IP9097 Filler T 20 IP9004 Total Accommodation Charges N 10 Must equal the sum of record type 50 revenue code data – Revenue Centers Two decimal places implied NT 10 IP9098 Filler N 10 Must the sum of record type 60 revenue code data IP9005 Ancillary Charges Revenue – Centers Two decimal places implied IP9099 Filler T 118 Implementation Data Date for New Element # Data Element Data Elements Type Length Description/Codes/Sources IP9901 Record Type T 2 99 IP9999 Filler T 190 HIPAA Reference ASC X12N/005010A1 UB-04 Transaction Set/Loop/ Form Segment ID/Code Value/ Data Element # Data Element Name Locator Reference Designator IP0101 Record Type NA NA IP0102 MHDO-Assigned Provider ID Submitter NA NA EIN IP0103 ProviderSubmitter Name 1 837/2010AA/NM1/85/2/03 IP0104 Address 1 837/2010AA/N3/01 IP0105 City 1 837/2010AA/N4/01
IP9097 Filler T 20 IP9004 Total Accommodation Charges – Revenue Centers N 10 Must equal the sum of record type 50 revenue code data Two decimal places implied IP9098 Filler NT 10 IP9005 Ancillary Charges – Revenue Centers N 10 Must the sum of record type 60 revenue code data Two decimal places implied IP9099 Filler T 118 Data Element # Data Element Implementation Date for New Data Elements Type Length Description/Codes/Sources IP9901 Record Type T 2 99 IP9999 Filler T 190 Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator IP0101 Record Type NA NA IP0102 MHDO-Assigned Provider ID Submitter EIN NA NA IP0103 ProviderSubmitter Name 1 837/2010AA/NM1/85/2/03 IP0104 Address 1 837/2010AA/N3/01 IP0105 City 1 837/2010AA/N4/01
Chapter%20241_20170907_v2.docx