-Data-DN2_ToothStatus DN206_CodeListQualifierCode DN206_CodeListQualifierCode PegaX125010

PegaX12-Data-DN2_ToothStatus DN204_DateTimePeriodFormatQualifier DN204_DateTimePeriodFormatQualifier PegaX125010PegaX12-Data-DN2_ToothStatus DN202_ToothStatusCode DN202_ToothStatusCode PegaX125010PegaX12-Data-DN2_ToothStatus DN201_ReferenceIdentification DN201_ReferenceIdentification PegaX125010PegaX12-Data-DN2_ToothStatus DN205_DateTimePeriod DN205_DateTimePeriod PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB03_OccupationCode Occupation Code PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB04_WorkIntensityCode Work Intensity Code PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB05_ProductOptionCode Product Option Code PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB07_ProductServiceIDQualifier Product/Service ID Qualifier PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB06_MonetaryAmount Monetary Amount PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB02_Quantity Quantity PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB01_DisabilityTypeCode Disability Type Code PegaX125010PegaX12-Data-DSB_DisabilityInformation DSB08_MedicalCodeValue Medical Code Value PegaX125010PegaX12-Data-DTP_DateOrTimeOrPeriod DTP03_DateTimePeriod DTP03_Date Time Period PegaX125010PegaX12-Data-DTP_DateOrTimeOrPeriod DTP01_DateTimeQualifier DTP01_Date/Time Qualifier PegaX125010

PegaX12-Data-DTP_DateOrTimeOrPeriod DTP02_DateTimePeriodFormatQualifier DTP02_Date Time Period Format Qualifier PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB13_CompositeMedicalProcedure Composite Medical Procedure PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB01_EligibilityorBenefitInformation Eligibility or Benefit Information PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB02_CoverageLevelCode Coverage Level Code PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB05_PlanCoverageDescription Plan Coverage Description PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB07_MonetaryAmount Monetary Amount PegaX125010


PegaX12-Data-EB_EligibilityorBenefitInformation EB09_QuantityQualifier Quantity Qualifier PegaX125010


PegaX12-Data-EB_EligibilityorBenefitInformation EB04_InsuranceTypeCode Insurance Type Code PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB06_TimePeriodQualifier Time Period Qualifier PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB03_ServiceTypeCode Service Type Code PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB14_CompositeDiagnosisCodePointer EB14_CompositeDiagnosisCodePointer PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB10_Quantity Quantity PegaX125010

PegaX12-Data-EB_EligibilityorBenefitInformation EB08_Percent Percent PegaX125010

PegaX12-Data-EB13_CompositeMedicalProcedure EB13_8_ProductORServiceID ProductORServiceID PegaX125010

PegaX12-Data-EB13_CompositeMedicalProcedure EB13_2_ProductServiceID Product/Service ID PegaX125010

PegaX12-Data-EB13_CompositeMedicalProcedure EB13_7_Description Description PegaX125010





PegaX12-Data-EB13_CompositeMedicalProcedure EB13_1_ProductServiceIDQualifier Product/Service ID Qualifier PegaX125010PegaX12-Data-

EB14_CompositeDiagnosisCodePointer EB14_1_DiagnosisCodePointer EB14_1_DiagnosisCodePointer PegaX125010PegaX12-Data-



EB14_CompositeDiagnosisCodePointer EB14_4_DiagnosisCodePointer EB14_4_DiagnosisCodePointer PegaX125010PegaX12-Data-EC_EmploymentClass EC03_EmploymentClassCode EC03_EmploymentClassCode PegaX125010PegaX12-Data-EC_EmploymentClass EC02_EmploymentClassCode EC02_EmploymentClassCode PegaX125010PegaX12-Data-EC_EmploymentClass EC01_EmploymentClassCode EC01_EmploymentClassCode PegaX125010

PegaX12-Data-EQ_EligibilityorBenefitInquiry EQ05_CompositeDiagnosisCodePointer EQ05_CompositeDiagnosisCodePointer PegaX125010PegaX12-Data-EQ_EligibilityorBenefitInquiry EQ04_InsuranceTypeCode Insurance Type Code PegaX125010

PegaX12-Data-EQ_EligibilityorBenefitInquiry

EQ02_CompositeMedicalProcedureIdentifi

er Composite Medical Procedure Identifier PegaX125010PegaX12-Data-EQ_EligibilityorBenefitInquiry EQ01_ServiceTypeCode Service Type Code PegaX125010PegaX12-Data-EQ_EligibilityorBenefitInquiry EQ03_CoverageLevelCode Coverage Level Code PegaX125010PegaX12-Data-


EQ02_CompositeMedicalProcedureIdentifier EQ02_1_ProductServiceIDQualifier Product/Service ID Qualifier PegaX125010PegaX12-Data-


EQ02_CompositeMedicalProcedureIdentifier EQ02_7_Description Description PegaX125010PegaX12-Data-


EQ02_CompositeMedicalProcedureIdentifier EQ02_2_ProductServiceID Product/Service ID PegaX125010PegaX12-Data-


EQ05_CompositeDiagnosisCodePointer EQ05_2_DiagnosisCodePointer EQ05_2_DiagnosisCodePointer PegaX125010

PegaX12-Data-

EQ05_CompositeDiagnosisCodePointer EQ05_3_DiagnosisCodePointer EQ05_3_DiagnosisCodePointer PegaX125010PegaX12-Data-

EQ05_CompositeDiagnosisCodePointer EQ05_4_DiagnosisCodePointer EQ05_4_DiagnosisCodePointer PegaX125010PegaX12-Data-

EQ05_CompositeDiagnosisCodePointer EQ05_1_DiagnosisCodePointer EQ05_1_DiagnosisCodePointer PegaX125010PegaX12-Data-FRM_SupportingDocumentation FRM01_AssignedIdentification FRM01_Assigned Identification PegaX125010PegaX12-Data-FRM_SupportingDocumentation FRM05_Percent FRM05_Percent PegaX125010

PegaX12-Data-FRM_SupportingDocumentation FRM02_YesNoConditionOrResponseCode

FRM02_Yes/No Condition Or Response

Code PegaX125010PegaX12-Data-FRM_SupportingDocumentation FRM03_ReferenceIdentification FRM03_Reference Identification PegaX125010PegaX12-Data-FRM_SupportingDocumentation FRM04_Date FRM04_Date PegaX125010

PegaX12-Data-GE_FunctionalGroupTrailer GE01_NumberofTransactionSetsIncluded Number of Transaction Sets Included PegaX125010PegaX12-Data-GE_FunctionalGroupTrailer GE02_GroupControlNumber Group Control Number PegaX125010PegaX12-Data-GS_FunctionalGroupHeader GS05_Time Time PegaX125010PegaX12-Data-GS_FunctionalGroupHeader GS06_GroupControlNumber Group Control Number PegaX125010PegaX12-Data-GS_FunctionalGroupHeader GS02_ApplicationSendersCode Application Senders Code PegaX125010PegaX12-Data-GS_FunctionalGroupHeader GS07_ResponsibleAgencyCode Responsible Agency Code PegaX125010



de Version Release Industry Identifier Code PegaX125010PegaX12-Data-GS_FunctionalGroupHeader GS04_Date Date PegaX125010PegaX12-Data-GS_FunctionalGroupHeader GS03_ApplicationReceiversCode Application Receivers Code PegaX125010PegaX12-Data-GS_FunctionalGroupHeader GS01_FunctionalIdentifierCode Functional Identifier Code PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP02_MonetaryAmount HCP02_Monetary Amount PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP07_MonetaryAmount HCP07_Monetary Amount PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP04_ReferenceIdentification HCP04_Reference Identification PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP01_PricingMethodology HCP01_Pricing Methodology PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP15_ExceptionCode HCP15_Exception Code PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP14_PolicyComplianceCode HCP14_Policy Compliance Code PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP13_RejectReasonCode HCP13_Reject Reason Code PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP08_ProductServiceId HCP08_Product/Service Id PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP03_MonetaryAmount HCP03_Monetary Amount PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP05_Rate HCP05_Rate PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP06_ReferenceIdentification HCP06_Reference Identification PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP09_ProductServiceIdQualifier HCP09_Product/Service Id Qualifier PegaX125010

PegaX12-Data-HCP_HealthCarePricing HCP11_UnitOrBasisForMeasurementCode

HCP11_Unit Or Basis For Measurement

Code PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP10_ProductServiceId HCP10_Product/Service Id PegaX125010PegaX12-Data-HCP_HealthCarePricing HCP12_Quantity HCP12_Quantity PegaX125010

PegaX12-Data-HCR_HealthCareServicesReview HCR02_ReferenceIdentification HCR02_ReferenceIdentification PegaX125010PegaX12-Data-HCR_HealthCareServicesReview HCR01_ActionCode HCR01_ActionCode PegaX125010PegaX12-Data-HCR_HealthCareServicesReview HCR03_RejectReasonCode Reject Reason Code PegaX125010

PegaX12-Data-HCR_HealthCareServicesReview HCR04_YesNoConditionorResponseCode HCR04_YesNoConditionorResponseCode PegaX125010PegaX12-Data-HD_HealthCoverage HD07_Count Count PegaX125010PegaX12-Data-HD_HealthCoverage HD01_MaintenanceTypeCode Maintenance Type Code PegaX125010PegaX12-Data-HD_HealthCoverage HD03_InsuranceLineCode Insurance Line Code PegaX125010PegaX12-Data-HD_HealthCoverage HD05_CoverageLevelCode Coverage Level Code PegaX125010

PegaX12-Data-HD_HealthCoverage HD09_YesNoConditionOrResponseCode Yes/No Condition Or Response Code PegaX125010

PegaX12-Data-HD_HealthCoverage HD11_YesNoConditionOrResponseCode Yes/No Condition Or Response Code PegaX125010PegaX12-Data-HD_HealthCoverage HD02_MaintenanceReasonCode Maintenance Reason Code PegaX125010PegaX12-Data-HD_HealthCoverage HD08_UnderwritingDecisionCode Underwriting Decision Code PegaX125010PegaX12-Data-HD_HealthCoverage HD10_DrugHouseCode Drug House Code PegaX125010PegaX12-Data-HD_HealthCoverage HD04_PlanCoverageDescription Plan Coverage Description PegaX125010PegaX12-Data-HD_HealthCoverage HD06_Count Count PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI08_HealthCareCodeInformation HI08_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI07_HealthCareCodeInformation HI07_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI11_HealthCareCodeInformation HI11_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI03_HealthCareCodeInformation HI03_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI09_HealthCareCodeInformation HI09_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI10_HealthCareCodeInformation HI10_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI02_HealthCareCodeInformation HI02_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI04_HealthCareCodeInformation HI04_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI12_HealthCareCodeInformation HI12_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI01_HealthCareCodeInformation HI01_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI05_HealthCareCodeInformation HI05_Health Care Code Information PegaX125010PegaX12-Data-HI_HealthCareInfoCodes HI06_HealthCareCodeInformation HI06_Health Care Code Information PegaX125010

PegaX12-Data-HI_HealthCareInformationCodes HI01_HealthCareCodeInformation HI01_Health Care Code Information PegaX125010







PegaX12-Data-HI01_HealthCareCodeInformation HI01_8_IndustryCode HI01_8_IndustryCode PegaX125010




PegaX12-Data-HI01_HealthCareCodeInformation HI01_9_YesNoConditionOrResponseCode HI01_9_YesNoConditionOrResponseCode PegaX125010






























PegaX12-Data-HI04_HealthCareCodeInformation HI04_9_PresentOnAdmissionIndicator HI04_9_PresentOnAdmissionIndicator PegaX125010

















PegaX12-Data-HI12_HealthCareCodeInformation HI12_6_Quantity HI12_6_Quantity PegaX125010PegaX12-Data-HL_HierarchicalLevel HL04_HierarchicalChildCode HL04_Hierarchical Child Code PegaX125010PegaX12-Data-HL_HierarchicalLevel HL01_HierarchicalIDNumber HL01_Hierarchical ID Number PegaX125010PegaX12-Data-HL_HierarchicalLevel HL03_HierarchicalLevelCode HL03_Hierarchical Level Code PegaX125010PegaX12-Data-HL_HierarchicalLevel HL02_HierarchicalParentIDNumber HL02_Hierarchical Parent ID Number PegaX125010PegaX12-Data-HLH_HealthInformation HLH07_Description Description PegaX125010PegaX12-Data-HLH_HealthInformation HLH04_Weight Weight PegaX125010PegaX12-Data-HLH_HealthInformation HLH02_Height Height PegaX125010PegaX12-Data-HLH_HealthInformation HLH03_Weight Weight PegaX125010PegaX12-Data-HLH_HealthInformation HLH01_HealthRelatedCode Health-Related Code PegaX125010PegaX12-Data-HLH_HealthInformation HLH05_Description Description PegaX125010PegaX12-Data-HLH_HealthInformation HLH06_CurrentHealthConditionCode Current Health Condition Code PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD02_Quantity HSD02_Quantity PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD08_ShipDeliveryPatternTimeCode HSD08_Ship/Delivery Pattern Time Code PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD04_SampleSelectionModulus HSD04_Sample Selection Modulus PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery

HSD07_ShipDeliveryOrCalendarPatternCo

de

HSD07_Ship/Delivery Or Calendar Pattern

Code PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD05_TimePeriodQualifier HSD05_Time Period Qualifier PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD03_UnitForBasisOrMeasurementCode

HSD03_Unit For Basis Or Measurement

Code PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD01_QuantityQualifier HSD01_QuantityQualifier PegaX125010

PegaX12-Data-HSD_HealthCareServicesDelivery HSD06_NumberOfPeriods HSD06_Number Of Periods PegaX125010PegaX12-Data-ICM_IndividualIncome ICM06_CurrencyCode Currency Code PegaX125010PegaX12-Data-ICM_IndividualIncome ICM01_FrequencyCode Frequency Code PegaX125010PegaX12-Data-ICM_IndividualIncome ICM03_Quantity ICM03_Quantity PegaX125010PegaX12-Data-ICM_IndividualIncome ICM05_SalaryGrade Salary Grade PegaX125010PegaX12-Data-ICM_IndividualIncome ICM02_MonetaryAmount Monetary Amount PegaX125010

PegaX12-Data-ICM_IndividualIncome ICM04_LocationIdentifier Location Identifier PegaX125010PegaX12-Data-IDC_IdentificationCard IDC04_ActionCode Action Code PegaX125010PegaX12-Data-IDC_IdentificationCard IDC03_Quantity Quantity PegaX125010PegaX12-Data-IDC_IdentificationCard IDC01_PlanCoverageDescription Plan Coverage Description PegaX125010PegaX12-Data-IDC_IdentificationCard IDC02_IdentificationCardTypeCode Identification Card Type Code PegaX125010

PegaX12-Data-IEA_InterchangeControlTrailer

IEA01_NumberofIncludedFunctionalGroup

s Number of Included Functional Groups PegaX125010PegaX12-Data-IEA_InterchangeControlTrailer IEA02_InterchangeControlNumber Interchange Control Number PegaX125010PegaX12-Data-III_Information III07_SurfaceLayerPositionCode Surface/Layer/Position Code PegaX125010PegaX12-Data-III_Information III08_SurfaceLayerPositionCode Surface/Layer/Position Code PegaX125010PegaX12-Data-III_Information III06_CompositeUnitOfMeasure Composite Unit Of Measure PegaX125010PegaX12-Data-III_Information III01_CodeListQualifierCode Code List Qualifier Code PegaX125010PegaX12-Data-III_Information III05_Quantity Quantity PegaX125010PegaX12-Data-III_Information III03_CodeCategory Code Category PegaX125010PegaX12-Data-III_Information III04_FreeFormMessageText Free-Form Message Text PegaX125010PegaX12-Data-III_Information III02_IndustryCode Industry Code PegaX125010PegaX12-Data-III_Information III09_SurfaceLayerPositionCode Surface/Layer/Position Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS10_YesNoConditionOrReponseCode Yes/No Condition or Reponse Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS13_ConfidentialityCode Confidentiality Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS16_CountryCode Country Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS06_MedicareStatusCode INS06_MedicareStatusCode PegaX125010PegaX12-Data-INS_InsuredBenefit INS09_StudentStatusCode Student Status Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS15_StateOrProvinceCode State or Province Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS08_EmploymentStatusCode Employment Status Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS02_IndividualRelationshipCode Individual Relationship Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS05_BenefitStatusCode Benefit Status Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS01_YesNoConditionOrReponseCode Yes/No Condition or Reponse Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS12_DateTimePeriod Date Time Period PegaX125010PegaX12-Data-INS_InsuredBenefit INS04_MaintenanceReasonCode Maintenance Reason Code PegaX125010PegaX12-Data-INS_InsuredBenefit INS17_Number Number PegaX125010

PegaX12-Data-INS_InsuredBenefit INS11_DateTimePeriodFormatQualifier Date Time Period Format Qualifier PegaX125010PegaX12-Data-INS_InsuredBenefit INS14_CityName City Name PegaX125010

PegaX12-Data-INS_InsuredBenefit INS07_COBRAQualifying

Consolidation Omnibus Budget Recon.

Act (COBRA) Qualifying PegaX125010PegaX12-Data-INS_InsuredBenefit INS03_MaintenanceTypeCode Maintenance Type Code PegaX125010PegaX12-Data-INS06_MedicareStatusCode INS06_2_EligibilityReasonCode INS06_2_EligibilityReasonCode PegaX125010PegaX12-Data-INS06_MedicareStatusCode INS06_1_MedicarePlanCode INS06_1_MedicarePlanCode PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA15_UsageIndicator UsageIndicator PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA08_InterchangeReceiverID InterchangeReceiverID PegaX125010

PegaX12-Data-ISA_InterchangeControlHeader ISA02_AuthorizationInformation AuthorizationInformation PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA09_InterchangeDate InterchangeDate PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA16_ComponentElementSeparator ComponentElementSeparator PegaX125010

PegaX12-Data-ISA_InterchangeControlHeader

ISA11_InterchangeControlStandardsIdenti

fier InterchangeControlStandardsIdentifier PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA04_SecurityInformation SecurityInformation PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA05_InterchangeSenderIDQualifier InterchangeSenderIDQualifier PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA07_InterchangeReceiverIDQualifier InterchangeReceiverIDQualifier PegaX125010

PegaX12-Data-ISA_InterchangeControlHeader ISA12_InterchangeControlVersionNumber InterchangeControlVersionNumber PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA03_SecurityInformationQualifier SecurityInformationQualifier PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA10_InterchangeTime InterchangeTime PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA06_InterchangeSenderID InterchangeSenderID PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA13_InterchangeControlNumber InterchangeControlNumber PegaX125010PegaX12-Data-ISA_InterchangeControlHeader ISA14_AcknowledgmentRequested AcknowledgmentRequested PegaX125010

PegaX12-Data-ISA_InterchangeControlHeader ISA01_AuthorizationInformationQualifier AuthorizationInformationQualifier PegaX125010PegaX12-Data-K3_FileInformation K301_FixedFormatInformation K301_Fixed Format Information PegaX125010PegaX12-Data-K3_FileInformation K303_CompositeUnitOfMeasure K303_Composite Unit Of Measure PegaX125010PegaX12-Data-K3_FileInformation K302_RecordFormatCode K302_Record Format Code PegaX125010PegaX12-Data-LE_LoopTrailer LE01_LoopIdentifierCode Loop Identifier Code PegaX125010PegaX12-Data-LIN_ItemIdentification LIN15_ProductServiceID LIN15_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN22_ProductServiceIDQualifier LIN22_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN25_ProductServiceID LIN25_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN20_ProductServiceIDQualifier LIN20_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN23_ProductServiceID LIN23_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN24_ProductServiceIDQualifier LIN24_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN14_ProductServiceIDQualifier LIN14_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN16_ProductServiceIDQualifier LIN16_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN19_ProductServiceID LIN19_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN04_ProductServiceIDQualifier LIN04_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN06_ProductServiceIDQualifier LIN06_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN08_ProductServiceIDQualifier LIN08_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN05_ProductServiceID LIN05_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN18_ProductServiceIDQualifier LIN18_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN29_ProductServiceID LIN29_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN30_ProductServiceIDQualifier LIN30_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN09_ProductServiceID LIN09_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN13_ProductServiceID LIN13_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN28_ProductServiceIDQualifier LIN28_ProductServiceIDQualifier PegaX125010

PegaX12-Data-LIN_ItemIdentification LIN27_ProductServiceID LIN27_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN31_ProductServiceID LIN31_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN02_ProductServiceIDQualifier LIN02_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN07_ProductServiceID LIN07_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN10_ProductServiceIDQualifier LIN10_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN11_ProductServiceID LIN11_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN12_ProductServiceIDQualifier LIN12_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN17_ProductServiceID LIN17_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN26_ProductServiceIDQualifier LIN26_ProductServiceIDQualifier PegaX125010PegaX12-Data-LIN_ItemIdentification LIN21_ProductServiceID LIN21_ProductServiceID PegaX125010PegaX12-Data-LIN_ItemIdentification LIN01_AssignedIdentification LIN01_AssignedIdentification PegaX125010PegaX12-Data-LIN_ItemIdentification LIN03_ProductServiceID LIN03_ProductServiceID PegaX125010PegaX12-Data-LQ_IndustryCode LQ01_CodeListQualifierCode LQ01_Code List Qualifier Code PegaX125010PegaX12-Data-LQ_IndustryCode LQ02_IndustryCode LQ02_Industry Code PegaX125010PegaX12-Data-LS_LoopHeader LS01_LoopIdentifierCode Loop Identifier Code PegaX125010PegaX12-Data-LUI_LanguageUse LUI05_LanguageProficiencyIndicator Language Proficiency Indicator PegaX125010PegaX12-Data-LUI_LanguageUse LUI03_Description Description PegaX125010PegaX12-Data-LUI_LanguageUse LUI04_UseofLanguageIndicator Use of Language Indicator PegaX125010PegaX12-Data-LUI_LanguageUse LUI02_IdentificationCode Identification Code PegaX125010PegaX12-Data-LUI_LanguageUse LUI01_IdentificationCodeQualifier Identification Code Qualifier PegaX125010PegaX12-Data-LX_AssignedNumber LX01_AssignedNumber LX01 Assigned Number PegaX125010PegaX12-Data-MEA_Measurements MEA12_Industry_Code MEA12_Industry_Code PegaX125010PegaX12-Data-MEA_Measurements MEA11_CodeListQualifierCode MEA11_CodeListQualifierCode PegaX125010

PegaX12-Data-MEA_Measurements MEA07_MeasurementSignificanceCode MEA07_Measurement Significance Code PegaX125010PegaX12-Data-MEA_Measurements MEA08_MeasurementAttributeCode MEA08_Measurement Attribute Code PegaX125010

PegaX12-Data-MEA_Measurements MEA01_MeasurementReferenceIDCode MEA01_MeasurementReferenceIDCode PegaX125010PegaX12-Data-MEA_Measurements MEA09_SurfaceLayerPositionCode MEA09_Surface/Layer/Position Code PegaX125010PegaX12-Data-MEA_Measurements MEA04_CompositeUnitOfMeasure MEA04_Composite Unit Of Measure PegaX125010PegaX12-Data-MEA_Measurements MEA05_RangeMinimum MEA05_Range Minimum PegaX125010

PegaX12-Data-MEA_Measurements MEA10_MeasurementMethodOrDevice MEA10_Measurement Method Or Device PegaX125010PegaX12-Data-MEA_Measurements MEA02_MeasurementQualifier MEA02_Measurement Qualifier PegaX125010PegaX12-Data-MEA_Measurements MEA06_RangeMaximum MEA06_Range Maximum PegaX125010PegaX12-Data-MEA_Measurements MEA03_MeasurementValue MEA03_Measurement Value PegaX125010




















PegaX12-Data-MIA_MedicareInpatientAdjudication MIA05_ReferenceIdentification MIA05_ReferenceIdentification PegaX125010




PegaX12-Data-MIA_MedicareInpatientAdjudication MIA23_ReferenceIdentification MIA23_Reference Identification PegaX125010PegaX12-Data-








MOA_MedicareOutpatientAdjudication MOA01_Percent MOA01_Percent PegaX125010PegaX12-Data-

MOA_MedicareOutpatientAdjudication MOA08_MonetaryAmount MOA08_Monetary Amount PegaX125010

PegaX12-Data-MPI_MilitaryPersonnelInformation MPI05_MilitaryServiceRankCode MPI04_Description PegaX125010

PegaX12-Data-MPI_MilitaryPersonnelInformation MPI07_DateTimePeriod MPI07_DateTimePeriod PegaX125010

PegaX12-Data-MPI_MilitaryPersonnelInformation MPI01_InformationStatusCode MPI01_InformationStatusCode PegaX125010

PegaX12-Data-MPI_MilitaryPersonnelInformation MPI04_Description MPI04_Description PegaX125010

PegaX12-Data-MPI_MilitaryPersonnelInformation MPI06_DateTimePeriodFormatQualifier MPI06_DateTimePeriodFormatQualifier PegaX125010

PegaX12-Data-MPI_MilitaryPersonnelInformation MPI03_GovernmentServiceAffiliationCode

MPI03_GovernmentServiceAffiliationCod

e PegaX125010

PegaX12-Data-MPI_MilitaryPersonnelInformation MPI02_EmploymentStatusCode MPI02_EmploymentStatusCode PegaX125010PegaX12-Data-MSG_MessageText MSG03_Number MSG03_Number PegaX125010PegaX12-Data-MSG_MessageText MSG01_FreeFormMessageText MSG01_FreeFormMessageText PegaX125010PegaX12-Data-MSG_MessageText MSG02_PrinterCarriageControlCode MSG02_PrintercarriageControlCode PegaX125010PegaX12-Data-N1_Name N103_IdentificationQualifierCode Identification Qualifier Code PegaX125010

PegaX12-Data-N1_Name N106_EntityIdentifierCode Entity Identifier Code PegaX125010PegaX12-Data-N1_Name N105_EntityRelationshipCode Entity Relationship Code PegaX125010PegaX12-Data-N1_Name N101_EntityIdentifierCode Entity Identifier Code PegaX125010PegaX12-Data-N1_Name N104_IdentificationCode Identification Code PegaX125010PegaX12-Data-N1_Name N102_Name Name PegaX125010

PegaX12-Data-N2_AdditionalNameInformation N202_Name Name PegaX125010

PegaX12-Data-N2_AdditionalNameInformation N201_Name Name PegaX125010PegaX12-Data-N270 EligibilityCoverageOrBenefitInquiry Eligibility, Coverage or Benefit Inquiry PegaX125010PegaX12-Data-N270 MaximumEQLimit MaximumEQLimit PegaX125010PegaX12-Data-N270-Dependent Loop2000DDependantLevel LOOP ID - 2000D DEPENDENT LEVEL PegaX125010PegaX12-Data-N270-

EligibilityCoverageOrBenefitInquiry FunctionalGroupTrailer Functional Group Trailer PegaX125010PegaX12-Data-N270-

EligibilityCoverageOrBenefitInquiry FunctionalGroupHeader Functional Group Header PegaX125010PegaX12-Data-N270-

EligibilityCoverageOrBenefitInquiry Transaction Transaction PegaX125010PegaX12-Data-N270-Header BeginningOfHierarchicalTransaction Beginning of Hierarchical Transaction PegaX125010PegaX12-Data-N270-Header TransactionSetHeader Transaction Set Header PegaX125010










Loop2000BInformationReceiverLevel Subscriber Subscriber PegaX125010PegaX12-Data-N270-

Loop2000BInformationReceiverLevel Loop2100BInformationReceverName


NAME PegaX125010


PegaX12-Data-N270-Loop2000CSubscriberLevel Dependent Dependent PegaX125010



PegaX12-Data-N270-Loop2000DDependantLevel Loop2100DDependantName LOOP ID - 2100D DEPENDENT NAME PegaX125010

PegaX12-Data-N270-Loop2000DDependantLevel DependentLevel Dependent Level PegaX125010

PegaX12-Data-N270-Loop2000DDependantLevel DependentTraceNumber Dependent Trace Number PegaX125010PegaX12-Data-N270-


Loop2100BInformationReceiverName InformationReceiverAddress Information Receiver Address PegaX125010PegaX12-Data-N270-

Loop2100BInformationReceiverName InformationReceiverName Information Receiver Name PegaX125010PegaX12-Data-N270-

Loop2100BInformationReceiverName InformationReceiverProviderInformation

Information Receiver Provider




n



Loop2100BInformationReceiverName InformationReceiverCityStateZIPCode Information Receiver City/State/ZIP Code PegaX125010


PegaX12-Data-N270-Loop2100CSubscriberName ProviderInformation Provider Information PegaX125010

PegaX12-Data-N270-Loop2100CSubscriberName Loop2110CSubscriberOrBIInfo


OR BENEFIT INQUIRY INFORM PegaX125010



PegaX12-Data-N270-Loop2100CSubscriberName SubscriberHealthCareDiagnosisCode SubscriberHealthCareDiagnosisCode PegaX125010





PegaX12-Data-N270-Loop2100DDependantName Loop2110DDependentEOrBIInfo


OR BENEFIT INQUIRY INFORMA PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentAdditionalIdentification Dependent Additional Identification PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentDate Dependent Date PegaX125010

PegaX12-Data-N270-Loop2100DDependantName ProviderInformation Provider Information PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentHealthCareDiagnosisCode DependentHealthCareDiagnosisCode PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentRelationship Dependent Relationship PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentDemographicInformation Dependent Demographic Information PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentCityStateZIPCode Dependent City/State/ZIP Code PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentAddress Dependent Address PegaX125010

PegaX12-Data-N270-Loop2100DDependantName DependentName Dependent Name PegaX125010PegaX12-Data-N270-

Loop2110CSubscriberEOrBIInfo SubscriberEligibilityOrBenefitDate Subscriber Eligibility/Benefit Date PegaX125010PegaX12-Data-N270-

Loop2110CSubscriberEOrBIInfo SubscriberSpendDownAmount Subscriber Spend Down Amount PegaX125010PegaX12-Data-N270-


SubscriberEligibilityOrBenefitInquiryInfor

mation

Subscriber Eligibility or Benefit Inquiry



SubscriberEligibilityOrBenefitAdditionalInq

uiryInformation



Loop2110CSubscriberEOrBIInfo SubscriberAdditionalInformation Subscriber Additional Information PegaX125010PegaX12-Data-N270-

Loop2110CSubscriberEOrBIInfo SubscriberSpendDownTotalBilledAmount Subscriber Spend Down Amount PegaX125010PegaX12-Data-N270-

Loop2110DDependentEOrBIInfo DependentAdditionalIdentification Dependent Additional Information PegaX125010

PegaX12-Data-N270-


DependentEligibilityOrBenefitInquiryInfor

mation

Dependent Eligibility or Benefit Inquiry


Loop2110DDependentEOrBIInfo DependentEligibilityOrBenefitDate Dependent Eligibility/Benefit Date PegaX125010PegaX12-Data-N270-


DependentEligibilityOrBenefitAdditionalIn

quiryInformation


Inquiry Information PegaX125010PegaX12-Data-N270-Subscriber Loop2000CSubscriberLevel LOOP ID - 2000C SUBSCRIBER LEVEL PegaX125010PegaX12-Data-N270-Trailer TransactionSetTrailer Transaction Set Trailer PegaX125010PegaX12-Data-N270-Transaction InformationSourceLevel Information Source Level PegaX125010PegaX12-Data-N270-Transaction Header Header PegaX125010PegaX12-Data-N270-Transaction Trailer Transaction Trailer PegaX125010

PegaX12-Data-N271 EligibilityCoverageOrBeneInfor

Eligibility, Coverage or Benefit

Information PegaX125010PegaX12-Data-N271-DependentLevel Loop2000DDependentLevel LOOP ID - 2000D DEPENDENT LEVEL PegaX125010PegaX12-Data-N271-

EligibilityCoverageOrBeneInfor FunctionalGroupTrailer Functional Group Trailer PegaX125010PegaX12-Data-N271-

EligibilityCoverageOrBeneInfor FunctionalGroupHeader Functional Group Header PegaX125010PegaX12-Data-N271-

EligibilityCoverageOrBeneInfor Transaction Transaction PegaX125010PegaX12-Data-N271-Header BeginningOfHierarchicalTransaction Beginning of Hierarchical Transaction PegaX125010PegaX12-Data-N271-Header TransactionSetHeader Transaction Set Header PegaX125010









Loop2000AInformationSourceLevel RequestValidation Request Validation PegaX125010PegaX12-Data-N271-

Loop2000BInformationReceiverLevel SubscriberLevel Subscriber Level PegaX125010PegaX12-Data-N271-






PegaX12-Data-N271-Loop2000CSubscriberLevel DependentLevel Dependent Level PegaX125010



PegaX12-Data-N271-Loop2000DDependentLevel DependentTraceNumber Dependent Trace Number PegaX125010


PegaX12-Data-N271-Loop2000DDependentLevel Loop2100DDependentName LOOP ID - 2100D DEPENDENT NAME PegaX125010PegaX12-Data-N271-


Loop2100AInformationSourceName RequestValidation Request Validation PegaX125010PegaX12-Data-N271-

Loop2100AInformationSourceName InformationSourceContactInformation Information Source Contact Information PegaX125010PegaX12-Data-N271-



n



Loop2100BInformationReceiverName InformationReceiverProviderInformation InformationReceiverProviderInformation PegaX125010PegaX12-Data-N271-

Loop2100BInformationReceiverName InformationReceiverRequestValidation Information Receiver Request Validation PegaX125010PegaX12-Data-N271-

Loop2100BInformationReceiverName InformationReceiverName Information Receiver Name PegaX125010

PegaX12-Data-N271-Loop2100CSubscriberName SubscriberContactInformation Subscriber Contact Information PegaX125010

PegaX12-Data-N271-Loop2100CSubscriberName SubscriberMilitaryPersonnelInformation SubscriberMilitaryPersonnelInformation PegaX125010


PegaX12-Data-N271-Loop2100CSubscriberName Loop2110CSubscriberEorBI



PegaX12-Data-N271-Loop2100CSubscriberName SubscriberHealthCareDiagnosisCode SubscriberHealthCareDiagnosisCode PegaX125010





PegaX12-Data-N271-Loop2100CSubscriberName ProviderInformation ProviderInformation PegaX125010




PegaX12-Data-N271-Loop2100DDependentName DependentAddress Dependent Address PegaX125010

PegaX12-Data-N271-Loop2100DDependentName Loop2110DDependentEorBI



PegaX12-Data-N271-Loop2100DDependentName DependentHealthCareDiagnosisCode DependentHealthCareDiagnosisCode PegaX125010

PegaX12-Data-N271-Loop2100DDependentName DependentDate Dependent Date PegaX125010

PegaX12-Data-N271-Loop2100DDependentName DependentCityStateZIPCode Dependent City/State/ZIP Code PegaX125010

PegaX12-Data-N271-Loop2100DDependentName DependentAdditionalIdentification Dependent Additional Identification PegaX125010




PegaX12-Data-N271-Loop2100DDependentName ProviderInformation ProviderInformation PegaX125010

PegaX12-Data-N271-Loop2100DDependentName DependentMilitaryPersonnelInformation DependentMilitaryPersonnelInformation PegaX125010

PegaX12-Data-N271-Loop2100DDependentName DependentRelationship Dependent Relationship PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI Loop2115CSubscriberEorBAI

Loop2115CSubscriberEligibilityorBenefitA

dditionalInformation PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberEligibilityBenefitDate Subscriber Eligibility/Benefit Date PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI HealthCareServicesDelivery Health Care Services Delivery PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI MessageText Message Text PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberRequestValidation Subscriber Request Validation PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberEligibilityorBenefitInformation

Subscriber Eligibility or Benefit


PegaX12-Data-N271-Loop2110CSubscriberEorBI Loop2120CSubscriberBenefitREN

LOOP ID - 2120C SUBSCRIBER BENEFIT


PegaX12-Data-N271-Loop2110CSubscriberEorBI LoopHeader Loop Header PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI LoopTrailer Loop Trailer PegaX125010

PegaX12-Data-N271-Loop2110CSubscriberEorBI SubscriberAdditionalIdentification Subscriber Additional Identification PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI DependentEligibilityorBenefitInformation

Dependent Eligibility or Benefit


PegaX12-Data-N271-Loop2110DDependentEorBI DependentEligibilityBenefitDate Dependent Eligibility/Benefit Date PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI DependentAdditionalIdentification Dependent Additional Identification PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI HealthCareServicesDelivery Health Care Services Delivery PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI LoopHeader Loop Header PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI Loop2120DDependentBenefitREN

LOOP ID - 2120D DEPENDENT BENEFIT


PegaX12-Data-N271-Loop2110DDependentEorBI MessageText Message Text PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI Loop2115DDependentEorBAI


OR BENEFIT ADDITIONAL INFO PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI LoopTrailer Loop Trailer PegaX125010

PegaX12-Data-N271-Loop2110DDependentEorBI DependentRequestValidation Dependent Request Validation PegaX125010

PegaX12-Data-N271-Loop2115CSubscriberEorBAI

SubscriberEligibilityorBenefitAdditionalInf

ormation



PegaX12-Data-N271-Loop2115DDependentEorBAI

DependentEligibilityorBenefitAdditionalInf

ormation



Loop2120CSubscriberBenefitREN SubscriberBenefitRelatedEntityName Subscriber Benefit Related Entity Name PegaX125010PegaX12-Data-N271-

Loop2120CSubscriberBenefitREN SubscriberBenefitRelatedCityStateZIPCode

Subscriber Benefit Related City/State/ZIP



SubscriberBenefitRelatedProviderInformat

ion

Subscriber Benefit Related Provider



SubscriberBenefitRelatedEntityContactInfo

rmation

Subscriber Benefit Related Entity Contact


Loop2120CSubscriberBenefitREN SubscriberBenefitRelatedEntityAddress Subscriber Benefit Related Entity Address PegaX125010PegaX12-Data-N271-

Loop2120DDependentBenefitREN DependentBenefitRelatedEntityAddress


Address PegaX125010PegaX12-Data-N271-


DependentBenefitRelatedProviderInforma

tion

Dependent Benefit Related Provider



DependentBenefitRelatedEntityCityStateZI

PCode


City/State/ZIP Code PegaX125010PegaX12-Data-N271-

Loop2120DDependentBenefitREN DependentBenefitRelatedEntityName Dependent Benefit Related Entity Name PegaX125010PegaX12-Data-N271-


DependentBenefitRelatedEntityContactInf

ormation

Dependent Benefit Related Entity Contact

Information PegaX125010PegaX12-Data-N271-SubscriberLevel Loop2000CSubscriberLevel LOOP ID - 2000C SUBSCRIBER LEVEL PegaX125010PegaX12-Data-N271-Trailer TransactionSetTrailer Transaction Set Trailer PegaX125010PegaX12-Data-N271-Transaction Header Header PegaX125010PegaX12-Data-N271-Transaction Trailer Transaction Trailer PegaX125010PegaX12-Data-N271-Transaction InformationSourceLevel Information Source Level PegaX125010PegaX12-Data-N276 HealthCareClaimStatusRequest HealthCareClaimStatusRequest PegaX125010PegaX12-Data-N276-DependentLevel Loop2000EDependentLevel LOOP ID - 2000E DEPENDENT LEVEL PegaX125010PegaX12-Data-N276-Header TransactionSetHeader Transaction Set Header PegaX125010PegaX12-Data-N276-Header BeginningOfHierarchicalTransaction Beginning of Hierarchical Transaction PegaX125010PegaX12-Data-N276-

HealthCareClaimStatusRequest FunctionalGroupHeader Functional Group Header PegaX125010PegaX12-Data-N276-

HealthCareClaimStatusRequest FunctionalGroupTrailer Functional Group Trailer PegaX125010PegaX12-Data-N276-

HealthCareClaimStatusRequest Transaction Transaction PegaX125010






Loop2000AInformationSourceLevel Loop2100APayerName LOOP ID - 2100A PAYER NAME PegaX125010PegaX12-Data-N276-







Loop2000CServiceProviderLevel SubscriberLevel Subscriber Level PegaX125010PegaX12-Data-N276-

Loop2000CServiceProviderLevel Loop2100CProviderName LOOP ID - 2100C PROVIDER NAME PegaX125010

PegaX12-Data-N276-Loop2000DSubscriberLevel Loop2200DClaimStatusTrackingNumber

LOOP ID - 2200D CLAIM SUBMITTER




PegaX12-Data-N276-Loop2000DSubscriberLevel Loop2100DSubscriberName LOOP ID - 2100D SUBSCRIBER NAME PegaX125010

PegaX12-Data-N276-Loop2000DSubscriberLevel Loop2000EDependentLevel LOOP ID - 2000E DEPENDENT LEVEL PegaX125010

PegaX12-Data-N276-Loop2000EDependentLevel Loop2100EDependentName LOOP ID - 2100E DEPENDENT NAME PegaX125010

PegaX12-Data-N276-Loop2000EDependentLevel Loop2200EClaimStatusTrackingNumber

LOOP ID - 2200E CLAIM SUBMITTER



PegaX12-Data-N276-Loop2000EDependentLevel DependentLevel Dependent Level PegaX125010PegaX12-Data-N276-Loop2100APayerName PayerName Payer Name PegaX125010

PegaX12-Data-N276-




Loop2200DClaimStatusTrackingNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber Loop2210DServiceLineInformation



Loop2200DClaimStatusTrackingNumber ClaimSubmittedCharges Claim Submitted Charges PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber PayerClaimControlNumber Payer Claim Identification Number PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber

ClaimIDNumForClearinghousesAndOtherT

ransmissionIntermediaries

ClaimIDNumForClearinghousesAndOther

TransmissionIntermediaries PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber ClaimServiceDate Claim Service Date PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber GroupNumber GroupNumber PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber InstitutionalBillTypeIdentification Institutional Bill Type Identification PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber ApplicationOrLocationSystemIdentifier ApplicationOrLocationSystemIdentifier PegaX125010PegaX12-Data-N276-

Loop2200DClaimStatusTrackingNumber PharmacyPrescriptionNumber Pharmac PrescriptionNumber PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber






Loop2200DClaimSubmitterTraceNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber ApplicationOrLocationSystemIdentifier ApplicationOrLocationSystemIdentifier PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber PharmacyPrescriptionNumber Pharmac PrescriptionNumber PegaX125010

PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber PayerClaimControlNumber Payer Claim Identification Number PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber ClaimSubmittedCharges Claim Submitted Charges PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber InstitutionalBillTypeIdentification Institutional Bill Type Identification PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber GroupNumber GroupNumber PegaX125010PegaX12-Data-N276-

Loop2200DClaimSubmitterTraceNumber Loop2210DServiceLineInformation



Loop2200EClaimStatusTrackingNumber





Loop2200EClaimStatusTrackingNumber ClaimSubmittedCharges Claim Submitted Charges PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber PharmacyPrescriptionNumber PharmacyPrescriptionNumber PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber ApplicationOrLocationSystemIdentifier ApplicationOrLocationSystemIdentifier PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber GroupNumber GroupNumber PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber Loop2210EServiceLineInformation



Loop2200EClaimStatusTrackingNumber ClaimServiceDate Claim Service Date PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber PayerClaimControlNumber Payer Claim Control Number PegaX125010PegaX12-Data-N276-

Loop2200EClaimStatusTrackingNumber InstitutionalBillTypeIdentification Institutional Bill Type Identification PegaX125010PegaX12-Data-N276-


Loop2200EClaimSubmitterTraceNumber GroupNumber GroupNumber PegaX125010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber ClaimSubmittedCharges Claim Submitted Charges PegaX125010

PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber Loop2210EServiceLineInformation



Loop2200EClaimSubmitterTraceNumber





Loop2200EClaimSubmitterTraceNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber PharmacyPrescriptionNumber PharmacyPrescriptionNumber PegaX125010PegaX12-Data-N276-


Loop2200EClaimSubmitterTraceNumber ApplicationOrLocationSystemIdentifier ApplicationOrLocationSystemIdentifier PegaX125010PegaX12-Data-N276-

Loop2200EClaimSubmitterTraceNumber PayerClaimControlNumber Payer Claim Control Number PegaX125010PegaX12-Data-N276-






Loop2210EServiceLineInformation ServiceLineItemIdentification Service Line Item Identification PegaX125010

PegaX12-Data-N276-ServiceProviderLevel Loop2000CServiceProviderLevel

LOOP ID - 2000C SERVICE PROVIDER

LEVEL PegaX125010PegaX12-Data-N276-SubscriberLevel Loop2000DSubscriberLevel LOOP ID - 2000D SUBSCRIBER LEVEL PegaX125010PegaX12-Data-N276-Trailer TransactionSetTrailer Transaction Set Trailer PegaX125010PegaX12-Data-N276-Transaction InformationSourceLevel Information Source Level PegaX125010PegaX12-Data-N276-Transaction Header Header PegaX125010PegaX12-Data-N276-Transaction Trailer Transaction Trailer PegaX125010PegaX12-Data-N277 HealthCareClaimStatusNotification Health Care Claim Status Notification PegaX125010PegaX12-Data-N277-DependentLevel Loop2000EDependentLevel Loop2000E Dependent Level PegaX125010

PegaX12-Data-N277-Header BeginningOfHierarchicalTransaction Beginning Of Hierarchical Transaction PegaX125010PegaX12-Data-N277-Header TransactionSetHeader Transaction Set Header PegaX125010

PegaX12-Data-N277-

HealthCareClaimStatusNotification FunctionalGroupTrailer Functional Group Trailer PegaX125010PegaX12-Data-N277-

HealthCareClaimStatusNotification FunctionalGroupHeader Functional Group Header PegaX125010PegaX12-Data-N277-

HealthCareClaimStatusNotification Transaction Transaction PegaX125010PegaX12-Data-N277-InformationReceiverLevel Loop2000BInformationReceiverLevel Loop2000B Information Receiver Level PegaX125010PegaX12-Data-N277-InformationSourceLevel Loop2000AInformationSourceLevel Loop2000A Information Source Level PegaX125010PegaX12-Data-N277-


Loop2000AInformationSourceLevel Loop2100APayerName Loop2100A Payer Name PegaX125010PegaX12-Data-N277-


Loop2000BInformationReceiverLevel

Loop2200BInformationReceiverTraceIdent

ifier

Loop2200BInformationReceiverTraceIden

tifier PegaX125010PegaX12-Data-N277-



Loop2000BInformationReceiverLevel Loop2100BInformationReceiverName Loop2100B Information Receiver Name PegaX125010PegaX12-Data-N277-

Loop2000CServiceProviderLevel Loop2000DSubscriberLevel Loop2000D Subscriber Level PegaX125010PegaX12-Data-N277-

Loop2000CServiceProviderLevel

Loop2200CProviderofServiceTraceIdentifie

r

Loop2200CProviderofServiceTraceIdentifi

er PegaX125010PegaX12-Data-N277-


Loop2000CServiceProviderLevel Loop2100CProviderName Loop2100C Provider Name PegaX125010

PegaX12-Data-N277-Loop2000DSubscriberLevel Loop2100DSubscriberName Loop2100D Subscriber Name PegaX125010


PegaX12-Data-N277-Loop2000DSubscriberLevel Loop2000EDependentLevel Loop2000E Dependent Level PegaX125010

PegaX12-Data-N277-Loop2000DSubscriberLevel Loop2200DClaimStatusTrackingNumber

Loop2200D Claim Submitter Trace

Number PegaX125010


PegaX12-Data-N277-Loop2000EDependentLevel DependentLevel Dependent Level PegaX125010

PegaX12-Data-N277-Loop2000EDependentLevel Loop2200EClaimStatusTrackingNumber

Loop2200E Claim Submitter Trace

Number PegaX125010


PegaX12-Data-N277-Loop2000EDependentLevel Loop2100EDependentName Loop2100E Dependent Name PegaX125010PegaX12-Data-N277-Loop2100APayerName PayerContactInformation Payer Contact Information PegaX125010PegaX12-Data-N277-Loop2100APayerName PayerName Payer Name PegaX125010PegaX12-Data-N277-




Loop2200BInformationRcvTracIdentifier InformationReceiverTraceIdentifier InformationReceiverTraceIdentifier PegaX125010PegaX12-Data-N277-

Loop2200BInformationRcvTracIdentifier InformationReceiverStatusInformation InformationReceiverStatusInformation PegaX125010PegaX12-Data-N277-

Loop2200CProviderOfSvcTrcIdentifier ProviderStatusInformation ProviderStatusInformation PegaX125010PegaX12-Data-N277-

Loop2200CProviderOfSvcTrcIdentifier ProviderOfServiceTraceIdentifier ProviderOfServiceTraceIdentifier PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber InstitutionalBillTypeIdentification Institutional Bil lType Identification PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber Loop2220DServiceLineInformation Loop2220D Service Line Information PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber MedicalRecordIdentification Medical Record Identification PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber VoucherIdentifier VoucherIdentifier PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber PharmacyPrescriptionNumber PharmacyPrescriptionNumber PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber ClaimLevelStatusInformation Claim Level Status Information PegaX125010

PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber ClaimServiceDate Claim Service Date PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber PayerClaimControlNumber Payer Claim Identification Number PegaX125010PegaX12-Data-N277-

Loop2200DClaimStatusTrackingNumber





Loop2200DClaimSubmitterTraceNumber Loop2220DServiceLineInformation Loop2220D Service Line Information PegaX125010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber ClaimLevelStatusInformation Claim Level Status Information PegaX125010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber PayerClaimControlNumber Payer Claim Identification Number PegaX125010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber VoucherIdentifier VoucherIdentifier PegaX125010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber





Loop2200DClaimSubmitterTraceNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N277-



Loop2200DClaimSubmitterTraceNumber InstitutionalBillTypeIdentification Institutional Bil lType Identification PegaX125010PegaX12-Data-N277-

Loop2200DClaimSubmitterTraceNumber PharmacyPrescriptionNumber PharmacyPrescriptionNumber PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber InstitutionalBillTypeIdentification Institutional Bill Type Identification PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber PayerClaimControlNumber Payer Claim Identification Number PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber VoucherIdentifier VoucherIdentifier PegaX125010

PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber MedicalRecordIdentification Medical Record Identification PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber





Loop2200EClaimStatusTrackingNumber ClaimServiceDate Claim Service Date PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber PharmacyPrescriptionNumber PharmacyPrescriptionNumber PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber Loop2220EServiceLineInformation Loop2220E Service Line Information PegaX125010PegaX12-Data-N277-

Loop2200EClaimStatusTrackingNumber ClaimLevelStatusInformation Claim Level Status Information PegaX125010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber PatientControlNumber PatientControlNumber PegaX125010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber






Loop2200EClaimSubmitterTraceNumber VoucherIdentifier VoucherIdentifier PegaX125010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber PharmacyPrescriptionNumber PharmacyPrescriptionNumber PegaX125010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber Loop2220EServiceLineInformation Loop2220E Service Line Information PegaX125010PegaX12-Data-N277-


Loop2200EClaimSubmitterTraceNumber ClaimLevelStatusInformation Claim Level Status Information PegaX125010PegaX12-Data-N277-

Loop2200EClaimSubmitterTraceNumber PayerClaimControlNumber Payer Claim Identification Number PegaX125010PegaX12-Data-N277-


Loop2200EClaimSubmitterTraceNumber ClaimStatusTrackingNumber Claim Submitter Trace Number PegaX125010PegaX12-Data-N277-



Loop2220DServiceLineInformation ServiceLineInformation Service Line Information PegaX125010

PegaX12-Data-N277-

Loop2220DServiceLineInformation ServiceLineStatusInformation Service Line Status Information PegaX125010PegaX12-Data-N277-

Loop2220EServiceLineInformation ServiceLineItemIdentification Service Line Item Identification PegaX125010PegaX12-Data-N277-



Loop2220EServiceLineInformation ServiceLineStatusInformation Service Line Status Information PegaX125010PegaX12-Data-N277-ServiceProviderLevel Loop2000CServiceProviderLevel Loop2000C Service Provider Level PegaX125010PegaX12-Data-N277-SubscriberLevel Loop2000DSubscriberLevel Loop2000D Subscriber Level PegaX125010PegaX12-Data-N277-Trailer TransactionSetTrailer Transaction Set Trailer PegaX125010PegaX12-Data-N277-Transaction Trailer Trailer PegaX125010PegaX12-Data-N277-Transaction Header Header PegaX125010PegaX12-Data-N277-Transaction InformationSourceLevel Information Source Level PegaX125010PegaX12-Data-N278 HealthcareServicesRequest Healthcare Services Request PegaX125010PegaX12-Data-N278 HealthcareServicesResponse Healthcare Services Response PegaX125010PegaX12-Data-N278-Header TransactionSetHeader Transaction Set Header PegaX125010

PegaX12-Data-N278-Header BeginningOfHierarchicalTransaction Beginning Of Hierarchical Transaction PegaX125010

PegaX12-Data-N278-HealthcareServicesRequest FunctionalGroupHeader Functional Group Header PegaX125010

PegaX12-Data-N278-HealthcareServicesRequest Transaction Transaction PegaX125010

PegaX12-Data-N278-HealthcareServicesRequest FunctionalGroupTrailer Functional Group Trailer PegaX125010

PegaX12-Data-N278-HealthcareServicesResponse FunctionalGroupHeader Functional Group Header PegaX125010

PegaX12-Data-N278-HealthcareServicesResponse Transaction Transaction PegaX125010

PegaX12-Data-N278-HealthcareServicesResponse FunctionalGroupTrailer Functional Group Trailer PegaX125010PegaX12-Data-N278-Loop2000AUMOLevel Loop2010AUMOName Loop 2010A - UMO Name PegaX125010PegaX12-Data-N278-Loop2000AUMOLevel RequestValidation Request Validation PegaX125010

PegaX12-Data-N278-Loop2000AUMOLevel UMOLevel


Level PegaX125010PegaX12-Data-N278-Loop2000AUMOLevel Loop2000BRequesterLevel Loop 2000B - Requester Level PegaX125010

PegaX12-Data-N278-Loop2000BRequesterLevel Loop2010BRequesterName Loop 2010B - Requester Name PegaX125010

PegaX12-Data-N278-Loop2000BRequesterLevel RequesterLevel Requester Level PegaX125010

PegaX12-Data-N278-Loop2000BRequesterLevel Loop2000CSubscriberLevel Loop 2000C - Subscriber Level PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel OnsetofCurrentSymptomsorIllnessDate


Date PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2010CBContactName Loop 2010CB - Contact Name PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel PatientEventTrackingNumber Patient Event Tracking Number PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2010CSubscriberName Loop 2010CA - Subscriber Name PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel AdditionalPatientInformation Additional Patient Information PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel AccidentDate Accident Date PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel SubscriberRequestValidation Subscriber Request Validation PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2010CASubscriberName Loop 2010CA - Subscriber Name PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel EstimatedDateofBirth Estimated Date of Birth PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel SubscriberDiagnosis Subscriber Diagnosis PegaX125010


PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2000EServiceProviderLevel Loop 2000E - Service Provider Level PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel LastMenstrualPeriodDate Last Menstrual Period Date PegaX125010

PegaX12-Data-N278-Loop2000CSubscriberLevel Loop2000DDependentLevel Loop 2000D - Dependent Level PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel Loop2010DBContactName Loop 2010DB - Contact Name PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel OnsetofCurrentSymptomsorIllnessDate


Date PegaX125010


PegaX12-Data-N278-Loop2000DDependentLevel PatientEventTrackingNumber Patient Event Tracking Number PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel Loop2010DDependentName Loop2010DDependentName PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel DependentDiagnosis Dependent Diagnosis PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel LastMenstrualPeriodDate LastMenstrualPeriodDate PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel EstimatedDateofBirth Estimated Date of Birth PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel Loop2010DADependentName Loop 2010DA - Dependent Name PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel AdditionalPatientInformation Additional Patient Information PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel Loop2000EServiceProviderLevel Loop 2000E - Service Provider Level PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel AccidentDate Accident Date PegaX125010

PegaX12-Data-N278-Loop2000DDependentLevel DependentRequestValidation Dependent Request Validation PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel DurableMedicalEquipmentInformation Patient Condition Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel HomeHealthCareInformation Home Health Care Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel SpinalManipulationServiceInformation Spinal Manipulation Service Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel

PreviousReviewAdministrativeReferenceN

umber

PreviousReviewAdministrativeReference

Number PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel

Loop2010EBPatientEventTransportInform

ation

Loop2010EBPatientEventTransportInform

ation PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel CertificationIssueDate Certification Issue Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel AdmissionDate Admission Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel PatientEventTrackingNumber Patient Event Tracking Number PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel PatientDiagnosis PatientDiagnosis PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel FunctionalLimitationsInformation Patient Condition Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel Loop2010EAPatientEventProviderName Loop2010EAPatientEventProviderName PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel Loop2010ECPatientEventOtherUMOName

Loop2010ECPatientEventOtherUMONam

e PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel ActivitiesPermittedInformation Patient Condition Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel HealthCareServicesReview Health Care Services Review PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel HomeOxygenTherapyInformation Home Oxygen Therapy Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel Loop2010ECPatientEventTransportInfo Loop2010ECPatientEventTransportInfo PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel PatientEventLevel Service Provider Level PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel CertificationEffectiveDate Certification Effective Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel ChiropracticCertificationInformation Patient Condition Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel HealthCareServicesDelivery HealthCareServicesDelivery PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel InstitutionalClaimCode Institutional Claim Code PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel LastMenstrualPeriodDate Last Menstrual Period Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel OxygenTherapyCertificationInformation Patient Condition Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel PreviousReviewAuthorizationNumber PreviousReviewAuthorizationNumber PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel AdditionalPatientInformation Additional Patient Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel OnsetofCurrentSymptomsorIllnessDate


Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel AccidentDate Accident Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel CertificationExpirationDate Certification Expiration Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel EstimatedDateofBirth Estimated Date of Birth PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel EventDate EventDate PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel HealthCareServicesReviewInformation Health Care Services Review Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel MentalStatusInformation Patient Condition Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel MessageText Message Text PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel AmbulanceCertificationInformation Patient Condition Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel AmbulanceTransportInformation Ambulance Transport Information PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel DischargeDate Discharge Date PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel Loop2010EBAdditionalPatientContactInfo Loop2010EBAdditionalPatientContactInfo PegaX125010

PegaX12-Data-N278-Loop2000EPatientEventLevel PatientEventRequestValidation Request Validation PegaX125010PegaX12-Data-N278-

Loop2000EServiceProviderLevel Loop2010EServiceProviderName Loop 2010E - Service Provider Name PegaX125010PegaX12-Data-N278-

Loop2000EServiceProviderLevel MessageText Message Text PegaX125010PegaX12-Data-N278-

Loop2000EServiceProviderLevel AccidentDate Accident Date PegaX125010PegaX12-Data-N278-

Loop2000EServiceProviderLevel ServiceProviderLevel Service Provider Level PegaX125010PegaX12-Data-N278-

Loop2000EServiceProviderLevel Loop2000FServiceLevel Loop 2000F - Service Level PegaX125010

PegaX12-Data-N278-Loop2000FServiceLevel

Loop2010FBAdditionalServiceInformation

ContactName Loop 2010F - Contact Name PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel Loop2010FContactName Loop 2010F - Contact Name PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel PreviousReviewAuthorizationNumber Previous Certification Identification PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel ServiceRequestValidation Service Request Validation PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel ToothInformation ToothInformation PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel CertificationEffectiveDate Certification Effective Date PegaX125010

PegaX12-Data-N278-Loop2000FServiceLevel HealthCareServicesReviewInformation Health Care Services Review Information PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel HomeHealthCareInformation Home Health Care Information PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel SurgeryDate Surgery Date PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel CertificationExpirationDate Certification Expiration Date PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel CertificationIssueDate Certification Issue Date PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel DischargeDate Discharge Date PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel HomeOxygenTherapyInformation Home Oxygen Therapy Information PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel Loop2010FAServiceProviderName Loop 2010F - Contact Name PegaX125010

PegaX12-Data-N278-Loop2000FServiceLevel PatientConditionInformation Patient Condition Information PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel Procedures Procedures PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel ServiceDate Service Date PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel AdmissionDate Admission Date PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel AmbulanceTransportInformation Ambulance Transport Information PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel HealthCareServicesReview Health Care Services Review PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel PreviousCertificationIdentification Previous Certification Identification PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel HealthCareServicesDelivery HealthCareServicesDelivery PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel InstitutionalClaimCode Institutional Claim Code PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel MessageText Message Text PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel ServiceTraceNumber Service Trace Number PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel AdditionalServiceInformation Additional Service Information PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel AdministrativeReferenceNumber Previous Certification Identification PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel DentalService DentalService PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel InstitutionalServiceLine InstitutionalServiceLine PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel Loop2010FServiceProviderName Loop 2010F - Contact Name PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel RequestForAdditionalInformation RequestForAdditionalInformation PegaX125010

PegaX12-Data-N278-Loop2000FServiceLevel SpinalManipulationServiceInformation Spinal Manipulation Service Information PegaX125010

PegaX12-Data-N278-Loop2000FServiceLevel

PreviousReviewAdministrativeReferenceN

umber Previous Certification Identification PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel ProfessionalService ProfessionalService PegaX125010PegaX12-Data-N278-Loop2000FServiceLevel ServiceLevel Service Level PegaX125010PegaX12-Data-N278-Loop2010AUMOName UMORequestValidation UMO Request Validation PegaX125010PegaX12-Data-N278-Loop2010AUMOName UMOContact UMO Contact PegaX125010

PegaX12-Data-N278-Loop2010AUMOName UMOName


Name PegaX125010

PegaX12-Data-N278-Loop2010BRequesterName RequesterProviderInformation Requester Provider Information PegaX125010

PegaX12-Data-N278-Loop2010BRequesterName RequesterRequestValidation Requester Request Validation PegaX125010

PegaX12-Data-N278-Loop2010BRequesterName RequesterAddress Requester Address PegaX125010

PegaX12-Data-N278-Loop2010BRequesterName RequesterName Requester Name PegaX125010

PegaX12-Data-N278-Loop2010BRequesterName RequesterContactInformation Requester Contact Information PegaX125010

PegaX12-Data-N278-Loop2010BRequesterName RequesterSupplementalIdentification Requester Supplemental Identification PegaX125010

PegaX12-Data-N278-Loop2010BRequesterName RequesterCityStateZIPCode Requester City, State, ZIP Code PegaX125010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberSupplementalIdentification Subscriber Supplemental Identification PegaX125010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberRequestValidation Subscriber Request Validation PegaX125010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberDemographicInformation Subscriber Demographic Information PegaX125010

PegaX12-Data-N278-Loop2010CASubscriberName SubscriberName Subscriber Name PegaX125010PegaX12-Data-N278-Loop2010CBContactName ContactAddress ContactAddress PegaX125010PegaX12-Data-N278-Loop2010CBContactName ContactInformation ContactInformation PegaX125010PegaX12-Data-N278-Loop2010CBContactName ContactCityStateZipCode ContactCityStateZipCode PegaX125010PegaX12-Data-N278-Loop2010CBContactName ContactName ContactName PegaX125010

PegaX12-Data-N278-Loop2010CSubscriberName SubscriberSupplementalIdentification Subscriber Supplemental Identification PegaX125010



PegaX12-Data-N278-Loop2010CSubscriberName SubscriberRelationship SubscriberRelationship PegaX125010

PegaX12-Data-N278-Loop2010CSubscriberName SubscriberCityStateZipCode ContactCityStateZipCode PegaX125010


PegaX12-Data-N278-Loop2010CSubscriberName SubscriberMailingAddress ContactAddress PegaX125010

PegaX12-Data-N278-Loop2010DADependentName DependentDemographicInformation Dependent Demographic Information PegaX125010

PegaX12-Data-N278-Loop2010DADependentName DependentName Dependent Name PegaX125010

PegaX12-Data-N278-Loop2010DADependentName DependentRelationship Dependent Relationship PegaX125010

PegaX12-Data-N278-Loop2010DADependentName DependentRequestValidation Dependent Request Validation PegaX125010

PegaX12-Data-N278-Loop2010DADependentName DependentSupplementalIdentification Dependent Supplemental Identification PegaX125010

PegaX12-Data-N278-Loop2010DBContactName ContactName ContactName PegaX125010

PegaX12-Data-N278-Loop2010DBContactName ContactInformation ContactInformation PegaX125010

PegaX12-Data-N278-Loop2010DBContactName ContactAddress ContactAddress PegaX125010

PegaX12-Data-N278-Loop2010DBContactName ContactCityStateZipCode ContactCityStateZipCode PegaX125010


PegaX12-Data-N278-Loop2010DDependentName DependentRelationship DependentRelationship PegaX125010


PegaX12-Data-N278-Loop2010DDependentName DependentSupplementalIdentification Dependent Supplemental Identification PegaX125010


PegaX12-Data-N278-Loop2010DDependentName DependentCityStateZipCode ContactCityStateZipCode PegaX125010

PegaX12-Data-N278-Loop2010DDependentName DependentAddress ContactAddress PegaX125010PegaX12-Data-N278-

Loop2010EAPatientEventProviderName PatientEventProviderName patient event provider Name PegaX125010PegaX12-Data-N278-

Loop2010EAPatientEventProviderName PatientEventProviderAddress Party Location PegaX125010PegaX12-Data-N278-

Loop2010EAPatientEventProviderName

PatientEventProviderSupplementalInform

ation

PatientEventProviderSupplementalInform

ation PegaX125010PegaX12-Data-N278-

Loop2010EAPatientEventProviderName PatientEventProviderContactInformation

Patient Event Provider Contact


Loop2010EAPatientEventProviderName PatientEventProviderCityStateZIPCode

Patient event Provider City, State, ZIP


Loop2010EAPatientEventProviderName PatientEventProviderInformation Patient Event Provider Information PegaX125010PegaX12-Data-N278-

Loop2010EAPatientEventProviderName PatientEventProviderRequestValidation PatientEventProviderRequestValidation PegaX125010PegaX12-Data-N278-

Loop2010EBAdditionalPatientContactInfo

AdditionalPatientInformationContactAddr

ess

AdditionalPatientInformationContactAdd

ress PegaX125010PegaX12-Data-N278-


AdditionalPatientInformationContactInfor

mation

AdditionalPatientInformationContactInfor

mation PegaX125010PegaX12-Data-N278-


AdditionalPatientInformationContactNam

e

AdditionalPatientInformationContactNam

e PegaX125010

PegaX12-Data-N278-


AdditionalPatientInformationContactCityS

tateZIPCode

AdditionalPatientInformationContactCity

StateZIPCode PegaX125010PegaX12-Data-N278-

Loop2010EBPatientEventTransportInfo PatientEventTransportInformation patient event transport information PegaX125010PegaX12-Data-N278-

Loop2010EBPatientEventTransportInfo PatientEventTransportLocationAddress Party Location PegaX125010PegaX12-Data-N278-

Loop2010EBPatientEventTransportInfo

PatientEventTransportLocationCityStateZI

PCode

Patient event Provider City, State, ZIP


Loop2010ECPatientEventOtherUMOName OtherUMODenialDate Other UMO Denial Date PegaX125010PegaX12-Data-N278-

Loop2010ECPatientEventOtherUMOName PatientEventOtherUMOName patient event other UMO name PegaX125010PegaX12-Data-N278-

Loop2010ECPatientEventOtherUMOName OtherUMODenialReason Other UMO Denial Reason PegaX125010PegaX12-Data-N278-

Loop2010ECPatientEventTransportInfo PatientEventTransportInformation PatientEventTransportInformation PegaX125010PegaX12-Data-N278-

Loop2010ECPatientEventTransportInfo PatientEventTransportLocationAddress PatientEventTransportLocationAddress PegaX125010PegaX12-Data-N278-

Loop2010ECPatientEventTransportInfo


PCode


PCode PegaX125010PegaX12-Data-N278-

Loop2010ECPatientEventTransportInfo

PatientEventTransportLocationRequestVal

idation

PatientEventTransportLocationRequestVa

lidation PegaX125010PegaX12-Data-N278-

Loop2010EServiceProviderName Loop2000FServiceLevel Loop 2000F - Service Level PegaX125010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderAddress Service Provider Address PegaX125010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderRequestValidation Service Provider Request Validation PegaX125010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderName Service Provider Name PegaX125010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderSupplementalIdentification

Service Provider Supplemental


Loop2010EServiceProviderName ServiceProviderContactInformation Service Provider Contact Information PegaX125010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderInformation Service Provider Information PegaX125010PegaX12-Data-N278-

Loop2010EServiceProviderName ServiceProviderCityStateZIPCode Service Provider City, State, ZIP Code PegaX125010PegaX12-Data-N278-

Loop2010FAServiceProviderName ServiceProviderAddress ServiceProviderAddress PegaX125010

PegaX12-Data-N278-

Loop2010FAServiceProviderName ServiceProviderRequestValidation ServiceProviderRequestValidation PegaX125010PegaX12-Data-N278-

Loop2010FAServiceProviderName ServiceProviderName ServiceProviderName PegaX125010PegaX12-Data-N278-

Loop2010FAServiceProviderName ServiceProviderCityStateZipCode ServiceProviderCityStateZipCode PegaX125010PegaX12-Data-N278-

Loop2010FAServiceProviderName ServiceProviderSupplementalIdentification

ServiceProviderSupplementalIdentificatio


Loop2010FAServiceProviderName ServiceProviderContactInformation ServiceProviderContactInformation PegaX125010PegaX12-Data-N278-

Loop2010FAServiceProviderName ServiceProviderInformation ServiceProviderInformation PegaX125010PegaX12-Data-N278-

Loop2010FBAddServiceInfoContactName

AdditionalServiceInformationContactNam

e ServiceProviderName PegaX125010PegaX12-Data-N278-


AdditionalServiceInformationContactInfor

mation ServiceProviderContactInformation PegaX125010PegaX12-Data-N278-


AdditionalServiceInformationContactCitySt

ateZipCode ServiceProviderCityStateZipCode PegaX125010PegaX12-Data-N278-


AdditionalServiceInformationContactAddr

ess

AdditionalServiceInformationContactNam

e PegaX125010PegaX12-Data-N278-Loop2010FContactName ContactInformation ContactInformation PegaX125010PegaX12-Data-N278-Loop2010FContactName ContactAddress ContactAddress PegaX125010PegaX12-Data-N278-Loop2010FContactName ContactCityStateZipCode ContactCityStateZipCode PegaX125010PegaX12-Data-N278-Loop2010FContactName ContactName ContactName PegaX125010PegaX12-Data-N278-

Loop2010FServiceProviderName ServiceProviderName ServiceProviderName PegaX125010PegaX12-Data-N278-

Loop2010FServiceProviderName ServiceProviderContactInformation ServiceProviderContactInformation PegaX125010PegaX12-Data-N278-

Loop2010FServiceProviderName ServiceProviderCityStateZipCode ServiceProviderCityStateZipCode PegaX125010PegaX12-Data-N278-

Loop2010FServiceProviderName ServiceProviderAddress ServiceProviderAddress PegaX125010PegaX12-Data-N278-

Loop2010FServiceProviderName ServiceProviderInformation ServiceProviderInformation PegaX125010PegaX12-Data-N278-

Loop2010FServiceProviderName ServiceProviderSupplementalIdentification

ServiceProviderSupplementalIdentificatio

n PegaX125010PegaX12-Data-N278-Trailer TransactionSetTrailer Transaction Set Trailer PegaX125010PegaX12-Data-N278-Transaction Loop2000DDependentLevel Loop2000DDependentLevel PegaX125010

PegaX12-Data-N278-Transaction Loop2000AUMOLevel

Loop 2000A - Utilization Management

Organization Level PegaX125010

PegaX12-Data-N278-Transaction Loop2000BRequesterLevel Loop2000BRequesterLevel PegaX125010PegaX12-Data-N278-Transaction Loop2000EPatientEventLevel Loop2000EPatientEventLevel PegaX125010PegaX12-Data-N278-Transaction Header Header PegaX125010PegaX12-Data-N278-Transaction Trailer Trailer PegaX125010PegaX12-Data-N278-Transaction Loop2000CSubscriberLevel Loop2000CSubscriberLevel PegaX125010PegaX12-Data-N278-Transaction Loop2000FServiceLevel Loop2000FServiceLevel PegaX125010PegaX12-Data-N3_AddressInformation N301_AddressInformation N301_Address Information PegaX125010PegaX12-Data-N3_AddressInformation N302_AddressInformation N302_Address Information PegaX125010PegaX12-Data-N4_GeographicLocation N401_CityName N401_City Name PegaX125010PegaX12-Data-N4_GeographicLocation N403_PostalCode N403_Postal Code PegaX125010PegaX12-Data-N4_GeographicLocation N407_CountrySubdivisionCode N407_CountrySubdivisionCode PegaX125010PegaX12-Data-N4_GeographicLocation N402_StateOrProvinceCode N402_State Or Province Code PegaX125010PegaX12-Data-N4_GeographicLocation N404_CountryCode N404_Country Code PegaX125010PegaX12-Data-N4_GeographicLocation N405_LocationQualifier N405_Location Qualifier PegaX125010PegaX12-Data-N4_GeographicLocation N406_LocationIdentifier N406_Location Identifier PegaX125010PegaX12-Data-N834 HealthcareEnrollment HealthcareEnrollment PegaX125010PegaX12-Data-N834-Header Loop1000BPayer Loop 1000B Payer PegaX125010PegaX12-Data-N834-Header TransactionSetHeader Transaction Set Header PegaX125010PegaX12-Data-N834-Header FileEffectiveDate File Effective Date PegaX125010PegaX12-Data-N834-Header Loop1000ASponsorName Loop 1000A Sponsor Name PegaX125010PegaX12-Data-N834-Header Loop1000CTPABrokerName Loop 1000C TPA/Broker Name PegaX125010PegaX12-Data-N834-Header BeginningSegment Beginning Segment PegaX125010PegaX12-Data-N834-Header TransactionSetPolicyNumber Transaction Set Policy Number PegaX125010PegaX12-Data-N834-Header TransactionSetControlTotal TransactionSetControlTotal PegaX125010PegaX12-Data-N834-HealthcareEnrollment FunctionalGroupTrailer FunctionalGroupTrailer PegaX125010PegaX12-Data-N834-HealthcareEnrollment Transaction Transaction PegaX125010PegaX12-Data-N834-HealthcareEnrollment FunctionalGroupHeader FunctionalGroupHeader PegaX125010PegaX12-Data-N834-Loop1000ASponsorName SponsorName Sponsor Name PegaX125010PegaX12-Data-N834-Loop1000BPayer Payer Payer PegaX125010

PegaX12-Data-N834-Loop1000CTPABrokerName TPABrokersName TPABrokerName PegaX125010

PegaX12-Data-N834-Loop1000CTPABrokerName Loop1100CTPABrokerAccountInformation TPA/Broker Account Information PegaX125010

PegaX12-Data-N834-Loop1000CTPABrokerName TPABrokerName TPABrokerName PegaX125010PegaX12-Data-N834-

Loop1100CTPABrokerAccountInfo TPABrokerAccountInformation TPA/Broker Account Information PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100AMemberName Loop 2100A - Member Name PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100FCustodialParent Loop2100FCustodialParent PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100GResponsiblePersonList Loop2100GResponsiblePersonList PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2300HealthCoverage Loop2300HealthCoverage PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberIdentificationNumber Member Identification Number PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail SubscriberNumber Subscriber Number PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100CMemberMailingAddress Loop2100CMemberMailingAddress PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail AdditionalReportingCategories AdditionalReportingCategories PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100EMemberSchool Loop2100EMemberSchool PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100HDropOffLocation Loop2100HDropOffLocation PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2700MemberReportingCategories MemberReportingCategories PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100BIncorrectMemberName Loop2100BIncorrectMemberName PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2100DMemberEmployer Loop2100DMemberEmployer PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberLevelDetail Member Level Detail PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberPolicyNumber Member Policy Number PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail Loop2200DisabilityInformation Loop2200DisabilityInformation PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail MemberLevelDates Member Level Dates PegaX125010

PegaX12-Data-N834-Loop2000MemberLevelDetail

AdditionalReportingCategoriesLoopTermin

ation

AdditionalReportingCategoriesLoopTermi

nation PegaX125010PegaX12-Data-N834-Loop2100AMemberName EmploymentClass EmploymentClass PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberResidenceCityStateZip Member Residence City State Zip PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberHealthInformation Member Health Information PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberResidenceStreetAddress Member Residence Street Address PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberLanguage Member Language PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberPolicyAmounts Member Policy Amounts PegaX125010

PegaX12-Data-N834-Loop2100AMemberName MemberName Member Name PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberDemographics Member Demographics PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberCommunicationsNumbers Member Communications Numbers PegaX125010PegaX12-Data-N834-Loop2100AMemberName MemberIncome Member Income PegaX125010PegaX12-Data-N834-

Loop2100BIncorrectMemberName IncorrectMemberDemographics Incorrect Member Demographics PegaX125010PegaX12-Data-N834-

Loop2100BIncorrectMemberName IncorrectMemberName Incorrect Member Name PegaX125010PegaX12-Data-N834-

Loop2100CMemberMailingAddress MemberMailStreetAddress Member Mail Street Address PegaX125010PegaX12-Data-N834-

Loop2100CMemberMailingAddress MemberMailCityStateZip Member Mail City State Zip PegaX125010PegaX12-Data-N834-

Loop2100CMemberMailingAddress MemberMailingAddress Member Mailing Address PegaX125010

PegaX12-Data-N834-Loop2100DMemberEmployer MemberEmployer Member Employer PegaX125010

PegaX12-Data-N834-Loop2100DMemberEmployer MemberEmployerStreetAddress Member Employer Street Address PegaX125010

PegaX12-Data-N834-Loop2100DMemberEmployer MemberEmployerCityStateZip Member Employer City State Zip PegaX125010

PegaX12-Data-N834-Loop2100DMemberEmployer

MemberEmployerCommunicationsNumbe

rs

MemberEmployerCommunicationsNumb

ers PegaX125010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchoolCommunicationsNumbers

Member School Communications

Numbers PegaX125010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchoolStreetAddress Member School Street Address PegaX125010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchoolCityStateZip Member School City State Zip PegaX125010

PegaX12-Data-N834-Loop2100EMemberSchool MemberSchool Member School PegaX125010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParentCommunicationsNumbers

Custodial Parent Communications

Numbers PegaX125010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParentStreetAddress Custodial Parent Street Address PegaX125010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParentCityStateZip Custodial Parent City State Zip PegaX125010

PegaX12-Data-N834-Loop2100FCustodialParent CustodialParent Custodial Parent PegaX125010

PegaX12-Data-N834-Loop2100GResponsiblePerson ResponsiblePersonStreetAddress Responsible Person Street Address PegaX125010

PegaX12-Data-N834-Loop2100GResponsiblePerson ResponsiblePersonCityStateZip Responsible Person City State Zip PegaX125010

PegaX12-Data-N834-Loop2100GResponsiblePerson ResponsiblePerson Responsible Person PegaX125010

PegaX12-Data-N834-Loop2100GResponsiblePerson

ResponsiblePersonCommunicationsNumb

ers

Responsible Person Communications

Numbers PegaX125010

PegaX12-Data-N834-Loop2100HDropOffLocation DropOffLocationStreetAddress DropOffLocationStreetAddress PegaX125010

PegaX12-Data-N834-Loop2100HDropOffLocation DropOffLocation DropOffLocation PegaX125010

PegaX12-Data-N834-Loop2100HDropOffLocation DropOffLocationCityStateZip DropOffLocationCityStateZip PegaX125010PegaX12-Data-N834-

Loop2200DisabilityInformation DisabilityEligibilityDates Disability Eligibility Dates PegaX125010PegaX12-Data-N834-

Loop2200DisabilityInformation DisabilityInformation Disability Information PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage Loop2320CoordinationOfBenefits Loop2320CoordinationOfBenefits PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage IdentificationCard Identification Card PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage PriorCoverageMonths Prior Coverage Months PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoverageDates Health Coverage Dates PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoverage Health Coverage PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoveragePolicy Health Coverage Policy PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage HealthCoveragePolicyNumber Health Coverage Policy Number PegaX125010PegaX12-Data-N834-Loop2300HealthCoverage Loop2310ProviderInformation Loop2310ProviderInformation PegaX125010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderAddress ProviderAddress PegaX125010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderName Provider Name PegaX125010

PegaX12-Data-N834-Loop2310ProviderInformation PCPChangeReason PCP Change Reason PegaX125010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderCityStateZip Provider City State Zip PegaX125010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderInformation Provider Information PegaX125010

PegaX12-Data-N834-Loop2310ProviderInformation ProviderCommunicationsNumbers Provider Communications Numbers PegaX125010PegaX12-Data-N834-


AdditionalCoordinationOfBenefitsIdentifie

rs

Additional Coordination Of Benefits

Identifiers PegaX125010PegaX12-Data-N834-

Loop2320CoordinationOfBenefits CoordinationOfBenefitsEligibilityDates Coordination Of Benefits Eligibility Dates PegaX125010

PegaX12-Data-N834-


Loop2330CoordinationOfBenefitsRelatedE

ntity

Loop2330CoordinationOfBenefitsRelated

Entity PegaX125010PegaX12-Data-N834-

Loop2320CoordinationOfBenefits CoordinationOfBenefits Coordination Of Benefits PegaX125010

PegaX12-Data-N834-Loop2330COBRelatedEntity COBOtherInsuranceCompanyCityStateZIP COBOtherInsuranceCompanyCityStateZIP PegaX125010

PegaX12-Data-N834-Loop2330COBRelatedEntity COBRelatedEntity COBRelatedEntity PegaX125010

PegaX12-Data-N834-Loop2330COBRelatedEntity AdministrativeCommunicationsContact AdministrativeCommunicationsContact PegaX125010

PegaX12-Data-N834-Loop2330COBRelatedEntity COBRelatedEntityAddress COBRelatedEntityAddress PegaX125010PegaX12-Data-N834-

Loop2700MemberReportingCategories MemberReportingCategories LX_MemberReportingCategories PegaX125010PegaX12-Data-N834-

Loop2700MemberReportingCategories Loop2750ReportingCategory ReportingCategory PegaX125010

PegaX12-Data-N834-Loop2750ReportingCategory ReportingCategoryDate DTP_ReportingCategoryDate PegaX125010

PegaX12-Data-N834-Loop2750ReportingCategory ReportingCategory N1_ReportingCategory PegaX125010

PegaX12-Data-N834-Loop2750ReportingCategory ReportingCategoryReference REF_ReportingCategoryReference PegaX125010PegaX12-Data-N834-Trailer TransactionSetTrailer TransactionSetTrailer PegaX125010PegaX12-Data-N834-Transaction Loop2000MemberLevelDetail Loop2000MemberLevelDetail PegaX125010PegaX12-Data-N834-Transaction Header Header PegaX125010PegaX12-Data-N834-Transaction Trailer Trailer PegaX125010PegaX12-Data-N837 HealthcareClaim Healthcare Claim PegaX125010

PegaX12-Data-N837-BillingPayToProviderLevel Loop2000ABillingPayToProvider Loop2000ABillingPayToProvider PegaX125010PegaX12-Data-N837-BillingProviderLevel Loop2000ABillingProvider Loop2000ABillingPayToProvider PegaX125010PegaX12-Data-N837-Header Loop1000ASubmitterName Loop1000ASubmitterName PegaX125010PegaX12-Data-N837-Header BeginningOfHierarchicalTransaction BeginningOfHierarchicalTransaction PegaX125010PegaX12-Data-N837-Header TransactionSetHeader TransactionSetHeader PegaX125010PegaX12-Data-N837-Header Loop1000BReceiverName Loop1000BReceiverName PegaX125010PegaX12-Data-N837-HealthcareClaim Transaction Transaction PegaX125010PegaX12-Data-N837-HealthcareClaim FunctionalGroupHeader Functional Group Header PegaX125010PegaX12-Data-N837-HealthcareClaim FunctionalGroupTrailer Functional Group Trailer PegaX125010

PegaX12-Data-N837-Loop1000ASubmitterName SubmitterName Submitter Name PegaX125010

PegaX12-Data-N837-Loop1000ASubmitterName SubmitterEDIContactInformation Submitter EDI Contact Information PegaX125010

PegaX12-Data-N837-Loop1000ASubmitterName AdditionalSubmitterName Additional Submitter Name PegaX125010PegaX12-Data-N837-Loop1000BReceiverName ReceiverName Receiver Name PegaX125010PegaX12-Data-N837-Loop1000BReceiverName AdditionalReceiverName Additional Receiver Name PegaX125010PegaX12-Data-N837-

Loop2000ABillingPayToProvider SubscriberLevel SubscriberLevel PegaX125010PegaX12-Data-N837-

Loop2000ABillingPayToProvider Loop2010ACPayToPlanName Loop2010ACPayToPlanName PegaX125010PegaX12-Data-N837-

Loop2000ABillingPayToProvider Loop2010AABillingProviderName Loop2010AABillingProviderName PegaX125010PegaX12-Data-N837-

Loop2000ABillingPayToProvider BillingPayToProviderSpecialty Billing Pay To Provider Specialty PegaX125010PegaX12-Data-N837-

Loop2000ABillingPayToProvider BillingPayToProviderHierarchicalLevel Billing Pay To Provider Hierarchical Level PegaX125010PegaX12-Data-N837-

Loop2000ABillingPayToProvider ForeignCurrencyInformation Foreign Currency Information PegaX125010PegaX12-Data-N837-

Loop2000ABillingPayToProvider Loop2010ABPayToProviderName Loop2010ABPayToProviderName PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider Loop2010ABPayToProviderName Loop2010ABPayToProviderName PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider ForeignCurrencyInformation Foreign Currency Information PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider SubscriberLevel SubscriberLevel PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider BillingProviderSpecialty Billing Pay To Provider Specialty PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider Loop2010ABPayToAddressName Loop2010ABPayToProviderName PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider BillingProviderHierarchicalLevel Billing Pay To Provider Hierarchical Level PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider Loop2010ACPayToPlanName Loop2010ACPayToPlanName PegaX125010

PegaX12-Data-N837-Loop2000ABillingProvider Loop2010AABillingProviderName Loop2010AABillingProviderName PegaX125010

PegaX12-Data-N837-Loop2000BSubscriber Loop2010BDCreditDebitCardHolderName

Loop2010BD Credit/Debit Card Holder

Name PegaX125010PegaX12-Data-N837-Loop2000BSubscriber Loop2300ClaimInformation Loop 2300 Claim Information PegaX125010PegaX12-Data-N837-Loop2000BSubscriber PatientInformation Patient Information PegaX125010

PegaX12-Data-N837-Loop2000BSubscriber Loop2010BCPayerName Loop 2010BC Payer Name PegaX125010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BASubscriberName Loop2010BASubscriberName PegaX125010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BCResponsiblePartyName Loop2010BC Responsible Party Name PegaX125010PegaX12-Data-N837-Loop2000BSubscriber Loop2010BBPayerName Loop 2010BB Payer Name PegaX125010PegaX12-Data-N837-Loop2000BSubscriber SubscriberInformation Subscriber Information PegaX125010PegaX12-Data-N837-Loop2000BSubscriber PatientLevel PatientLevel PegaX125010PegaX12-Data-N837-Loop2000BSubscriber SubscriberHierarchicalLevel Subscriber Hierarchical Level PegaX125010PegaX12-Data-N837-Loop2000CPatient PatientHierarchicalLevel Patient Hierarchical Level PegaX125010PegaX12-Data-N837-Loop2000CPatient Loop2010CAPatientName Loop 2010CA Patient Name PegaX125010PegaX12-Data-N837-Loop2000CPatient Loop2300ClaimInformation Loop 2300 Claim Information PegaX125010PegaX12-Data-N837-Loop2000CPatient PatientInformation Patient Information PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderCityStateZipCode Billing Provider City State Zip Code PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderName Billing Provider Name PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderTaxIdentification Billing Provider Tax Identification PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderSecondaryIdentification Billing Provider Secondary Identification PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderUPINLicenseInformation Billing Provider UPIN License Information PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderContactInformation Billing Provider Contact Information PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingProviderAddress Billing Provider Address PegaX125010PegaX12-Data-N837-

Loop2010AABillingProviderName BillingPayToProviderSpecialty Billing Pay To Provider Specialty PegaX125010PegaX12-Data-N837-

Loop2010ABPayToAddressName PayToAddressCityStateZipCode Pay To Address City State Zip Code PegaX125010PegaX12-Data-N837-

Loop2010ABPayToAddressName PayToAddressAddress Pay To Address Address PegaX125010PegaX12-Data-N837-

Loop2010ABPayToAddressName PayToAddressName Pay To Address Name PegaX125010PegaX12-Data-N837-

Loop2010ABPayToProviderName PayToProviderName Pay To Provider Name PegaX125010PegaX12-Data-N837-

Loop2010ABPayToProviderName PayToProviderCityStateZipCode Pay To Provider City State Zip Code PegaX125010PegaX12-Data-N837-

Loop2010ABPayToProviderName PayToProviderAddress Pay To Provider Address PegaX125010

PegaX12-Data-N837-Loop2010ACPayToPlanName PayToPlanSecondaryIdentification PayToPlanSecondaryIdentification PegaX125010

PegaX12-Data-N837-Loop2010ACPayToPlanName PayToPlanCityStateZipCode PayToPlanCityStateZIPCode PegaX125010

PegaX12-Data-N837-Loop2010ACPayToPlanName PayToPlanName PayToPlanName PegaX125010

PegaX12-Data-N837-Loop2010ACPayToPlanName PayToPlanTaxIdentification PayToPlanTaxIdentificationNumber PegaX125010

PegaX12-Data-N837-Loop2010ACPayToPlanName PayToPlanAddress PayToPlanAddress PegaX125010

PegaX12-Data-N837-Loop2010ACPayToPlanName PayToPlanTaxIdentificationNumber PayToPlanTaxIdentificationNumber PegaX125010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberName Subscriber Name PegaX125010

PegaX12-Data-N837-Loop2010BASubscriberName PropertyAndCasualtyClaimNumber Property and Casualty Claim Number PegaX125010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberCityStateZipCode Subscriber City State Zip Code PegaX125010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberDemographicInformation Subscriber Demographic Information PegaX125010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberAddress Subscriber Address PegaX125010

PegaX12-Data-N837-Loop2010BASubscriberName SubscriberSecondaryIdentification Subscriber Secondary Identification PegaX125010

PegaX12-Data-N837-Loop2010BASubscriberName

PropertyAndCasualtySubscriberContactInf

ormation

PropertyAndCasualtySubscriberContactIn

formation PegaX125010PegaX12-Data-N837-

Loop2010BBCreditDebitCardHolderName CreditDebitCardHolderName Credit/Debit Card Holder Name PegaX125010PegaX12-Data-N837-

Loop2010BBCreditDebitCardHolderName CreditDebitCardInformation CreditDebitCardInformation PegaX125010

PegaX12-Data-N837-Loop2010BBPayerName BillingProviderSecondaryIdentification BillingProviderSecondaryIdentification PegaX125010PegaX12-Data-N837-Loop2010BBPayerName PayerAddress Payer Address PegaX125010PegaX12-Data-N837-Loop2010BBPayerName AdditionalNameInformation Additional Name Information PegaX125010PegaX12-Data-N837-Loop2010BBPayerName PayerName Payer Name PegaX125010PegaX12-Data-N837-Loop2010BBPayerName PayerCityStateZipCode Payer City State Zip Code PegaX125010PegaX12-Data-N837-Loop2010BBPayerName PayerSecondaryIdentification Payer Secondary Identification PegaX125010PegaX12-Data-N837-Loop2010BCPayerName PayerName Payer Name PegaX125010PegaX12-Data-N837-Loop2010BCPayerName PayerSecondaryIdentification Payer Secondary Identification PegaX125010PegaX12-Data-N837-Loop2010BCPayerName PayerAddress Payer Address PegaX125010

PegaX12-Data-N837-Loop2010BCPayerName PayerCityStateZipCode Payer City State Zip Code PegaX125010PegaX12-Data-N837-Loop2010BCPayerName AdditionalNameInformation Additional Name Information PegaX125010PegaX12-Data-N837-

Loop2010BCResponsiblePartyName ResponsiblePartyAddress Responsible Party Address PegaX125010PegaX12-Data-N837-

Loop2010BCResponsiblePartyName ResponsiblePartyName Responsible Party Name PegaX125010PegaX12-Data-N837-

Loop2010BCResponsiblePartyName ResponsiblePartyCityStateZipCode ResponsiblePartyCityStateZipCode PegaX125010PegaX12-Data-N837-

Loop2010BDCreditDebitCardHolderName CreditDebitCardInformation CreditDebitCardInformation PegaX125010PegaX12-Data-N837-

Loop2010BDCreditDebitCardHolderName CreditDebitCardHolderName Credit/Debit Card Holder Name PegaX125010PegaX12-Data-N837-

Loop2010BDResponsiblePartyName ResponsiblePartyCityStateZipCode ResponsiblePartyCityStateZipCode PegaX125010PegaX12-Data-N837-

Loop2010BDResponsiblePartyName ResponsiblePartyName Responsible Party Name PegaX125010PegaX12-Data-N837-

Loop2010BDResponsiblePartyName ResponsiblePartyAddress Responsible Party Address PegaX125010

PegaX12-Data-N837-Loop2010CAPatientName

PropertyAndCasualtyPatientContactInfor

mation

PropertyAndCasualtyPatientContactInfor

mation PegaX125010PegaX12-Data-N837-Loop2010CAPatientName PatientAddress Patient Address PegaX125010PegaX12-Data-N837-Loop2010CAPatientName PatientCityStateZipCode Patient City/State/Zip Code PegaX125010PegaX12-Data-N837-Loop2010CAPatientName PatientDemographicInformation Patient Demographic Information PegaX125010

PegaX12-Data-N837-Loop2010CAPatientName PropertyAndCasualtyPatientIdentifier Property And Casualty Patient Identifier PegaX125010PegaX12-Data-N837-Loop2010CAPatientName PropertyAndCasualtyClaimNumber Property And Casualty Claim Number PegaX125010PegaX12-Data-N837-Loop2010CAPatientName PatientName Patient Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation OtherDiagnosisInformation Other Diagnosis Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PatientEstimatedAmountDue Patient Estimated Amount Due PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ToothStatus Tooth Status PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation AmbulanceTransportInformation Ambulance Transport Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation BillingNote Billing Note PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateEstimatedDateOfBirth

Date - Estimated Date Of Birth - obsolete

per the IG Addendum PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateHearingAndVisionPrescriptionDate

Date - Hearing And Vision Prescription

Date PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastWorked Date - Last Worked PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation FileInformation File Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310AAttendingProviderName Loop2310A Attending Physician Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation CarePlanOversight CarePlanOversight PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimCode Claim Code PegaX125010


ClaimIdentificationNumberForClearingHou

ses


Houses PegaX125010



ntNumber


Amendment Number PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ConditionInformation Condition Information2 - type pagelist PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ContractInformation Contract Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateAssumedAndRelinquishedCareDates

Date - Assumed And Relinquished Care

Dates PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateDisabilityEnd Date - Disability End PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DentalClaimNote Claim Note PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DocumentIdentificationCode DocumentIdentificationCode PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DocumentIdentificationCode2 DocumentIdentificationCode2 PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ExternalCauseOfInjury ExternalCauseOfInjury PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310BRenderingProviderName Loop - 2310B Rendering Provider Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PriorAuthorization PriorAuthorization PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ValueInformation Value Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation RepricedClaimNumber Repriced Claim Number PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ServiceAuthorizationExceptionCode Service Authorization Exception Code PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation AnesthesiaModifyingUnits Anesthesia Modifying Units PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimSupplementalInformation Claim Supplemental Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateAcuteManifestation Date - Acute Manifestation PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateInitialTreatment Date - Initial Treatment PegaX125010


DatePropertyAndCasualtyDateOfFirstCont

act

DatePropertyAndCasualtyDateOfFirstCon

tact PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation InvestigationalDeviceExemptionNumber Investigational Device Exemption Number PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310AAttendingPhysicianName Loop2310A Attending Physician Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310BOperatingPhysicianName Loop2310B Operating Physician Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation OtherProcedureInformation Other Procedure Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PatientConditionInformationVision Patient Condition Information: Vision PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PROApprovalNumber PRO Approval Number PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310COtherProviderName Loop - 2310C Other Provider Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2400ServiceLine Loop2400 Service Line PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ProcedureInformation Procedure Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation SpinalManipulationServiceInformation Spinal Manipulation Service Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateAuthorizedReturnToWork Date - Authorized Return To Work PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateOnsetOfCurrentIllnessSymptom Date - Onset Of Current Illness/Symptom PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateReferralDate

Date - Referral Date - obsolete per the IG

Addendum PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DemonstrationProjectIdentifier Demonstration Project Identifier PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DiagnosisInformation DiagnosisInformation PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation EPSDTReferral EPSDT Referral PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation HomeHealthFunctionalLimitations HomeHealthFunctionalLimitations PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310AOperatingPhysicianName Loop2310A Operating Physician Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2320OtherSubscriberInformation Loop2320 Other Subscriber Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation OccurrenceInformation OccurrenceInformation2 - pagelist PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PatientAmountDue Patient Amount Due PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PatientAmountPaid Patient Amount Paid PegaX125010


PeerReviewOrganizationPROApprovalNum

ber

PeerReviewOrganizationPROApprovalNu

mber PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateOrderDate

Date - Order Date - obsolete - deleted

from IG in Addendum PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateRepricerReceivedDate DateRepricerReceivedDate PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateStatement Date - Statement PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2330FOtherPayerOtherProvider Loop - 2330F Other Payer Other Provider PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation MandatoryMedicareCrossoverIndicator Mandatory Medicare Crossover Indicator PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ReferralNumber ReferralNumber PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation AnesthesiaRelatedProcedure AnesthesiaRelatedProcedure PegaX125010


ClaimIdentifierForTransmissionIntermedia

ries


Houses PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateAccident Date - Accident PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateAdmission Date - Admission PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastSeen Date - Last Seen PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DischargeHour Discharge Hour PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation HealthCareDiagnosisCode HealthCareDiagnosisCode PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation AdmittingDiagnosis AdmittingDiagnosis PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation AmbulanceCertification Ambulance Certification PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimAmountDue Claim Amount Due PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimNote2

Claim Note 2 - page list version of

ClaimNote PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateAppliancePlacement Date - Appliance Placement PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateDischarge DateDischarge PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastMenstrualPeriod Date - Last Menstrual Period PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateLastXRay Date - Last X-Ray PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateServiceDate Date - Service Date PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310COtherOperatingPhysicianName Loop - 2310C Other Provider Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310CServiceFacilityLocation Loop - 2310C ServiceFacilityLocation PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310DSupervisingProviderName Loop2310D Supervising Provider Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310EServiceFacilityName Loop - 2310E Service Facility Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310ESupervisingProviderName Loop - 2310E Supervising Provider Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation MammographyCertificationNumber Mammography Certification Number PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation MedicalRecordNumber Medical Record Number PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation OccurrenceSpanInformation Occurrence Span Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PatientsReasonForVisit PatientsReasonForVisit PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation HomeboundIndicator Homebound Indicator PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310DAssistantSurgeonName Loop2310DAssistantSurgeonName PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310DRenderingProviderName Loop2310DRenderingProviderName PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation TreatmentCodeInformation Treatment Code Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation AdjustedRepricedClaimNumber Adjusted Repriced Claim Number PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimInformation Claim Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimNote Claim Note PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation ClaimPricingRepricingInformation Claim Pricing Repricing Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation OrthodonticTotalMonthsOfTreatment OrthodonticTotalMonthsOfTreatment PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PayerClaimControlNumber PayerClaimControlNumber PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation PredeterminationIdentification Predetermination Identification PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation AutoAccidentState AutoAccidentState PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DateDisabilityDates DateDisabilityDates PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation DiagnosisRelatedGroupInformation Diagnosis Related Group Information PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310AReferringProviderName Loop2310A Referring Provider Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310FAmbulanceDropOffLocation Loop2310F Referring Provider Name PegaX125010

PegaX12-Data-N837-Loop2300ClaimInformation Loop2310FReferringProviderName Loop2310F Referring Provider Name PegaX125010PegaX12-Data-N837-

Loop2305HomeHealthCarePlan HealthCareServicesDelivery Health Care Services Delivery PegaX125010PegaX12-Data-N837-

Loop2305HomeHealthCarePlan HomeHealthCarePlanInformation Home Health Care Plan Information PegaX125010PegaX12-Data-N837-

Loop2310AAttendingPhysicianName AttendingPhysicianSpecialityInformation Referring Provider Speciality Information PegaX125010

PegaX12-Data-N837-



n



Loop2310AAttendingPhysicianName AttendingPhysicianName Attending Provider Name PegaX125010PegaX12-Data-N837-

Loop2310AAttendingProviderName AttendingProviderSecondaryIdentification



Loop2310AAttendingProviderName AttendingProviderSpecialityInformation Referring Provider Speciality Information PegaX125010PegaX12-Data-N837-

Loop2310AAttendingProviderName AttendingProviderName Attending Provider Name PegaX125010PegaX12-Data-N837-

Loop2310AOperatingPhysicianName OperatingPhysicianName Operating Provider Name PegaX125010PegaX12-Data-N837-



n



Loop2310AOperatingPhysicianName OperatingPhysicianSpecialityInformation Operating Provider Speciality Information PegaX125010PegaX12-Data-N837-

Loop2310AReferringProviderName ReferringProviderName Referring Provider Name PegaX125010PegaX12-Data-N837-

Loop2310AReferringProviderName ReferringProviderSpecialtyInformation ReferringProviderSpecialtyInformation PegaX125010PegaX12-Data-N837-

Loop2310AReferringProviderName ReferringProviderSecondaryIdentification



Loop2310BOperatingPhysicianName OperatingPhysicianName Operating Provider Name PegaX125010PegaX12-Data-N837-

Loop2310BOperatingPhysicianName OperatingPhysicianSpecialityInformation

Operating Physician Speciality Info -




n



Loop2310BRenderingProviderName RenderingProviderSecondaryIdentification



Loop2310BRenderingProviderName RenderingProviderName Rendering Provider Name PegaX125010PegaX12-Data-N837-

Loop2310BRenderingProviderName RenderingProviderSpecialtyInformation Rendering Provider Specialty Information PegaX125010PegaX12-Data-N837-

Loop2310COtherOperatingPhysicianName OtherOperatingPhysicianName Other Operating Physician Name PegaX125010PegaX12-Data-N837-

Loop2310COtherOperatingPhysicianName

OtherOperatingPhysicianSecondaryIdentifi

cation Other Operating Physician Identification PegaX125010PegaX12-Data-N837-

Loop2310COtherProviderName OtherProviderSecondaryIdentification



PegaX12-Data-N837-

Loop2310COtherProviderName OtherProviderName Referring Provider Name PegaX125010PegaX12-Data-N837-

Loop2310COtherProviderName OtherProviderSpecialityInformation

Other Provider Speciality Information -


Loop2310CPurchasedServiceProviderNm


fication



Loop2310CPurchasedServiceProviderNm PurchasedServiceProviderName Purchased Service Provider Name PegaX125010PegaX12-Data-N837-

Loop2310CServiceFacilityLocation ServiceFacilityLocationCityStateZipCode







tion



Loop2310CServiceFacilityLocation ServiceFacilityContactInformation Subscriber Contact Information PegaX125010PegaX12-Data-N837-

Loop2310DAssistantSurgeonName AssistantSurgeonName AssistantSurgeonName PegaX125010PegaX12-Data-N837-

Loop2310DAssistantSurgeonName AssistantSurgeonSecondaryIdentification

Assistant Surgeon Secondary


Loop2310DAssistantSurgeonName AssistantSurgeonSpecialtyInformation AssistantSurgeonSpecialityInformation PegaX125010PegaX12-Data-N837-





Referring Provider Name - obsolete per IG


Loop2310DReferringProviderName ReferringProviderSpecialityInformation

Referring Provider Speciality Info -


Loop2310DRenderingProviderName RenderingProviderName RenderingProviderName PegaX125010PegaX12-Data-N837-

Loop2310DRenderingProviderName RenderingProviderSecondaryIdentification

RenderingProviderSecondaryIdentificatio


Loop2310DServiceFacilityLocation ServiceFacilityLocation Service Facility Location PegaX125010PegaX12-Data-N837-

Loop2310DServiceFacilityLocation ServiceFacilityLocationAddress Service Facility Location Address PegaX125010PegaX12-Data-N837-

Loop2310DServiceFacilityLocation ServiceFacilityLocationCityStateZipCode


Code PegaX125010

PegaX12-Data-N837-

Loop2310DServiceFacilityLocation


tion






n



Loop2310EAmbulancePickUpLocation AmbulancePickUpLocationCityStateZip Ambulance Pick Up Location City State Zip PegaX125010PegaX12-Data-N837-

Loop2310EAmbulancePickUpLocation AmbulancePickUpLocation Ambulance Pick Up Location PegaX125010PegaX12-Data-N837-

Loop2310EAmbulancePickUpLocation AmbulancePickUpLocationAddress Ambulance Pick Up Location Address PegaX125010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilityAddress Service Facility Location Address PegaX125010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilityCityStateZipCode



Loop2310EServiceFacilityName ServiceFacilitySpecialtyInformation

Service Facility Specialty Info - obsolete

per IG Addendum PegaX125010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilityName ServiceFacilityName PegaX125010PegaX12-Data-N837-

Loop2310EServiceFacilityName ServiceFacilitySecondaryIdentification



Loop2310ESupervisingProviderName SupervisingProviderName Supervising Provider Name PegaX125010PegaX12-Data-N837-

Loop2310ESupervisingProviderName


n



Loop2310FAmbulanceDropOffLocation AmbulanceDropOffLocationCityStateZip

Ambulance Drop Off Location City State

Zip PegaX125010PegaX12-Data-N837-

Loop2310FAmbulanceDropOffLocation AmbulanceDropOffLocation Ambulance Drop Off Location PegaX125010PegaX12-Data-N837-

Loop2310FAmbulanceDropOffLocation AmbulanceDropOffLocationAddress Ambulance Drop Off Location Address PegaX125010PegaX12-Data-N837-


Loop2310FReferringProviderName ReferringProviderSecondaryIdentification Referring Provider Secondary Ident PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation SubscriberDemographicInformation Subscriber Demographic Information PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation ClaimLevelAdjustments Claim Level Adjustments PegaX125010

PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330COtherPayerAttendingProvidr Loop2330DOtherPayerAttendingProvidr PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330GOtherPayerSvcFacilityLoc Loop2330HOtherPayerSvcFacProvider PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330HOtherPayerReferringProvider

Loop2330H Other Payer Supervising


Loop2320OtherSubscriberInformation Loop2330DOtherPayerOperatingProvidr Loop2330DOtherPayerOperatingProvidr PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330EOtherPayerOperatingProvidr Loop2330EOtherPayerOperatingProvidr PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330EOtherPayerSvcFacilityLoc Loop2330EOtherPayerSvcFacilityLoc PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330GOtherPayerRenderingProvider




Loop2330GOtherPayerServiceFacilityLocat

ion



Loop2320OtherSubscriberInformation Loop2330HOtherPayerAssistantSurgeon Loop2330HOtherPayerAssistantSurgeon PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation PayerPriorPayment PayerPriorPayment PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation CoordinationOfBenefitsPayerPaidAmount

Coordination Of Benefits Payer Paid



CoordinationOfBenefitsTotalNonCoveredA

mount

CoordinationOfBenefitsTotalNonCovered




n




CoordinationOfBenefitsMedicareATrustFu

ndPaidAmount

CoordinationOfBenefitsMedicareATrustF

undPaidAmount PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330BOtherPayerName Loop2330B Other Payer Name PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330COtherPayerReferringProvider

Loop2330C Other Payer Referring


Loop2320OtherSubscriberInformation Loop2330DOtherPayerRenderingProvider

Loop2330D Other Payer Rendering


Loop2320OtherSubscriberInformation Loop2330EOtherPayerSupervisingProvider

Loop2330EOtherPayerSupervisingProvide

r PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation COBTotalNoncoveredAmount COBTotalNoncoveredAmount PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330EOtherPayerOtherOpProvidr Loop2330FOtherPayerOtherProvider PegaX125010

PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330FOtherPayerOtherProvider Loop2330FOtherPayerOtherProvider PegaX125010PegaX12-Data-N837-


MedicareOutpatientAdjudicationInformati

on

Medicare Outpatient Adjudication


Loop2320OtherSubscriberInformation COBPayerPaidAmount COB Payer Paid Amount PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330DOtherPayerAttendingProvidr Loop2330DOtherPayerAttendingProvidr PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330IOtherPayerBillingProvider Loop2330HOtherPayerSvcFacProvider PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation OtherSubscriberInformation Other Subscriber Information PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation RemainingPatientLiability Remaining Patient Liability PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330AOtherSubscriberName Loop2330A Other Subscriber Name PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330FOtherPayerBillingProvider Loop2330GOtherPayerBillingProvider PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330FOtherPayerSupervisingProvider

Loop2330FOtherPayerSupervisingProvide

r PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330GOtherPayerBillingProvider Loop2330GOtherPayerBillingProvider PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330FOtherPayerSvcFacLocation Loop2330FOtherPayerOtherProvider PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation Loop2330HOtherPayerSvcFacProvider Loop2330HOtherPayerSvcFacProvider PegaX125010PegaX12-Data-N837-

Loop2320OtherSubscriberInformation OtherInsuranceCoverageInformation Other Insurance Coverage Information PegaX125010PegaX12-Data-N837-

Loop2330AOtherSubscriberName OtherSubscriberDemographicInformation



Loop2330AOtherSubscriberName OtherSubscriberSecondaryIdentification Other Subscriber Secondary Identification PegaX125010PegaX12-Data-N837-

Loop2330AOtherSubscriberName OtherSubscriberAddress Other Subscriber Address PegaX125010PegaX12-Data-N837-

Loop2330AOtherSubscriberName OtherSubscriberCityStateZipCode Other Subscriber City/State/Zip Code PegaX125010PegaX12-Data-N837-

Loop2330AOtherSubscriberName OtherSubscriberName Other Subscriber Name PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerPriorAuthorizationNumber Other Payer Prior Authorization Number PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerAddress Other Payer Address PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerPredeterminationIdentification Other Payer Predetermination Identifier PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerClaimAdjustmentIndicator Other Payer Claim Adjustment Indicator PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerReferralNumber Other Payer Referral Number PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName Date_ClaimCheckOrRemittanceDate Date_ClaimCheck PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerClaimAdjustmentIndicator2 OtherPayerClaimAdjustmentIndicator2 PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerClaimControlNumber2 OtherPayerClaimControlNumber2 PegaX125010



umber2


Referral Number - Page type PegaX125010



umber


Referral Number PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerCityStateZipCode Other Payer City/State/Zip Code PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerClaimControlNumber Other Payer Claim Control Number PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerName Other Payer Name PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerSecondaryIdentification Other Payer Secondary Identifier PegaX125010

PegaX12-Data-N837-Loop2330BOtherPayerName OtherPayerSecondaryIdentifier Other Payer Secondary Identifier PegaX125010PegaX12-Data-N837-

Loop2330COtherPayerAttendingProvidr


n



Loop2330COtherPayerAttendingProvidr OtherPayerAttendingProvider Other Payer Attending Provider PegaX125010PegaX12-Data-N837-

Loop2330COtherPayerPatientInfo OtherPayerPatientIdentification Other Payer Patient Identification PegaX125010PegaX12-Data-N837-

Loop2330COtherPayerPatientInfo OtherPayerPatientInformation Other Payer Patient Information PegaX125010PegaX12-Data-N837-

Loop2330COtherPayerReferringProvidr OtherPayerReferringProvider Other Payer Referring Provider PegaX125010PegaX12-Data-N837-

Loop2330COtherPayerReferringProvidr

OtherPayerReferringProviderSecondaryIde

ntifier



PegaX12-Data-N837-

Loop2330DOtherPayerAttendingProvidr OtherPayerAttendingProvider Other Payer Attending Provider PegaX125010PegaX12-Data-N837-

Loop2330DOtherPayerAttendingProvidr


n



Loop2330DOtherPayerOperatingProvidr

OtherPayerOperatingProviderSecondaryId

entification



Loop2330DOtherPayerOperatingProvidr OtherPayerOperatingProvider Other Payer Operating Provider PegaX125010PegaX12-Data-N837-

Loop2330DOtherPayerReferringProvidr OtherPayerReferringProviderIdentification



Loop2330DOtherPayerReferringProvidr OtherPayerReferringProvider Other Payer Referring Provider PegaX125010PegaX12-Data-N837-

Loop2330DOtherPayerRenderingProvidr


entifier



Loop2330DOtherPayerRenderingProvidr OtherPayerRenderingProvider Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330EOtherPayerOperatingProvidr OtherPayerOperatingProvider Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-


OtherPayerOperatingProviderIdentificatio

n




OtherPayerOperatingProviderSecondaryId

entification



Loop2330EOtherPayerOtherOpProvidr OtherPayerOtherOperatingProvider Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330EOtherPayerOtherOpProvidr

OtherPayerOtherOperatingProviderSecon

daryIdentification

Other Payer Other Operating Provider


Loop2330EOtherPayerRenderingProvidr OtherPayerRenderingProvider Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330EOtherPayerRenderingProvidr


entification



Loop2330EOtherPayerSuperivisingProvdr OtherPayerSupervisingProvider OtherPayerSupervisingProvider PegaX125010PegaX12-Data-N837-

Loop2330EOtherPayerSuperivisingProvdr

OtherPayerSupervisingProviderSecondaryI

dentification

OtherPayorSupervisingProviderSecondary


Loop2330EOtherPayerSvcFacilityLoc

OtherPayerServiceFacilityLocationSeconda

ryIdentifier

OtherPayerServiceFacilityLocationSecond

aryIdentification PegaX125010PegaX12-Data-N837-

Loop2330EOtherPayerSvcFacilityLoc OtherPayerServiceFacilityLocation Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330FOtherPayerBillingProvider OtherPayerBillingProvider OtherPayerBillingProvider PegaX125010

PegaX12-Data-N837-

Loop2330FOtherPayerBillingProvider

OtherPayerBillingProviderSecondaryIdenti

fication

OtherPayerBillingProviderSecondaryIdent

ification PegaX125010PegaX12-Data-N837-

Loop2330FOtherPayerOtherProvider OtherPayerOtherProvider Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330FOtherPayerOtherProvider

OtherPayerOtherOperatingProviderSecon

daryIdentification

Other Payer Other Operating Provider


Loop2330FOtherPayerOtherProvider OtherPayerOtherProviderIdentification



Loop2330FOtherPayerPurchSvcProvider OtherPayerPurchasedServiceProvider Other Payer Purchased Service Provider PegaX125010PegaX12-Data-N837-

Loop2330FOtherPayerPurchSvcProvider

OtherPayerPurchasedServiceProviderIdent

ification

Other Payer Purchased Service Provider


Loop2330FOtherPayerSupervisingProvider OtherPayerSupervisingProvider Other Payer Supervising Provider PegaX125010PegaX12-Data-N837-

Loop2330FOtherPayerSupervisingProvider

OtherPayerSupervisingProviderSecondaryI

dentification



Loop2330FOtherPayerSvcFacLocation OtherPayerServiceFacilityLocation Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330FOtherPayerSvcFacLocation


ryIdentifier



Loop2330FOtherPayerSvcFacLocation


ryIdentification



Loop2330GOtherPayerBillingProvider


fication

Other Payer Billiing Provider


Loop2330GOtherPayerBillingProvider OtherPayerBillingProvider Other Payer Billing Provider PegaX125010PegaX12-Data-N837-

Loop2330GOtherPayerReferringProvidr OtherPayerReferringProvider

Other Payer Rendering Provider -


Loop2330GOtherPayerReferringProvidr OtherPayerReferringProviderIdentification

OtherPayerReferringProviderIdent -


Loop2330GOtherPayerRenderingProvider OtherPayerRenderingProvider Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330GOtherPayerRenderingProvider


entifier



Loop2330GOtherPayerSvcFacilityLoc OtherPayerServiceFacilityLocation Other Payer Service Facility Location PegaX125010PegaX12-Data-N837-

Loop2330GOtherPayerSvcFacilityLoc

OtherPayerServiceFacilityLocationIdentific

ation

Other Payer Service Facility Location


Loop2330HOtherPayerAssistantSurgeon

OtherPayerAssistantSurgeonSecondaryIde

ntifier

OtherPayerAssistantSurgeonSecondaryId

entifier PegaX125010

PegaX12-Data-N837-

Loop2330HOtherPayerAssistantSurgeon OtherPayerAssistantSurgeon OtherPayerAssistantSurgeon PegaX125010PegaX12-Data-N837-

Loop2330HOtherPayerReferringProvider

OtherPayerReferringProviderSecondaryIde

ntifier

Other Payer Referring Provider Secondary


Loop2330HOtherPayerReferringProvider OtherPayerReferringProvider Other Payer Referring Provider PegaX125010PegaX12-Data-N837-

Loop2330HOtherPayerSuperviseProvidr

OtherPayerSupervisingProviderIdentificati

on



Loop2330HOtherPayerSuperviseProvidr OtherPayerSupervisingProvider Other Payer Supervising Provider PegaX125010PegaX12-Data-N837-

Loop2330HOtherPayerSvcFacProvider OtherPayerServiceFacilityProvider Other Payer Rendering Provider PegaX125010PegaX12-Data-N837-

Loop2330HOtherPayerSvcFacProvider

OtherPayerServiceFacilityProviderIdentific

ation



Loop2330IOtherPayerBillingProvider OtherPayerBillingProvider Other Payer Billing Provider PegaX125010PegaX12-Data-N837-

Loop2330IOtherPayerBillingProvider


fication

Other Payer Billiing Provider

Identification PegaX125010PegaX12-Data-N837-Loop2400ServiceLine DMERCConditionIndicator DMERC Condition Indicator PegaX125010PegaX12-Data-N837-Loop2400ServiceLine LinePricingRepricingInformation Line Pricing/Repricing Information PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2410DrugIdentification Loop2410DrugIdentification PegaX125010PegaX12-Data-N837-Loop2400ServiceLine InstitutionalService Institutional Service PegaX125010PegaX12-Data-N837-Loop2400ServiceLine LineNote Line Note PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420BOperatingPhysicianName Loop2420BOperatingPhysicianName PegaX125010


Loop2420GOtherPayerPriorAuthorization

OrReferralNumber


Authorization Or Referral Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine MammographyCertificationNumber Mammography Certification Number PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine PrescriptionNumber

Prescription Number - Obsolete (removed

from IG) PegaX125010PegaX12-Data-N837-Loop2400ServiceLine RepricedClaimNumber RepricedClaimNumber PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420ARenderingProviderName Loop2420A Rendering Provider Name PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420CSupervisingProviderName Loop2420CSupervising Provider Name PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Loop2420GAmbulancePickupLocation


Authorization Or Referral Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ObstetricAnesthesiaAdditionalUnits Obstetric Anesthesia Additional Units PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine PriorAuthorizationOrReferralNumber Prior Authorization Or Referral Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420DSupervisingProvierName Loop2420D Supervising Provier Name PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Loop2420HAmbulanceDropOffLocation Loop2420H Ambulance Drop Off Location PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Loop2430LineAdjudicationInformation Loop2430 Line Adjudication Information PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ServiceLine Service Line PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ServiceLineDate AssessmentDate PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ThirdPartyOrganizationNote Third Party Organization Note PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ToothInformation ToothInformation PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_LastCertificationDate Date_Last Certification Date PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_PrescriptionDate Date_PrescriptionDate PegaX125010PegaX12-Data-N837-Loop2400ServiceLine DentalService Dental Service PegaX125010PegaX12-Data-N837-Loop2400ServiceLine DurableMedicalEquipmentService Durable Medical Equipment Service PegaX125010PegaX12-Data-N837-Loop2400ServiceLine FileInformation File Information PegaX125010PegaX12-Data-N837-Loop2400ServiceLine SalesTaxAmount Sales Tax Amount PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine ServicePredeterminationIdentification ServicePredeterminationIdentification PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_DateLastSeen Date_Date Last Seen PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_LastXRay Date_Last X-Ray PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Date_OrderDate

Date_Order Date - obsolete per the IG

Addendum PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_TestDate Date_TestDate - Replaces Date_Test PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine DurableMedicalEquipmentCertification Durable Medical Equipment Certification PegaX125010PegaX12-Data-N837-Loop2400ServiceLine HealthCareServicesDelivery Health Care Services Delivery PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ImmunizationBatchNumber Immunization Batch Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine LineSupplementalInformation LineSupplementalInformation PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420AOperatingPhysicianName Loop2420BOperatingPhysicianName PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420BAssistantSurgeonName Loop2420BAssistantSurgeonName PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Loop2420BOtherOperatingPhysicianName Loop2420BOperatingPhysicianName PegaX125010


AdjustedRepricedLineItemReferenceNumb

er

Adjusted Repriced Line Item Reference

Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine AmbulanceTransportInformation Ambulance Transport Information PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ContractInformation Contract Information PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_BeginTherapyDate Date_Begin Therapy Date PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_CertificationRevisionDate Date_Certification Revision Date PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine AnesthesiaModifyingUnits

Anesthesia Modifying Units - obsolete per

IG Addendum PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_Shipped Date_Shipped PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Date_Test

Date_Test - obsolete - use Date_TestDate

instead. PegaX125010PegaX12-Data-N837-Loop2400ServiceLine HospiceEmployeeIndicator Hospice Employee Indicator PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine ItemReferenceNumber Item Reference Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420DReferringProviderName Loop2420BOperatingPhysicianName PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420FReferringProviderName Loop2420F Referring Provider Name PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2440FormIdentificationCode Loop2440 Form Identification Code PegaX125010PegaX12-Data-N837-Loop2400ServiceLine PostageClaimedAmount Postage Claimed Amount PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Loop2420DServiceFacilityLocationName Loop2420DServiceFacilityLocationName PegaX125010


ReferringClinicalLaboratoryImprovementA

mendmentFacilityIdent

Referring Clinical Laboratory

Improvement AmendmentFacilityIdent PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420CServiceFacilityLocation Loop2420C Service Facility Location PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ReferralNumber Referral Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine TestResult Test Result PegaX125010



est

Date_OxygenSaturation/ArterialBloodGas

Test -obsolete-see history PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Date_ReferralDate

Date_Referral Date - obsolete per the IG

Addendum PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_ServiceDate Date - Service Date PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_TreatmentCompletion Date - Treatment Completion PegaX125010PegaX12-Data-N837-Loop2400ServiceLine FacilityTaxAmount FacilityTaxAmount PegaX125010


Loop2420BPurchasedServiceProviderNam

e

Loop2420B Purchased Service Provider

Name PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420COtherProviderName Loop2420COtherProviderName PegaX125010PegaX12-Data-N837-Loop2400ServiceLine PurchasedServiceInformation Purchased Service Information PegaX125010PegaX12-Data-N837-Loop2400ServiceLine AmbulancePatientCount Ambulance Patient Count PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_InitialTreatment Date_Initial Treatment PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_PriorPlacement Date - PriorPlacement PegaX125010PegaX12-Data-N837-Loop2400ServiceLine DMERCCMNIndicator DMERC CMN Indicator PegaX125010


DurableMedicalEquipmentCertificateOfMe

dicalNecessityIndicator DMERC CMN Indicator PegaX125010PegaX12-Data-N837-Loop2400ServiceLine LineItemControlNumber Line Item Control Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420CRenderingProviderName Loop2420BOperatingPhysicianName PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_Replacement Date - Replacement PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_TreatmentStart Date - Treatment Start PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine Loop2420DSupervisingProviderName Loop2420D Supervising Provider Name PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Loop2420EOrderingProviderName Loop2420E Ordering Provider Name PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ProfessionalService Professional Service PegaX125010PegaX12-Data-N837-Loop2400ServiceLine RepricedLineItemReferenceNumber Repriced Line Item Reference Number PegaX125010PegaX12-Data-N837-Loop2400ServiceLine ServiceTaxAmount ServiceTaxAmount PegaX125010PegaX12-Data-N837-Loop2400ServiceLine AmbulanceCertification Ambulance Certification PegaX125010

PegaX12-Data-N837-Loop2400ServiceLine AdjustedRepricedClaimNumber AdjustedRepricedClaimNumber PegaX125010



ntIdentification


Amendment Identification PegaX125010PegaX12-Data-N837-Loop2400ServiceLine Date_AppliancePlacement Date - AppliancePlacement PegaX125010

PegaX12-Data-N837-Loop2410DrugIdentification

PrescriptionOrCompoundDrugAssociation

Number

Prescription Or Compound Drug

Association Number PegaX125010

PegaX12-Data-N837-Loop2410DrugIdentification DrugIdentification DrugIdentification PegaX125010

PegaX12-Data-N837-Loop2410DrugIdentification PrescriptionNumber PrescriptionNumber PegaX125010

PegaX12-Data-N837-Loop2410DrugIdentification DrugPricing DrugPricing PegaX125010PegaX12-Data-N837-



n



Loop2420AAttendingPhysicianName AttendingPhysicianName Rendering Provider Name PegaX125010PegaX12-Data-N837-

Loop2420AAttendingPhysicianName AttendingPhysicianSpecialityInformation

Attending Physician Speciality Info -




n2



Loop2420AOperatingPhysicianName OperatingPhysicianName OperatingPhysicianName PegaX125010PegaX12-Data-N837-



n



Loop2420ARenderingProviderName RenderingProviderSecondaryIdentification



Loop2420ARenderingProviderName RenderingProviderName Rendering Provider Name PegaX125010PegaX12-Data-N837-

Loop2420ARenderingProviderName RenderingProviderSpecialityInformation Rendering Provider Speciality Information PegaX125010PegaX12-Data-N837-

Loop2420BAssistantSurgeonName AssistantSurgeonName AssistantSurgeonName PegaX125010PegaX12-Data-N837-

Loop2420BAssistantSurgeonName AssistantSurgeonSpecialtyInformation AssistantSurgeonSpecialtyInformation PegaX125010PegaX12-Data-N837-

Loop2420BAssistantSurgeonName AssistantSurgeonSecondaryIdentification AssistantSurgeonSecondaryIdentification PegaX125010PegaX12-Data-N837-

Loop2420BOperatingPhysicianName OperatingPhysicianName OperatingPhysicianName PegaX125010PegaX12-Data-N837-



n


n PegaX125010

PegaX12-Data-N837-

Loop2420BOperatingPhysicianName OperatingPhysicianSpecialtyInformation

OperatingPhysicianSpecialtyInfo -


Loop2420BOtherOperatingPhysicianName OtherOperatingPhysicianName Other Operating Physician Name PegaX125010PegaX12-Data-N837-

Loop2420BOtherOperatingPhysicianName

OtherOperatingPhysicianSecondaryIdentifi

cation

Other Operating Physician Secondary


Loop2420BPurchasedServiceProviderNm PurchasedServiceProviderName Purchased Service Provider Name PegaX125010PegaX12-Data-N837-

Loop2420BPurchasedServiceProviderNm


fication



Loop2420COtherProviderName OtherProviderSpecialtyInformation

OtherProviderSpecialtyInformation -


Loop2420COtherProviderName OtherProviderName Other Provider Name PegaX125010PegaX12-Data-N837-

Loop2420COtherProviderName OtherProviderSecondaryIdentification Other Provider Secondary Identification PegaX125010PegaX12-Data-N837-

Loop2420CRenderingProviderName RenderingProviderName Rendering Provider Name PegaX125010PegaX12-Data-N837-

Loop2420CRenderingProviderName RenderingProviderSecondaryIdentification






tion



Loop2420CServiceFacilityLocation ServiceFacilityLocationCityStateZip Service Facility Location City/State/Zip PegaX125010PegaX12-Data-N837-


Loop2420CSupervisingProviderName


n

SupervisingProviderSecondaryIdentificati

on PegaX125010PegaX12-Data-N837-

Loop2420CSupervisingProviderName SupervisingProviderName SupervisingProviderName PegaX125010PegaX12-Data-N837-


ReferringProviderName - obsolete per IG


Loop2420DReferringProviderName ReferringProviderSpecialtyInformation

Referring Provider Specialty Info -


Loop2420DReferringProviderName ReferringProviderSecondaryIdentification Referring Provider Secondary Ident PegaX125010PegaX12-Data-N837-

Loop2420DServiceFacilityLocationName


tion

ServiceFacilityLocationSecondaryIdentific

ation PegaX125010

PegaX12-Data-N837-

Loop2420DServiceFacilityLocationName ServiceFacilityLocationCityStateZipCode ServiceFacilityLocationCityStateZipCode PegaX125010PegaX12-Data-N837-

Loop2420DServiceFacilityLocationName ServiceFacilityLocationName ServiceFacilityLocationName PegaX125010PegaX12-Data-N837-

Loop2420DServiceFacilityLocationName ServiceFacilityLocationAddress ServiceFacilityLocationAddress PegaX125010PegaX12-Data-N837-



n




Loop2420EOrderingProviderName OrderingProviderSecondaryIdentification

Ordering Provider Secondary


Loop2420EOrderingProviderName OrderingProviderCityStateZip Ordering Provider City/State/Zip PegaX125010PegaX12-Data-N837-

Loop2420EOrderingProviderName OrderingProviderContactInformation Ordering Provider Contact Information PegaX125010PegaX12-Data-N837-

Loop2420EOrderingProviderName OrderingProviderName Ordering Provider Name PegaX125010PegaX12-Data-N837-

Loop2420EOrderingProviderName OrderingProviderAddress Ordering Provider Address PegaX125010PegaX12-Data-N837-

Loop2420FReferringProviderName ReferringProviderSecondaryIdentification




Loop2420GAmbulancePickUpLocation AmbulancePickUpLocationAddress Ambulance Pick Up Location Address PegaX125010PegaX12-Data-N837-

Loop2420GAmbulancePickUpLocation AmbulancePickUpLocation Ambulance Pick Up Location PegaX125010PegaX12-Data-N837-

Loop2420GAmbulancePickUpLocation AmbulancePickUpLocationCityStateZip Ambulance Pick Up Location City State Zip PegaX125010PegaX12-Data-N837-


OtherPayerPriorAuthorizationorReferralN

umber

Other Payer Prior Authorization or

Referral Number PegaX125010PegaX12-Data-N837-



umberName


Referral Number Name PegaX125010PegaX12-Data-N837-

Loop2420HAmbulanceDropOffLocation AmbulanceDropOffLocationCityStateZip AmbulanceDropOffLocationCityStateZip PegaX125010PegaX12-Data-N837-

Loop2420HAmbulanceDropOffLocation AmbulanceDropOffLocationAddress AmbulanceDropOffLocationAddress PegaX125010PegaX12-Data-N837-

Loop2420HAmbulanceDropOffLocation AmbulanceDropOffLocation AmbulanceDropOffLocation PegaX125010

PegaX12-Data-N837-

Loop2430LineAdjudicationInformation LineAdjustment Line Adjustment PegaX125010PegaX12-Data-N837-

Loop2430LineAdjudicationInformation RemainingPatientLiability Remaining Patient Liability PegaX125010PegaX12-Data-N837-

Loop2430LineAdjudicationInformation LineAdjudicationDate Line Adjudication Date PegaX125010PegaX12-Data-N837-

Loop2430LineAdjudicationInformation LineAdjudicationInformation Line Adjudication Information PegaX125010PegaX12-Data-N837-

Loop2430LineAdjudicationInformation LineCheckOrRemittanceDate Line Check Or Remittance Date PegaX125010PegaX12-Data-N837-

Loop2440FormIdentificationCode FormIdentificationCode Form Identification Code PegaX125010PegaX12-Data-N837-

Loop2440FormIdentificationCode SupportingDocumentation Supporting Documentation PegaX125010PegaX12-Data-N837-PatientLevel Loop2000CPatient Loop2000CPatient PegaX125010PegaX12-Data-N837-SubscriberLevel Loop2000BSubscriber Loop2000BSubscriber PegaX125010PegaX12-Data-N837-Trailer TransactionSetTrailer Transaction Set Trailer PegaX125010PegaX12-Data-N837-Transaction BillingProviderLevel BillingPayToProviderLevel PegaX125010PegaX12-Data-N837-Transaction Header Header PegaX125010PegaX12-Data-N837-Transaction Trailer Transaction Trailer PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM103_NameLastorOrganizationName Name Last or Organization Name PegaX125010PegaX12-Data-


NM1_IndividualorOrganizationalName NM102_EntityTypeQualifier Entity Type Qualifier PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM106_NamePrefix Name Prefix PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM112_NameLastorOrganizationName NM112_NameLastorOrganizationName PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM105_NameMiddle Name Middle PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM108_IdentificationCodeQualifier Identification Code Qualifier PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM110_EntityRelationshipCode EntityRelationshipCode PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM109_IdentificationCode Identification Code PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM111_EntityIdentifierCode Entity Identifier Code PegaX125010

PegaX12-Data-

NM1_IndividualorOrganizationalName NM104_NameFirst Name First PegaX125010PegaX12-Data-

NM1_IndividualorOrganizationalName NM107_NameSuffix Name Suffix PegaX125010PegaX12-Data-NTE_NoteSpecialInstruction NTE02_Description NTE02_Description PegaX125010PegaX12-Data-NTE_NoteSpecialInstruction NTE01_NoteReferenceCode NTE01_Note Reference Code PegaX125010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI01_ClaimFilingIndicatorCode OI01_Claim Filing Indicator Code PegaX125010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI05_ProviderAgreementCode OI05_Provider Agreement Code PegaX125010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI04_PatientSignatureSourceCode OI04_Patient Signature Source Code PegaX125010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI03_YesNoConditionOrResponseCode

OI03_Yes/No Condition Or Response


OI_OtherHealthInsuranceInformation OI06_ReleaseOfInformationCode OI06_Release Of Information Code PegaX125010PegaX12-Data-

OI_OtherHealthInsuranceInformation OI02_ClaimSubmissionReasonCode OI02_Claim Submission Reason Code PegaX125010

PegaX12-Data-PAT_PatientInformation PAT07_UnitOrBasisForMeasurementCode Code specifying units for weight PegaX125010

PegaX12-Data-PAT_PatientInformation PAT05_DateTimePeriodFormatQualifier

Code indicating the date format and/or

time format PegaX125010PegaX12-Data-PAT_PatientInformation PAT01_IndividualRelationshipCode Individual Relationship Code PegaX125010PegaX12-Data-PAT_PatientInformation PAT08_Weight Numeric value of weight PegaX125010

PegaX12-Data-PAT_PatientInformation PAT06_DateTimePeriod

Expression of a date, a time or a range of

dates and times PegaX125010PegaX12-Data-PAT_PatientInformation PAT02_PatientLocationCode Patient Location Code PegaX125010PegaX12-Data-PAT_PatientInformation PAT03_EmploymentStatusCode Employment Status Code PegaX125010PegaX12-Data-PAT_PatientInformation PAT04_StudentStatusCode Student Status Code PegaX125010

PegaX12-Data-PAT_PatientInformation PAT09_YesNoConditionOrResponseCode

Code indicating Yes/No Condition or

Response PegaX125010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER09_ContactInquiryReference Contact Inquiry Reference PegaX125010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER02_Name Name PegaX125010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER01_ContactFunctionCode Contact Function Code PegaX125010PegaX12-Data-

PER_AdministrativeCommunicationsContact PER06_CommunicationNumber Communication Number 1 PegaX125010

PegaX12-Data-





PER_AdministrativeCommunicationsContact PER05_CommunicationNumberQualifier Communication Number Qualifier PegaX125010PegaX12-Data-PLA_PlaceOrLocation PLA03_Date Date PegaX125010PegaX12-Data-PLA_PlaceOrLocation PLA05_MaintenanceReasonCode Maintenance Reason Code PegaX125010PegaX12-Data-PLA_PlaceOrLocation PLA04_Time Time PegaX125010PegaX12-Data-PLA_PlaceOrLocation PLA01_ActionCode Action Code PegaX125010PegaX12-Data-PLA_PlaceOrLocation PLA02_EntityIdentifierCode Entity Identifier Code PegaX125010PegaX12-Data-ProcessingStatistics RunDate RunDate PegaX125010PegaX12-Data-ProcessingStatistics NumberFunctionalGroupsSent NumberFunctionalGroupsSent PegaX125010PegaX12-Data-ProcessingStatistics ErrorMsg ErrorMsg PegaX125010PegaX12-Data-ProcessingStatistics testingGroup testingGroup PegaX125010PegaX12-Data-ProcessingStatistics NumberFunctionalGroups NumberFunctionalGroups PegaX125010PegaX12-Data-ProcessingStatistics EndTime End Time PegaX125010PegaX12-Data-ProcessingStatistics NumberTransactionSetsPerType NumberTransactionSetsPerType PegaX125010PegaX12-Data-ProcessingStatistics NumberTransactionSetsSent NumberTransactionSetsSent PegaX125010PegaX12-Data-ProcessingStatistics NumberTransactionSetsTotal NumberTransactionSetsTotal PegaX125010PegaX12-Data-ProcessingStatistics StartTime Start Time PegaX125010

PegaX12-Data-ProcessingStatisticsTransactionType NumberMessagesInError Number Messages In Error PegaX125010

PegaX12-Data-ProcessingStatisticsTransactionType FirstWorkID FirstWorkID PegaX125010

PegaX12-Data-ProcessingStatisticsTransactionType LastWorkID LastWorkID PegaX125010

PegaX12-Data-ProcessingStatisticsTransactionType NumberTransactionSetsProcessed NumberTransactionSetsProcessed PegaX125010

PegaX12-Data-ProcessingStatisticsTransactionType NumberWorkObjectsCreated Number Work Objects Created PegaX125010PegaX12-Data-PRV_ProviderInformation PRV01_ProviderCode PRV01_Provider Code PegaX125010PegaX12-Data-PRV_ProviderInformation PRV03_ReferenceIdentification PRV03_Reference Identification PegaX125010

PegaX12-Data-PRV_ProviderInformation PRV05_ProviderSpecialtyInformation PRV05_Provider Specialty Information PegaX125010PegaX12-Data-PRV_ProviderInformation PRV04_StateorProvinceCode PRV04_State or Province Code PegaX125010

PegaX12-Data-PRV_ProviderInformation PRV02_ReferenceIdentificationQualifier PRV02_Reference Identification Qualifier PegaX125010PegaX12-Data-PRV_ProviderInformation PRV06_ProviderOrganizationCode PRV06_Provider Organization Code PegaX125010PegaX12-Data-PS1_PurchaseService PS101_ReferenceIdentification PS101_Reference Identification PegaX125010PegaX12-Data-PS1_PurchaseService PS103_StateOrProvinceCode PS103_State Or Province Code PegaX125010PegaX12-Data-PS1_PurchaseService PS102_MonetaryAmount PS102_Monetary Amount PegaX125010PegaX12-Data-PWK_Paperwork PWK01_ReportTypeCode PWK01_Report Type Code PegaX125010PegaX12-Data-PWK_Paperwork PWK03_ReportCopiesNeeded PWK03_Report Copies Needed PegaX125010PegaX12-Data-PWK_Paperwork PWK08_ActionsIndicated PWK08_Actions Indicated PegaX125010PegaX12-Data-PWK_Paperwork PWK04_EntityIdentifierCode PWK04_Entity Identifier Code PegaX125010PegaX12-Data-PWK_Paperwork PWK07_Description PWK07_Description PegaX125010PegaX12-Data-PWK_Paperwork PWK06_IdentificationCode PWK06_Identification Code PegaX125010PegaX12-Data-PWK_Paperwork PWK09_RequestCategoryCode PWK09_Request Category Code PegaX125010PegaX12-Data-PWK_Paperwork PWK05_IdentificationCodeQualifier PWK05_Identification Code Qualifier PegaX125010PegaX12-Data-PWK_Paperwork PWK02_ReportTransmissionCode PWK02_Report Transmission Code PegaX125010PegaX12-Data-QTY_Quantity QTY01_QuantityQualifier QTY01_Quantity Qualifier PegaX125010PegaX12-Data-QTY_Quantity QTY02_Quantity QTY02_Quantity PegaX125010PegaX12-Data-QTY_Quantity QTY03_CompositeUnitOfMeasure QTY03_Composite Unit Of Measure PegaX125010PegaX12-Data-QTY_Quantity QTY04_FreeFormMessage QTY04_Free-Form Message PegaX125010PegaX12-Data-REF_ReferenceIdentification REF03_Description Description PegaX125010

PegaX12-Data-REF_ReferenceIdentification REF01_ReferenceIdentificationQualifier Reference Identification Qualifier PegaX125010PegaX12-Data-REF_ReferenceIdentification REF02_ReferenceIdentification Reference Identification PegaX125010PegaX12-Data-REF_ReferenceIdentification REF04_ReferenceIdentifier ReferenceIdentifier PegaX125010PegaX12-Data-REF04_ReferenceIdentifier REF04_6_ReferenceIdentification REF04_6_ReferenceIdentification PegaX125010PegaX12-Data-REF04_ReferenceIdentifier REF04_4_ReferenceIdentification REF04_4_ReferenceIdentification PegaX125010

PegaX12-Data-REF04_ReferenceIdentifier REF04_3_ReferenceIdentificationQualifier REF04_3_ReferenceIdentificationQualifier PegaX125010PegaX12-Data-REF04_ReferenceIdentifier REF04_2_OtherPayerPrimaryIdenitifer REF04_2_OtherPayerPrimaryIdenitifer PegaX125010

PegaX12-Data-REF04_ReferenceIdentifier REF04_5_ReferenceIdentificationQualifier REF04_5_ReferenceIdentificationQualifier PegaX125010PegaX12-Data-REF04_ReferenceIdentifier REF04_1_ReferenceIdentifierQualifier REF04_1_ReferenceIdentifierQualifier PegaX125010

PegaX12-Data-SBR_SubscriberInformation

SBR01_PayerResponsibilitySequenceNumb

erCode


Code PegaX125010PegaX12-Data-SBR_SubscriberInformation SBR05_InsuranceTypeCode Insurance Type Code PegaX125010PegaX12-Data-SBR_SubscriberInformation SBR09_ClaimFilingIndicatorCode Claim Filing Indicator Code PegaX125010PegaX12-Data-SBR_SubscriberInformation SBR04_Name Name PegaX125010

PegaX12-Data-SBR_SubscriberInformation SBR07_YesNoConditionOrResponseCode Yes/No Condition or Response Code PegaX125010PegaX12-Data-SBR_SubscriberInformation SBR02_IndividualRelationshipCode Individual Relationship Code PegaX125010

PegaX12-Data-SBR_SubscriberInformation SBR08_EmploymentStatusCode Employment Status Code PegaX125010PegaX12-Data-SBR_SubscriberInformation SBR03_ReferenceIdentification Reference Identification PegaX125010PegaX12-Data-SBR_SubscriberInformation SBR06_CoordinationOfBenefitsCode Coordination Of Benefits Code PegaX125010PegaX12-Data-SE_TransactionSetTrailer SE01_NumberofIncludedSegments Number of Included Segments PegaX125010PegaX12-Data-SE_TransactionSetTrailer SE02_TransactionSetControlNumber Transaction Set Control Number PegaX125010

PegaX12-Data-ST_TransactionSetHeader ST03_ImplementationGuideVersionName ST03_ImplementationGuideVersionName PegaX125010

PegaX12-Data-ST_TransactionSetHeader

ST03_ImplementationConventionReferenc

e

ST03_ImplementationConventionReferen

ce PegaX125010PegaX12-Data-ST_TransactionSetHeader ST02_TransactionSetControlNumber TransactionSetControlNumber PegaX125010PegaX12-Data-ST_TransactionSetHeader ST01_TransactionSetIdentifierCode TransactionSetIdentifierCode PegaX125010PegaX12-Data-STC_StatusInformation STC04_MonetaryAmount Monetary Amount PegaX125010PegaX12-Data-STC_StatusInformation STC11_HealthCareClaimStatus Health Care Claim Status PegaX125010PegaX12-Data-STC_StatusInformation STC10_HealthCareClaimStatus Health Care Claim Status PegaX125010PegaX12-Data-STC_StatusInformation STC07_PaymentMethodCode Payment Method Code PegaX125010PegaX12-Data-STC_StatusInformation STC06_Date Date PegaX125010PegaX12-Data-STC_StatusInformation STC02_Date Date PegaX125010PegaX12-Data-STC_StatusInformation STC09_CheckNumber Check Number PegaX125010PegaX12-Data-STC_StatusInformation STC05_MonetaryAmount Monetary Amount PegaX125010PegaX12-Data-STC_StatusInformation STC12_FreeFormMessageText Free-Form Message Text PegaX125010PegaX12-Data-STC_StatusInformation STC03_ActionCode Action Code PegaX125010PegaX12-Data-STC_StatusInformation STC01_HealthCareClaimStatus Health Care Claim Status PegaX125010PegaX12-Data-STC_StatusInformation STC08_Date Date PegaX125010PegaX12-Data-STC01_HealthCareClaimStatus STC01_1_IndustryCode Industry Code PegaX125010PegaX12-Data-STC01_HealthCareClaimStatus STC01_2_IndustryCode Industry Code PegaX125010PegaX12-Data-STC01_HealthCareClaimStatus STC01_3_EntityIdentifierCode Entity Identifier Code PegaX125010PegaX12-Data-STC01_HealthCareClaimStatus STC01_4_CodeListQualifierCode Code List Qualifier Code PegaX125010PegaX12-Data-STC10_HealthCareClaimStatus STC10_2_IndustryCode Industry Code PegaX125010PegaX12-Data-STC10_HealthCareClaimStatus STC10_4_CodeListQualifierCode Code List Qualifier Code PegaX125010PegaX12-Data-STC10_HealthCareClaimStatus STC10_1_IndustryCode Industry Code PegaX125010PegaX12-Data-STC10_HealthCareClaimStatus STC10_3_EntityIdentifierCode Entity Identifier Code PegaX125010PegaX12-Data-STC11_HealthCareClaimStatus STC11_1_IndustryCode Industry Code PegaX125010PegaX12-Data-STC11_HealthCareClaimStatus STC11_4_CodeListQualifierCode Code List Qualifier Code PegaX125010PegaX12-Data-STC11_HealthCareClaimStatus STC11_2_IndustryCode Industry Code PegaX125010PegaX12-Data-STC11_HealthCareClaimStatus STC11_3_EntityIdentifierCode Entity Identifier Code PegaX125010



fier


ifier PegaX125010

PegaX12-Data-SV1_ProfessionalService SV103_UnitOrBasisForMeasurementCode

SV103 Unit Or Basis For Measurement

Code PegaX125010PegaX12-Data-SV1_ProfessionalService SV106_ServiceTypeCode SV106 Service Type Code PegaX125010



Code PegaX125010


SV116_HealthCareProfessionalShortageAr

eaCode

SV116 HealthCare Professional Shortage

Area Code PegaX125010PegaX12-Data-SV1_ProfessionalService SV121_ProviderAgreementCode SV121 Provider Agreement Code PegaX125010PegaX12-Data-SV1_ProfessionalService SV118_PostalCode SV118 Postal Code PegaX125010



Code PegaX125010PegaX12-Data-SV1_ProfessionalService SV115_CopayStatusCode SV115_CopayStatusCode PegaX125010PegaX12-Data-SV1_ProfessionalService SV102_MonetaryAmount SV102 Monetary Amount PegaX125010PegaX12-Data-SV1_ProfessionalService SV113_ReviewCode SV113 Review Code PegaX125010PegaX12-Data-SV1_ProfessionalService SV119_MonetaryAmount SV119 Monetary Amount PegaX125010PegaX12-Data-SV1_ProfessionalService SV120_LevelOfCareCode SV120 Level Of Care Code PegaX125010PegaX12-Data-SV1_ProfessionalService SV104_Quantity SV104 Quantity PegaX125010PegaX12-Data-SV1_ProfessionalService SV110_MultipleProcedureCode SV110 Multiple Procedure Code PegaX125010


SV114_NationalOrLocalAssignedReviewVal

ue

SV114 National Or Local Assigned Review

Value PegaX125010PegaX12-Data-SV1_ProfessionalService SV117_ReferenceIdentification SV117 Reference Identification PegaX125010



Code PegaX125010PegaX12-Data-SV1_ProfessionalService SV105_FacilityCodeValue SV105 Facility Code Value PegaX125010

PegaX12-Data-SV1_ProfessionalService SV107_CompositeDiagnosisCodePointer SV107_CompositeDiagnosisCodePointer PegaX125010PegaX12-Data-SV1_ProfessionalService SV108_MonetaryAmount SV108 Monetary Amount PegaX125010PegaX12-Data-








SV101_CompositeMedicalProcedureIdent SV101_1_ProductServiceIDQualifier SV101-1 Product/Service ID Qualifier PegaX125010

PegaX12-Data-




SV107_CompositeDiagnosisCodePointer SV107_1_DiagnosisCodePointer SV107-1 Diagnosis Code Pointer PegaX125010PegaX12-Data-SV2_InstitutionalService SV210_LevelOfCareCode SV210_LevelOfCareCode PegaX125010PegaX12-Data-SV2_InstitutionalService SV205_Quantity SV205_Quantity PegaX125010PegaX12-Data-SV2_InstitutionalService SV201_ServiceID SV201_ServiceID PegaX125010

PegaX12-Data-SV2_InstitutionalService SV204_UnitOrBasisForMeasurementCode SV204_UnitOrBasisForMeasurementCode PegaX125010



fier


ifier PegaX125010PegaX12-Data-SV2_InstitutionalService SV206_UnitRate SV206_UnitRate PegaX125010


SV209_NursingHomeResidentialStatusCod

e

SV209_NursingHomeResidentialStatusCo

de PegaX125010

PegaX12-Data-SV2_InstitutionalService SV208_YesNoConditionOrResponseCode SV208_YesNoConditionOrResponseCode PegaX125010PegaX12-Data-SV2_InstitutionalService SV203_MonetaryAmount SV203_MonetaryAmount PegaX125010PegaX12-Data-SV2_InstitutionalService SV201_ServiceID2 SV201_ServiceID2 PegaX125010PegaX12-Data-SV2_InstitutionalService SV207_MonetaryAmount SV207_MonetaryAmount PegaX125010PegaX12-Data-








SV202_CompositeMedicalProcedureIdent SV202_1_ProductServiceIDQualifier SV202-1 Product/Service ID Qualifier PegaX125010

PegaX12-Data-SV3_DentalService


fier


ifier PegaX125010PegaX12-Data-SV3_DentalService SV302_MonetaryAmount SV302_MonetaryAmount PegaX125010

PegaX12-Data-SV3_DentalService SV310_YesNoConditionorResponseCode SV310_YesNoConditionorResponseCode PegaX125010PegaX12-Data-SV3_DentalService SV309_ProviderAgreementCode SV309_ProviderAgreementCode PegaX125010PegaX12-Data-SV3_DentalService SV306_Quantity SV306_Quantity PegaX125010PegaX12-Data-SV3_DentalService SV305_ProsthesisCrownInlayCode SV305_ProsthesisCrownInlayCode PegaX125010PegaX12-Data-SV3_DentalService SV303_FacilityCodeValue SV303_FacilityCodeValue PegaX125010

PegaX12-Data-SV3_DentalService SV311_CompositeDiagnosisCodePointer SV311_CompositeDiagnosisCodePointer PegaX125010PegaX12-Data-SV3_DentalService SV308_CopayStatusCode SV308_CopayStatusCode PegaX125010PegaX12-Data-SV3_DentalService SV307_Description SV307_Description PegaX125010PegaX12-Data-SV3_DentalService SV304_OralCavityDesignation SV304_OralCavityDesignation PegaX125010PegaX12-Data-SV301_DentalService SV301_3_ProcedureModifier SV3013_ProcedureModifier PegaX125010PegaX12-Data-SV301_DentalService SV301_8_ProductorServiceID SV3018_ProductorServiceID PegaX125010PegaX12-Data-SV301_DentalService SV301_5_ProcedureModifier SV3015_ProcedureModifier PegaX125010PegaX12-Data-SV301_DentalService SV301_2_ProductorServiceID SV3012_ProductorServiceID PegaX125010PegaX12-Data-SV301_DentalService SV301_1_ProductorServiceIDQualifier SV3011_ProductorServiceIDQualifier PegaX125010PegaX12-Data-SV301_DentalService SV301_7_Description SV3017_Description PegaX125010PegaX12-Data-SV301_DentalService SV301_6_ProcedureModifier SV3016_ProcedureModifier PegaX125010PegaX12-Data-SV301_DentalService SV301_4_ProcedureModifier SV3014_ProcedureModifier PegaX125010PegaX12-Data-SV304_DentalService SV304_1_OralCavityDesignationCode SV3041_OralCavityDesignationCode PegaX125010PegaX12-Data-SV304_DentalService SV304_5_OralCavityDesignationCode SV3045_OralCavityDesignationCode PegaX125010PegaX12-Data-SV304_DentalService SV304_2_OralCavityDesignationCode SV3042_OralCavityDesignationCode PegaX125010PegaX12-Data-SV304_DentalService SV304_3_OralCavityDesignationCode SV3043_OralCavityDesignationCode PegaX125010PegaX12-Data-SV304_DentalService SV304_4_OralCavityDesignationCode SV3044_OralCavityDesignationCode PegaX125010PegaX12-Data-SV311_DentalService SV311_1_DiagnosisCodePointer SV311_1_DiagnosisCodePointer PegaX125010PegaX12-Data-SV311_DentalService SV311_2_DiagnosisCodePointer SV311_1_DiagnosisCodePointer PegaX125010PegaX12-Data-SV311_DentalService SV311_4_DiagnosisCodePointer SV311_1_DiagnosisCodePointer PegaX125010PegaX12-Data-SV311_DentalService SV311_3_DiagnosisCodePointer SV311_1_DiagnosisCodePointer PegaX125010



fier


ifier PegaX125010PegaX12-Data-SV4_DrugService SV414_DosageFormCode SV414_Dosage Form Code PegaX125010PegaX12-Data-SV4_DrugService SV401_ReferenceIdentification SV401_Reference Identification PegaX125010PegaX12-Data-SV4_DrugService SV407_PrescriptionOriginCode SV407_Prescription Origin Code PegaX125010



Code PegaX125010



Code PegaX125010


SV413_BasisOfDaysSupplyDeterminationC

ode

SV413_Basis Of Days Supply

Determination Code PegaX125010PegaX12-Data-SV4_DrugService SV415_CoPayStatusCode SV415_CoPay Status Code PegaX125010PegaX12-Data-SV4_DrugService SV416_PatientLocationCode SV416_Patient Location Code PegaX125010PegaX12-Data-SV4_DrugService SV408_Description SV408_Description PegaX125010

PegaX12-Data-SV4_DrugService SV412_BasisOfCostDeterminationCode SV412_Basis Of Cost Determination Code PegaX125010PegaX12-Data-SV4_DrugService SV405_DispenseAsWrittenCode SV405_Dispense As Written Code PegaX125010PegaX12-Data-SV4_DrugService SV417_LevelOfCareCode SV417_Level Of Care Code PegaX125010PegaX12-Data-SV4_DrugService SV418_PriorAuthorizationTypeCode SV418_Prior Authorization Type Code PegaX125010PegaX12-Data-SV4_DrugService SV403_ReferenceIdentification SV403_Reference Identification PegaX125010PegaX12-Data-SV4_DrugService SV406_LevelOfServiceCode SV406_Level Of Service Code PegaX125010



Code PegaX125010PegaX12-Data-SV4_DrugService SV411_UnitDoseCode SV411_Unit Dose Code PegaX125010PegaX12-Data-



SV5_DurableMedicalEquipmentService SV506_FrequencyCode SV506_FrequencyCode PegaX125010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV503_Quantity SV503_Quantity PegaX125010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV502_UnitOrBasisForMeasurementCode SV502_UnitOrBasisForMeasurementCode PegaX125010PegaX12-Data-

SV5_DurableMedicalEquipmentService


fier


ifier PegaX125010PegaX12-Data-

SV5_DurableMedicalEquipmentService SV507_PrognosisCode SV507_PrognosisCode PegaX125010PegaX12-Data-



SV501_CompositeMedicalProcedureIdent SV501_7_Description SV501_7_Description PegaX125010PegaX12-Data-


SV501_CompositeMedicalProcedureIdent SV501_3_ProcedureModifier SV501_3_ProcedureModifier PegaX125010

PegaX12-Data-


SV501_CompositeMedicalProcedureIdent SV501_1_ProductServiceIDQualifier SV501_1_ProductServiceIDQualifier PegaX125010PegaX12-Data-

SV501_CompositeMedicalProcedureIdent SV501_4_ProcedureModifier SV501_4_ProcedureModifier PegaX125010PegaX12-Data-SVC_ServiceInformation SVC07_Quantity Quantity PegaX125010



fier Composite Medical Procedure Identifier PegaX125010PegaX12-Data-SVC_ServiceInformation SVC05_Quantity Quantity PegaX125010PegaX12-Data-SVC_ServiceInformation SVC04_ProductServiceID Product/Service ID PegaX125010



fier Composite Medical Procedure Identifier PegaX125010PegaX12-Data-SVC_ServiceInformation SVC03_MonetaryAmount Monetary Amount PegaX125010PegaX12-Data-SVC_ServiceInformation SVC02_MonetaryAmount Monetary Amount PegaX125010PegaX12-Data-



SVC01_CompositeMediProcedureIdentifier SVC01_2_ProductServiceID Product/Service ID PegaX125010PegaX12-Data-



SVC01_CompositeMediProcedureIdentifier SVC01_1_ProductServiceIDQualifier Product/Service ID Qualifier PegaX125010PegaX12-Data-

SVC01_CompositeMediProcedureIdentifier SVC01_8_ProductServiceID ProductServiceID PegaX125010PegaX12-Data-

SVC01_CompositeMediProcedureIdentifier SVC01_7_Description Description PegaX125010PegaX12-Data-SVD_ServiceLineAdjudication SVD05_Quantity SVD05_Quantity PegaX125010

PegaX12-Data-SVD_ServiceLineAdjudication

SVD03_CompositeMedicalProcedureIdenti

fier

SVD03_Composite Medical Procedure

Identifier PegaX125010PegaX12-Data-SVD_ServiceLineAdjudication SVD04_ProductServiceId SVD04_Product/Service Id PegaX125010PegaX12-Data-SVD_ServiceLineAdjudication SVD01_IdentificationCode SVD01_Identification Code PegaX125010PegaX12-Data-SVD_ServiceLineAdjudication SVD06_AssignedNumber SVD06_Assigned Number PegaX125010PegaX12-Data-SVD_ServiceLineAdjudication SVD02_MonetaryAmount SVD02_Monetary Amount PegaX125010PegaX12-Data-

SVD03_CompositeMedicalProcedureId SVD03_8_ProductID SVD03_8_ProductID PegaX125010

PegaX12-Data-



SVD03_CompositeMedicalProcedureId SVD03_1_ProductServiceIdQualifier SVD03_1_Product/Service Id Qualifier PegaX125010PegaX12-Data-

SVD03_CompositeMedicalProcedureId SVD03_7_Description SVD03_7_Description PegaX125010PegaX12-Data-



SVD03_CompositeMedicalProcedureId SVD03_2_ProductServiceId SVD03_2_Product/Service Id PegaX125010PegaX12-Data-TOO_ToothInformation TOO03_ToothSurface TOO03_ToothSurface PegaX125010PegaX12-Data-TOO_ToothInformation TOO01_CodeListQualifierCode TOO01_CodeListQualifierCode PegaX125010PegaX12-Data-TOO_ToothInformation TOO02_IndustryCode TOO02_IndustryCode PegaX125010PegaX12-Data-TOO03_ToothInformation TOO03_2_ToothSurfaceCode TOO032_ToothSurfaceCode PegaX125010PegaX12-Data-TOO03_ToothInformation TOO03_5_ToothSurfaceCode TOO035_ToothSurfaceCode PegaX125010PegaX12-Data-TOO03_ToothInformation TOO03_3_ToothSurfaceCode TOO033_ToothSurfaceCode PegaX125010PegaX12-Data-TOO03_ToothInformation TOO03_4_ToothSurfaceCode TOO034_ToothSurfaceCode PegaX125010PegaX12-Data-TOO03_ToothInformation TOO03_1_ToothSurfaceCode TOO031_ToothSurfaceCode PegaX125010PegaX12-Data-TRN_Trace TRN04_ReferenceIdentification TRN04_ReferenceIdentification PegaX125010PegaX12-Data-TRN_Trace TRN03_OriginatingCompanyIdentifier TRN03_OriginatingCompanyIdentifier PegaX125010PegaX12-Data-TRN_Trace TRN01_TraceTypeCode TRN01_TraceTypeCode PegaX125010PegaX12-Data-TRN_Trace TRN02_ReferenceIdentification TRN02_ReferenceIdentification PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation

UM04_HealthCareServiceLocationInforma

tion

UM04_HealthCareServiceLocationInform

ation PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM01_RequestCategoryCode UM01_RequestCategoryCode PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM03_ServiceTypeCode UM03_ServiceTypeCode PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM07_CurrentHealthConditionCode UM07_CurrentHealthConditionCode PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM05_RelatedCausesInformation UM05_RelatedCausesInformation PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM10_DelayReasonCode UM10_DelayReasonCode PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM09_ReleaseofInformationCode UM09_ReleaseofInformationCode PegaX125010

PegaX12-Data-

UM_HealthCareServicesReviewInformation UM08_PrognosisCode UM08_PrognosisCode PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM02_CertificationCode UM02_CertificationCode PegaX125010PegaX12-Data-

UM_HealthCareServicesReviewInformation UM06_LevelofServiceCode UM06_LevelofServiceCode PegaX125010PegaX12-Data-

UM04_HealthCareServiceLocationInfo UM04_3_ClaimFrequencyTypeCode UM04_3_ClaimFrequencyTypeCode PegaX125010PegaX12-Data-

UM04_HealthCareServiceLocationInfo UM04_1_FacilityCodeValue UM04_1_FacilityCodeValue PegaX125010PegaX12-Data-

UM04_HealthCareServiceLocationInfo UM04_2_FacilityCodeQualifier UM04_2_FacilityCodeQualifier PegaX125010


PegaX12-Data-UM05_RelatedCausesInformation UM05_5_CountryCode UM05_5_CountryCode PegaX125010


PegaX12-Data-UM05_RelatedCausesInformation UM05_4_StateorProvinceCode UM05_4_StateorProvinceCode PegaX125010



Data-Portal MapICDCodes MapICDCodesRB PegaHealthCodesData-WorkAttach-File EffectiveDate EffectiveDate PegaHealthCodesData-WorkAttach-File ExpirationDate ExpirationDate PegaHealthCodesData-WorkAttach-File Description Description PegaHealthCodesData-WorkAttach-File CodeSetType CodeSetType PegaHealthCodesEmbed-HCCodes-CodeChanges UpdateFlag UpdateFlag PegaHealthCodesEmbed-HCCodes-CodeChanges EndDate EndDate PegaHealthCodesEmbed-HCCodes-CodeChanges Description Description PegaHealthCodesEmbed-HCCodes-CodeChanges StartDate StartDate PegaHealthCodesEmbed-HCCodes-CodeChanges Code Code PegaHealthCodesLink-Attachment EffectiveDate EffectiveDate PegaHealthCodesLink-Attachment FileName FileName PegaHealthCodesLink-Attachment ExpirationDate ExpirationDate PegaHealthCodesPegaHealth-Codes-Data- Category2 Category2 PegaHealthCodesPegaHealth-Codes-Data- Code Code PegaHealthCodesPegaHealth-Codes-Data- FullDescription FullDescription PegaHealthCodesPegaHealth-Codes-Data- Notes Notes PegaHealthCodesPegaHealth-Codes-Data- LISTING_SEQ_NO LISTING_SEQ_NO PegaHealthCodesPegaHealth-Codes-Data- Status Status PegaHealthCodesPegaHealth-Codes-Data- Category1 Category1 PegaHealthCodesPegaHealth-Codes-Data- Name Name PegaHealthCodesPegaHealth-Codes-Data- Description Description PegaHealthCodesPegaHealth-Codes-Data- EffectiveDate_String EffectiveDate_String PegaHealthCodesPegaHealth-Codes-Data- ExpirationDate ExpirationDate PegaHealthCodesPegaHealth-Codes-Data- ExpirationDate_String ExpirationDate_String PegaHealthCodesPegaHealth-Codes-Data- LastModifiedDate_String LastModifiedDate_String PegaHealthCodesPegaHealth-Codes-Data- LongDescription LongDescription PegaHealthCodesPegaHealth-Codes-Data- Category3 Category3 PegaHealthCodesPegaHealth-Codes-Data- Category4 Category4 PegaHealthCodesPegaHealth-Codes-Data- Category5 Category5 PegaHealthCodesPegaHealth-Codes-Data- EffectiveDate EffectiveDate PegaHealthCodesPegaHealth-Codes-Data- LastModifiedDate LastModifiedDate PegaHealthCodesPegaHealth-Codes-Data-BillType CodeType CodeType PegaHealthCodes

PegaHealth-Codes-Data-ClaimAdjustmentReason LastModifiedDate Last Modified Date PegaHealthCodes

PegaHealth-Codes-Data-ClaimAdjustmentReason DeactivationDate Deactivation Date PegaHealthCodes

PegaHealth-Codes-Data-ClaimAdjustmentReason Code Code PegaHealthCodes

PegaHealth-Codes-Data-ClaimAdjustmentReason Notes Notes PegaHealthCodes

PegaHealth-Codes-Data-ClaimAdjustmentReason Description Description PegaHealthCodes

PegaHealth-Codes-Data-ClaimAdjustmentReason EffectiveDate Effective Date PegaHealthCodesPegaHealth-Codes-Data-ClaimRemark DeactivationDate Deactivation Date PegaHealthCodesPegaHealth-Codes-Data-ClaimRemark LastModifiedDate Last Modified Date PegaHealthCodesPegaHealth-Codes-Data-ClaimRemark Description Description PegaHealthCodesPegaHealth-Codes-Data-ClaimRemark Code Code PegaHealthCodesPegaHealth-Codes-Data-ClaimRemark Notes Notes PegaHealthCodesPegaHealth-Codes-Data-ClaimRemark EffectiveDate Effective Date PegaHealthCodesPegaHealth-Codes-Data-ClaimStatus Description Description PegaHealthCodesPegaHealth-Codes-Data-ClaimStatus EffectiveDate Effective Date PegaHealthCodesPegaHealth-Codes-Data-ClaimStatus LastModifiedDate Last Modified Date PegaHealthCodesPegaHealth-Codes-Data-ClaimStatus Code Code PegaHealthCodesPegaHealth-Codes-Data-ClaimStatus Notes Notes PegaHealthCodesPegaHealth-Codes-Data-ClaimStatus DeactivationDate Deactivation Date PegaHealthCodesPegaHealth-Codes-Data-ClaimStatusCategory Notes Notes PegaHealthCodesPegaHealth-Codes-Data-ClaimStatusCategory EffectiveDate EffectiveDate PegaHealthCodesPegaHealth-Codes-Data-ClaimStatusCategory Description Description PegaHealthCodesPegaHealth-Codes-Data-ClaimStatusCategory Code Code PegaHealthCodesPegaHealth-Codes-Data-ClaimStatusCategory DeactivationDate DeactivationDate PegaHealthCodesPegaHealth-Codes-Data-ClaimStatusCategory LastModifiedDate LastModifiedDate PegaHealthCodesPegaHealth-Codes-Data-CodeGroup Description Description PegaHealthCodesPegaHealth-Codes-Data-CodeGroup CodeType CodeType PegaHealthCodesPegaHealth-Codes-Data-CodeGroup GroupName GroupName PegaHealthCodesPegaHealth-Codes-Data-CodeGroup CodeList CodeList PegaHealthCodesPegaHealth-Codes-Data-CPT Code Code PegaHealthCodesPegaHealth-Codes-Data-CPT Description Code Description PegaHealthCodesPegaHealth-Codes-Data-CPT PlaceHolder PlaceHolder PegaHealthCodesPegaHealth-Codes-Data-CPT CodeDescription Code Description PegaHealthCodesPegaHealth-Codes-Data-CPT NF_TOTAL_RVU NF_TOTAL_RVU PegaHealthCodesPegaHealth-Codes-Data-CPT FAC_TOTAL_RVU FAC_TOTAL_RVU PegaHealthCodesPegaHealth-Codes-Data-CPT Resequenced Resequenced PegaHealthCodesPegaHealth-Codes-Data-CPT Seq_Order Seq_Order PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD10 ICD10Description ICD10Description PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD10 Description Description PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD10 Code Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD10 NoOfICD9CodesMapped NoOfICD9CodesMapped PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map ApproximateFlag ApproximateFlag PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map MapICD9Code MapICD9Code PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map Description Description PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map Code Code PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map Scenario Scenario PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map ChoiceList ChoiceList PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map Annotation Annotation PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map NoMapFlag NoMapFlag PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map CombinationFlag CombinationFlag PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD109Map TargetCode TargetCode PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement MapICD9Code MapICD9Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement SecondICD9Code SecondICD9Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement NoOfICD9CodesMapped NoOfICD9CodesMapped PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement FourthICD9Code FourthICD9Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement SixthICD9Code SixthICD9Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement Description Description PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement Annotation Annotation PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement ThirdICD9Code ThirdICD9Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement FirstICD9Code FirstICD9Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement FifthICD9Code FifthICD9Code PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-

ICD109MapReimbursement TargetCode TargetCode PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 DiagnosisTypeCode Diagnosis Type Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 DiagnosisDate DiagnosisDate PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 DiagnosisCategory DiagnosisCategory PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 Validity Validity PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 DiagnosisCode Diagnosis Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 Code Code PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 Type Type PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 Description CodeDescription PegaHealthCodesPegaHealth-Codes-Data-Diagnosis-ICD9 DiagnosisDescription DiagnosisDescription PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map TargetCode TargetCode PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map CombinationFlag CombinationFlag PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map ApproximateFlag ApproximateFlag PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map Code Code PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map Annotation Annotation PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map NoMapFlag NoMapFlag PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map Scenario Scenario PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map ChoiceList ChoiceList PegaHealthCodes

PegaHealth-Codes-Data-Diagnosis-ICD910Map Description Description PegaHealthCodesPegaHealth-Codes-Data-DRG Med_Surg Med_Surg PegaHealthCodesPegaHealth-Codes-Data-DRG GM_LOS GM_LOS PegaHealthCodesPegaHealth-Codes-Data-DRG RelativeWeight RelativeWeight PegaHealthCodesPegaHealth-Codes-Data-DRG AM_LOS AM_LOS PegaHealthCodesPegaHealth-Codes-Data-DRG National_Payment National_Payment PegaHealthCodesPegaHealth-Codes-Data-DRG MDC MDC PegaHealthCodesPegaHealth-Codes-Data-GCN DrugClass Drug Class PegaHealthCodesPegaHealth-Codes-Data-GCN Description Description PegaHealthCodesPegaHealth-Codes-Data-GCN Code ID PegaHealthCodesPegaHealth-Codes-Data-GCN CodeDescription Description PegaHealthCodesPegaHealth-Codes-Data-HCPCS Code Code PegaHealthCodes

PegaHealth-Codes-Data-HCPCS HCPC HCPC PegaHealthCodesPegaHealth-Codes-Data-HCPCS ShortDesc Short Desc PegaHealthCodesPegaHealth-Codes-Data-HCPCS LongDesc Long Desc PegaHealthCodesPegaHealth-Codes-Data-HCPCS Description CodeDescription PegaHealthCodesPegaHealth-Codes-Data-Modifier Name Name PegaHealthCodesPegaHealth-Codes-Data-NDC STRENGTH STRENGTH PegaHealthCodesPegaHealth-Codes-Data-NDC Code Code PegaHealthCodesPegaHealth-Codes-Data-NDC NDCCode NDCCode PegaHealthCodesPegaHealth-Codes-Data-NDC PRODCODE PRODCODE PegaHealthCodesPegaHealth-Codes-Data-NDC UNIT UNIT PegaHealthCodesPegaHealth-Codes-Data-NDC Description CodeDescription PegaHealthCodesPegaHealth-Codes-Data-NDC LBLCODE LBLCODE PegaHealthCodesPegaHealth-Codes-Data-NDC TRADENAME TRADENAME PegaHealthCodesPegaHealth-Codes-Data-NDC LISTING_SEQ_NO LISTING_SEQ_NO PegaHealthCodesPegaHealth-Codes-Data-NDC RX_OTC RX_OTC PegaHealthCodesPegaHealth-Codes-Data-POS Name Name PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD10 Description Description PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD10 Code Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD10 NoOfICD9CodesMapped NoOfICD9CodesMapped PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map ApproximateFlag ApproximateFlag PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map CombinationFlag CombinationFlag PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map TargetCode TargetCode PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map Scenario Scenario PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map Annotation Annotation PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map ChoiceList ChoiceList PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map MapICD9Code MapICD9Code PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map Description Description PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map Code Code PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD109Map NoMapFlag NoMapFlag PegaHealthCodes

PegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement NoOfICD9CodesMapped NoOfICD9CodesMapped PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement ThirdICD9Code ThirdICD9Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement Description Description PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement FourthICD9Code FourthICD9Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement Annotation Annotation PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement FirstICD9Code FirstICD9Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement SecondICD9Code SecondICD9Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement MapICD9Code MapICD9Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement FifthICD9Code FifthICD9Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-

ICD109MapReimbursement SixthICD9Code SixthICD9Code PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD9 Validity Validity PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD9 ProcedureDescription ProcedureDescription PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD9 ProcedureCode ProcedureCode PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD9 Description CodeDescription PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD9 Type Type PegaHealthCodesPegaHealth-Codes-Data-Procedure-ICD9 Code Code PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map Description Description PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map NoMapFlag NoMapFlag PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map Code Code PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map Annotation Annotation PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map ChoiceList ChoiceList PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map TargetCode TargetCode PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map CombinationFlag CombinationFlag PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map Scenario Scenario PegaHealthCodes

PegaHealth-Codes-Data-Procedure-ICD910Map ApproximateFlag ApproximateFlag PegaHealthCodesPegaHealth-Codes-Data-ProviderTaxonomy Type Type PegaHealthCodesPegaHealth-Codes-Data-ProviderTaxonomy Classification Classification PegaHealthCodesPegaHealth-Codes-Data-ProviderTaxonomy Specialization Specialization PegaHealthCodesPegaHealth-Codes-Data-ProviderTaxonomy NPIType NPIType PegaHealthCodesPegaHealth-Codes-Data-ServiceReview LastModifiedDate Last Modified Date PegaHealthCodesPegaHealth-Codes-Data-ServiceReview Code Code PegaHealthCodesPegaHealth-Codes-Data-ServiceReview Notes Notes PegaHealthCodesPegaHealth-Codes-Data-ServiceReview EffectiveDate Effective Date PegaHealthCodesPegaHealth-Codes-Data-ServiceReview DeactivationDate Deactivation Date PegaHealthCodesPegaHealth-Codes-Data-ServiceReview Description Description PegaHealthCodesPegaHealth-Landing SampleCodesSourceFile SampleCodesSourceFile PegaHealthCodesPegaHealth-Landing MapICDCodes MapICDCodesRB PegaHealthCodesPegaHealth-Landing NumberOfCodesLoaded NumberOfCodesLoaded PegaHealthCodesPegaHealth-Landing LoadSampleCodesRB LoadFullSampleDataRB PegaHealthCodesPegaHealth-Landing SearchCodeSysRB SearchCodeSysRB PegaHealthCodesPegaHealth-Work HCPCSCode HCPCSCode PegaHealthCodesPegaHealth-Work MapICD10To9 MapICD9To10 PegaHealthCodesPegaHealth-Work MapICD10To9ProcedureList MapICD10To9ProcedureList PegaHealthCodesPegaHealth-Work MapICD9To10ProcedureList MapICD9To10ProcedureList PegaHealthCodesPegaHealth-Work ObjectModel Object Model PegaHealthCodesPegaHealth-Work SaveOption Save Option PegaHealthCodesPegaHealth-Work CodeGroup CodeGroup PegaHealthCodesPegaHealth-Work DrugIDCodeList Drug ID Code List PegaHealthCodesPegaHealth-Work ICD9Procedure ICD9Procedure PegaHealthCodesPegaHealth-Work ICD9ProcedureList ICD9 Procedure List PegaHealthCodesPegaHealth-Work IndustryCodeType IndustryCodeType PegaHealthCodesPegaHealth-Work MapICD10To9DiagosisList MapICD10To9DiagosisList PegaHealthCodesPegaHealth-Work MapICD10To9Reimb MapICD9To10 PegaHealthCodes

PegaHealth-Work MapICD10To9ReimbDiagosisList MapICD10To9ReimbDiagosisList PegaHealthCodesPegaHealth-Work NDCCodeList NDC Code List PegaHealthCodesPegaHealth-Work Description Description PegaHealthCodesPegaHealth-Work HCPCSCodeList HCPCS Code Group PegaHealthCodesPegaHealth-Work IndustryCodeTypeGroups IndustryCodeTypeGroups PegaHealthCodesPegaHealth-Work CPTCodeList CPT Code Group PegaHealthCodesPegaHealth-Work ICD9Diagnosis ICD9Diagnosis PegaHealthCodes

PegaHealth-Work SelectedFirstCode Description PegaHealthCodesPegaHealth-Work SelectedFourthCode Description PegaHealthCodesPegaHealth-Work CPTCode CPTCode PegaHealthCodesPegaHealth-Work DrugIDCode DrugIDCode PegaHealthCodesPegaHealth-Work ExpirationDate ExpirationDate PegaHealthCodesPegaHealth-Work ICD10Procedure ICD10Procedure PegaHealthCodesPegaHealth-Work ICDCodeType ICDCodeType PegaHealthCodesPegaHealth-Work MapICDCodesLP MapICDCodesRB PegaHealthCodesPegaHealth-Work SelectedCode Description PegaHealthCodes

PegaHealth-Work SelectedCodeProcedureDescription Procedure Description PegaHealthCodesPegaHealth-Work SelectedFifthCode Description PegaHealthCodesPegaHealth-Work SelectedSixthCode Description PegaHealthCodesPegaHealth-Work SelectedTradeName Selected Trade Name PegaHealthCodesPegaHealth-Work ICD10Diagnosis ICD10Diagnosis PegaHealthCodesPegaHealth-Work ICD9DiagnosisList ICD9 Diagnosis List PegaHealthCodesPegaHealth-Work NumOfCodesMapped Description PegaHealthCodesPegaHealth-Work SelectedDrugClass Description PegaHealthCodesPegaHealth-Work SelectedSecondCode Description PegaHealthCodesPegaHealth-Work SelectedTargetCode Target Code PegaHealthCodesPegaHealth-Work SelectedThirdCode Description PegaHealthCodesPegaHealth-Work ICD10ProcedureList ICD10Procedure List PegaHealthCodesPegaHealth-Work NDCCode NDCCode PegaHealthCodesPegaHealth-Work SearchCodesSysRBLP SearchCodeSysRB PegaHealthCodesPegaHealth-Work SelectedCodeDescription Description PegaHealthCodesPegaHealth-Work SelectedLabelerCode Selected Labeler Code PegaHealthCodesPegaHealth-Work CreateDescription Description PegaHealthCodesPegaHealth-Work EffectiveDate EffectiveDate PegaHealthCodesPegaHealth-Work ICD10DiagnosisList ICD10DiagnosisList PegaHealthCodes

PegaHealth-Work MapICD10To9ReimbProcedureList

MapICD10To9ReimbProcedureL

ist PegaHealthCodesPegaHealth-Work MapICD9To10 MapICD9To10 PegaHealthCodesPegaHealth-Work MapICD9To10DiagosisList MapICD9To10DiagosisList PegaHealthCodesPegaHealth-Work SelectedAnnotation Annotation PegaHealthCodesPegaHealth-Work SelectedProcedureCode Procedure Code PegaHealthCodesPegaHealth-Work Codes_ValueList Codes_ValueLIst PegaHealthCodesPegaHealth-Work-CodeGroup CoCDescription CoCDescription PegaHealthCodesPegaHealth-Work-CodeSet NewCode_ProdCode NewCode_ProdCode PegaHealthCodesPegaHealth-Work-CodeSet FilterByCode FilterByCode PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Type NewCode_Type PegaHealthCodes

PegaHealth-Work-CodeSet CreateExpDate CreateEffDate PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Category2 NewCode_Category1 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Category4 NewCode_Category1 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_DrugClass NewCode_DrugClass PegaHealthCodesPegaHealth-Work-CodeSet NewCode_EffDate EffDate PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Full_Description NewCode_Full_Description PegaHealthCodesPegaHealth-Work-CodeSet NewCode_ICD9PcsType NewCode_ICD9PcsType PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Med_Surg NewCode_Med_Surg PegaHealthCodes

PegaHealth-Work-CodeSet NewCode_ProcessingDecision NewCode_ProcessingDecision PegaHealthCodesPegaHealth-Work-CodeSet NewCode_RX_OTC NewCode_RX_OTC PegaHealthCodesPegaHealth-Work-CodeSet FilterByField2 FilterByField2 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_AM_LOS NewCode_AM_LOS PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Category1 NewCode_Category1 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Category3 NewCode_Category1 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Desc CodeDescription PegaHealthCodesPegaHealth-Work-CodeSet NewCode_MDC NewCode_MDC PegaHealthCodesPegaHealth-Work-CodeSet NewCode_NPIType NewCode_NPIType PegaHealthCodesPegaHealth-Work-CodeSet UploadStatus UploadStatus PegaHealthCodesPegaHealth-Work-CodeSet SearchCodeSetRB SearchCodeSysRB PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Fac_Total_RVU NewCode_Fac_Total_RVU PegaHealthCodesPegaHealth-Work-CodeSet NewCode_National_Payment NewCode_National_Payment PegaHealthCodesPegaHealth-Work-CodeSet NewCode_RW NewCode_RW PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Unit NewCode_Unit PegaHealthCodesPegaHealth-Work-CodeSet CodeSetType CodeSetType PegaHealthCodesPegaHealth-Work-CodeSet CodeSource CodeSource PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Category5 NewCode_Category5 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_ExpDate ExpDate PegaHealthCodesPegaHealth-Work-CodeSet NewCode_LBLCode NewCode_LBLCode PegaHealthCodesPegaHealth-Work-CodeSet NewCode_ListingSeqNo NewCode_ListingSeqNo PegaHealthCodesPegaHealth-Work-CodeSet NewCode_NDCCode NewCode_NDCCode PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Resequenced NewCode_Resequenced PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Seq_Order NewCode_Seq_Order PegaHealthCodesPegaHealth-Work-CodeSet TestCodeCategory TestCodeCategory PegaHealthCodesPegaHealth-Work-CodeSet CodeChanges CodeChanges PegaHealthCodesPegaHealth-Work-CodeSet CodeSearchValue CodeSearchValue PegaHealthCodesPegaHealth-Work-CodeSet CodesFromParser CodesFromParser PegaHealthCodesPegaHealth-Work-CodeSet CreateEffDate CreateEffDate PegaHealthCodesPegaHealth-Work-CodeSet FilterByField4 FilterByField4 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_ClaimType NewCode_ClaimType PegaHealthCodes

PegaHealth-Work-CodeSet NewCode_CodeType NewCode_CodeType PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Name NewCode_Name PegaHealthCodes

PegaHealth-Work-CodeSet NewCode_NoICD9CodesMapped

NewCode_NoICD9CodesMappe

d PegaHealthCodesPegaHealth-Work-CodeSet TotalCodes TotalCodes PegaHealthCodesPegaHealth-Work-CodeSet CodeSetClass CodeSetClass PegaHealthCodesPegaHealth-Work-CodeSet CodeSetType_Search CodeSetType PegaHealthCodesPegaHealth-Work-CodeSet FilterByDesc FilterByDesc PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Classification NewCode_Classification PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Code Code PegaHealthCodesPegaHealth-Work-CodeSet NewCode_GM_LOS NewCode_GM_LOS PegaHealthCodesPegaHealth-Work-CodeSet Codes Codes PegaHealthCodesPegaHealth-Work-CodeSet FileName ImportFilePath PegaHealthCodesPegaHealth-Work-CodeSet FilterByField3 FilterByField3 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Long_Description NewCode_Long_Description PegaHealthCodesPegaHealth-Work-CodeSet NewCode_NF_Total_RVU NewCode_NF_Total_RVU PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Specialization NewCode_Specialization PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Validity NewCode_Validity PegaHealthCodesPegaHealth-Work-CodeSet FilterByField1 FilterByField1 PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Status NewCode_Status PegaHealthCodesPegaHealth-Work-CodeSet NewCode_TradeName NewCode_TradeName PegaHealthCodesPegaHealth-Work-CodeSet SelectCodeCB SelectCodeCB PegaHealthCodesPegaHealth-Work-CodeSet NewCode_Strength NewCode_Strength PegaHealthCodesRule-HCCodes- CoCDescription CoCDescription PegaHealthCodesRule-HCCodes-CodeGroup EffectiveStartDate EffectiveStartDate PegaHealthCodesRule-HCCodes-CodeGroup Type Code Group Type PegaHealthCodesRule-HCCodes-CodeGroup EffectiveDate EffectiveDate PegaHealthCodesRule-HCCodes-CodeGroup Name Code Group Name PegaHealthCodesRule-HCCodes-CodeGroup TermDate TermDate PegaHealthCodesWork- CodesFromParser CodesFromParser PegaHealthCodesWork- EditInProgress EditInProgress PegaHealthCodesData-Admin-System-Settings DefaultClass DefaultClass PegaHealthCodeGroupsEmbed-HCCodes-Code Type Type PegaHealthCodeGroupsEmbed-HCCodes-Code FromCode FromCode PegaHealthCodeGroupsEmbed-HCCodes-Code isRange isRange PegaHealthCodeGroupsEmbed-HCCodes-Code Description Description PegaHealthCodeGroupsEmbed-HCCodes-CodeRange DescriptionFrom Description PegaHealthCodeGroupsEmbed-HCCodes-CodeRange ToCode ToCode PegaHealthCodeGroupsEmbed-HCCodes-CodeRange Type Type PegaHealthCodeGroupsEmbed-HCCodes-CodeRange DescriptionTo Description PegaHealthCodeGroups

Embed-HCCodes-CodeRange Description Description PegaHealthCodeGroupsEmbed-HCCodes-CodeRange FromCode FromCode PegaHealthCodeGroupsEmbed-HCCodes-CodeRange isRange isRange PegaHealthCodeGroupsEmbed-HCCodes-Codeset CompareCodes CompareCodes PegaHealthCodeGroupsEmbed-HCCodes-Codeset Test Test PegaHealthCodeGroupsEmbed-HCCodes-Codeset PageHandle PageHandle PegaHealthCodeGroupsEmbed-HCCodes-Codeset CodeRange CodeRange PegaHealthCodeGroupsEmbed-HCCodes-Codeset ValidValue ValidValue PegaHealthCodeGroupsEmbed-HCCodes-Codeset ValueHolder ValueHolder PegaHealthCodeGroupsEmbed-HCCodes-Codeset FCode FCode PegaHealthCodeGroupsEmbed-HCCodes-Codeset CodeType CodeType PegaHealthCodeGroupsEmbed-HCCodes-Codeset Codes Codes PegaHealthCodeGroupsEmbed-Rule-FutureQueue BulkUpdate_ScheduleFreq BulkUpdate_ScheduleFreq PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup ToCode ToCode PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup CodeGroupName CodeGroupName PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup isRange isRange PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup EffectiveDate EffectiveDate PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup Category Category PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup FromCode FromCode PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup Purpose Purpose PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup CodeGroupDesc CodeGroupDesc PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup CodeType CodeType PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup ExpirationDate ExpirationDate PegaHealthCodeGroupsIndex-HC-Codes-CodeGroup CodeGroupID CodeGroupID PegaHealthCodeGroupsLog-Delete StatisticsKey StatisticsKey PegaHealthCodeGroupsPegaHealth-Codes-Data- DescriptionFrom DescriptionFrom PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate CodeChanges_Add CodeChanges PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate NumberOfCodesEndDates NumberOfCodesEndDates PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate CodeGroupCategory CodeGroupCategory PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate CodeGroupName CodeGroupName PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate NumberOfCodesAdded NumberOfCodesAdded PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate CodeChanges CodeChanges PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate CodeChanges_Edit CodeChanges PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdate NumberOfCodesUpdated NumberOfCodesUpdated PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdateStatistics BUStats BUStats PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdateStatistics NumberOfCodeGroupsSkipped NumberOfCodeSetsSkipped PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdateStatistics BatchKey BatchKey PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdateStatistics NumberOfCodeSetsSkipped NumberOfCodeSetsSkipped PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdateStatistics NumberCodeGroupsUpdated NumberCodeGroupsUpdated PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdateStatistics SkippedCodeSets SkippedCodeSets PegaHealthCodeGroups

PegaHealth-Codes-Data-BulkUpdateStatistics SkippedCodeGroups SkippedCodeGroups PegaHealthCodeGroupsPegaHealth-Codes-Data-BulkUpdateStatistics ExecutionMode ExecutionMode PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet MarkDelete Mark Delete PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet COGPName COGPName PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet Code Code PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet CodeSetType CodeSetType PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet EndDate EndDate PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet Category Category PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet Codekey Codekey PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet COGPDesc COGPDesc PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet RangeKey RangeKey PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet StartDate StartDate PegaHealthCodeGroupsPegaHealth-Codes-Data-CodeSet CodeKeyList CodeKeyList PegaHealthCodeGroupsPegaHealth-Codes-Data-Settings CodeGroupRuleSet CodeGroupRuleSet PegaHealthCodeGroupsPegaHealth-Codes-Data-Settings CodeGroupRulesetVersion CodeGroupRulesetVersion PegaHealthCodeGroupsPegaHealth-Codes-Data-Settings Application Application PegaHealthCodeGroupsPegaHealth-Landing DefaultClass DefaultClass PegaHealthCodeGroupsPegaHealth-Work SearchParam SearchParam PegaHealthCodeGroupsPegaHealth-Work COGP COGP PegaHealthCodeGroupsPegaHealth-Work CodeSets CodeSets PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Day_AMPM BulkUpdate_Day_AMPM PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Week_Minutes BulkUpdate_Day_Time PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CodeCategoryList CodeCategoryList PegaHealthCodeGroupsPegaHealth-Work-CodeGroup IsCPTCodeGroup IsCPTCodeGroup PegaHealthCodeGroupsPegaHealth-Work-CodeGroup IsEditable IsEditable PegaHealthCodeGroupsPegaHealth-Work-CodeGroup RuleEnds RuleEnds PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Code BulkUpdate_Code PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CodeSearchValue CodeSearchValue PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CodeSetType CodeSetType PegaHealthCodeGroupsPegaHealth-Work-CodeGroup COGPUpdateDatetime COGPUpdateDatetime PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CodeGroupID CodeGroupID PegaHealthCodeGroupsPegaHealth-Work-CodeGroup COGPProductCategory COGPName PegaHealthCodeGroupsPegaHealth-Work-CodeGroup isSentBack isSentBack PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Day_Minutes BulkUpdate_Day_Time PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Month_Hours BulkUpdate_Day_Time PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CategoryList CategoryList PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CodeGroupNew CodeGroupOld PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CodeGroupOld CodeGroupOld PegaHealthCodeGroupsPegaHealth-Work-CodeGroup RuleStarts RuleStarts PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Category Code Group Type PegaHealthCodeGroups

PegaHealth-Work-CodeGroup BulkUpdate_CodeSetType BulkUpdate_CodeSetType PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Day_Hours BulkUpdate_Day_Time PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Month_Day BulkUpdate_Month_Day PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_ScheduleFreq BulkUpdate_ScheduleFreq PegaHealthCodeGroupsPegaHealth-Work-CodeGroup CGSearchValue CGSearchValue PegaHealthCodeGroupsPegaHealth-Work-CodeGroup COGP_Category_Search Code Group Type PegaHealthCodeGroupsPegaHealth-Work-CodeGroup Level Level PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Week_AMPM BulkUpdate_Day_AMPM PegaHealthCodeGroupsPegaHealth-Work-CodeGroup COGPName COGPName PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Month_AMPM BulkUpdate_Day_AMPM PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Week_Day BulkUpdate_Week_Day PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Week_Hours BulkUpdate_Day_Time PegaHealthCodeGroupsPegaHealth-Work-CodeGroup BulkUpdate_Month_Minutes BulkUpdate_Day_Time PegaHealthCodeGroupsPegaHealth-Work-CodeGroup Category Category PegaHealthCodeGroupsPegaHealth-Work-CodeGroup COGPDesc COGPDesc PegaHealthCodeGroupsPegaHealth-Work-CodeGroup Version Version PegaHealthCodeGroupsRule-HCCodes-CodeGroup Purpose Purpose PegaHealthCodeGroupsRule-HCCodes-CodeGroup CodegroupID CodegroupID PegaHealthCodeGroupsRule-HCCodes-CodeGroup ProductCategory ProductCategory PegaHealthCodeGroupsRule-HCCodes-CodeGroup Type Code Group Type PegaHealthCodeGroupsRule-HCCodes-CodeGroup ExpirationDate ExpirationDate PegaHealthCodeGroupsRule-HCCodes-CodeGroup CodeSets CodeSets PegaHealthCodeGroupsRule-HCCodes-CodeGroup Category Category PegaHealthCodeGroups

healthcare industry foundation object model · 2019-05-22 · healthcare payer industry and claims...

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