| Data Element |
Code |
| Billing Account Description | B1.4 |
| Billing Alert User | B1.2 |
| Billing Benefits Assignment | B1.5 |
| Billing Employer's Address | B1.13 |
| Billing Employer's Address 2 | B1.27 |
| Billing Employer's City | B1.23 |
| Billing Employer's State | B1.24 |
| Billing Employer's Telephone Number | B1.15 |
| Billing Employer's Zip Code | B1.22 |
| Billing Employment Status | B1.19 |
| Billing Erase Statement Comment | B1.18 |
| Billing Fee Schedule (Alternate Fee) | B1.11 |
| Billing Finance Charges | B1.16 |
| Billing Group Code | B1.1 |
| Billing Group Description | B1.1d |
| Billing Guarantor's Employer | B1.12 |
| Billing Internal Comment | B1.8 |
| Billing Medicare Patient | B1.10 |
| Billing Print Aging Message | B1.17 |
| Billing Release of Information | B1.28 |
| Billing Report Comment | B1.7 |
| Billing Send Statement | B1.3 |
| Billing Statement Comment | B1.6 |
| Billing Suppress Collections | B1.21 |
| Billing Use Primary Address | B1.9 |
| Card Expire Date | C1.3 |
| Card/Account Holder Name | C1.8 |
| Card/Account Number | C1.4 |
| Card/Account Status | C1.0 |
| Card/Account Type | C1.5 |
| Card/Account Zip Code | C1.9 |
| Case Accident State Code | C2.15 |
| Case Accident State Description | C2.15d |
| Case Accident Type | C2.27 |
| Case Adjuster Code | C2.46 |
| Case Adjuster Fax | C2.34 |
| Case Adjuster Name | C2.32 |
| Case Adjuster Phone | C2.33 |
| Case Billing Group Code | C2.38 |
| Case Billing Group Description | C2.38d |
| Case Claim Number | C2.31 |
| Case Comment | C2.5 |
| Case Date Able To Work | C2.11 |
| Case Date First PCP Visit | C2.26 |
| Case Date Last Worked | C2.24 |
| Case Date of First Visit | C2.3 |
| Case Date of Illness/Injury/LMP | C2.2 |
| Case Date Unable To Work | C2.39 |
| Case Description | C2.4 |
| Case Discharge Date/MMI | C2.12 |
| Case Doctor Code | C2.29 |
| Case Doctor Description | C2.29d |
| Case Employer Code | C2.35 |
| Case Employer Description | C2.35d |
| Case End Light Duty Date | C2.41 |
| Case End Partial Disability Date | C2.10 |
| Case End Total Disability Date | C2.8 |
| Case Fee Schedule | C2.48 |
| Case Ins Primary Code | C2.16 |
| Case Ins Primary Description | C2.16d |
| Case Ins Primary Policy # | C2.16p |
| Case Ins Secondary Code | C2.17 |
| Case Ins Secondary Description | C2.17d |
| Case Ins Secondary Policy # | C2.17p |
| Case Ins Tertiary Code | C2.18 |
| Case Ins Tertiary Description | C2.18d |
| Case Ins Tertiary Policy # | C2.18p |
| Case Location Code | C2.49 |
| Case Location Description | C2.49d |
| Case Manager Code | C2.47 |
| Case Manager Fax | C2.44 |
| Case Manager Name | C2.42 |
| Case Manager Phone | C2.43 |
| Case Permanent Restrictions | C2.37 |
| Case Primary Diagnosis Code | C2.21 |
| Case Primary Diagnosis Description | C2.21d |
| Case Protocol Code | C2.45 |
| Case Protocol Description | C2.45d |
| Case Referring Doctor Code | C2.36 |
| Case Referring Doctor Description | C2.36d |
| Case Restrictions | C2.22 |
| Case Start Light Duty Date | C2.40 |
| Case Start Partial Disability Date | C2.9 |
| Case Start Total Disability Date | C2.7 |
| Case Statement Billing | C2.20 |
| Case Termination Date | C2.23 |
| Case Therapist Code | C2.30 |
| Case Therapist Description | C2.30d |
| Case Type Code | C2.25 |
| Case Type Description | C2.25d |
| Guarantor Address Line One | G1.4 |
| Guarantor Address Line Two | G1.5 |
| Guarantor Birth Date | G1.18 |
| Guarantor Cell Phone | G1.24 |
| Guarantor City | G1.6 |
| Guarantor Country Code | G1.19 |
| Guarantor County | G1.20 |
| Guarantor E-Mail Address | G1.17 |
| Guarantor First Name | G1.2 |
| Guarantor Last Name | G1.1 |
| Guarantor Middle Initial | G1.3 |
| Guarantor Middle Name | G1.26 |
| Guarantor Secondary Address One | G1.11 |
| Guarantor Secondary Address Two | G1.12 |
| Guarantor Secondary City | G1.13 |
| Guarantor Secondary Country Code | G1.21 |
| Guarantor Secondary County | G1.22 |
| Guarantor Secondary Phone | G1.16 |
| Guarantor Secondary State | G1.14 |
| Guarantor Secondary Subdivision | G1.29 |
| Guarantor Secondary Zip Code | G1.15 |
| Guarantor State Code | G1.7 |
| Guarantor Subdivision | G1.30 |
| Guarantor Suffix | G1.27 |
| Guarantor Telephone | G1.9 |
| Guarantor Zip Code | G1.8 |
| Patient Account Number | P1.0 |
| Patient Address Line 1 | P1.4 |
| Patient Address Line 2 | P1.5 |
| Patient Age | P1.13a |
| Patient Birth Date | P1.13 |
| Patient Cell | P1.24 |
| Patient City | P1.6 |
| Patient Class Code | P1.22 |
| Patient Class Description | P1.22d |
| Patient Country Code | P1.30 |
| Patient County Code | P1.31 |
| Patient Death Date | P1.37 |
| Patient Default Diagnosis | P1.11 |
| Patient Default Location Code | P1.18 |
| Patient Default Location Description | P1.18d |
| Patient Email | P1.23 |
| Patient Ethnicity Code | P1.33 |
| Patient Ethnicity Description | P1.33a |
| Patient First Name | P1.2 |
| Patient First Visit Date | P1.17 |
| Patient Firstname, Lastname | P1.1b |
| Patient Home Phone | P1.9 |
| Patient Identifier | P1.29 |
| Patient Language | P1.27 |
| Patient Last Name | P1.1 |
| Patient Lastname, Firstname | P1.1a |
| Patient Middle Initial | P1.3 |
| Patient Primary Doctor Code | P1.19 |
| Patient Primary Doctor Description | P1.19d |
| Patient Race Code | P1.28 |
| Patient Race Description | P1.28a |
| Patient Referral Code | P1.15 |
| Patient Referral First Name | P1.15c |
| Patient Referral Last Name | P1.15b |
| Patient Referral Middle | P1.15d |
| Patient Referral Printing Name | P1.15a |
| Patient Referral Suffix | P1.15e |
| Patient Referral Type | P1.32 |
| Patient Responsible Doctor Code | P1.16 |
| Patient Responsible Doctor Description | P1.16d |
| Patient Sex | P1.12 |
| Patient Social Security # | P1.10 |
| Patient State | P1.7 |
| Patient Status | P1.20 |
| Patient Subdivision | P1.38 |
| Patient Suffix | P1.36 |
| Patient Zip Code | P1.8 |
| Primary Carrier Auth Required | I1.01 |
| Primary Carrier Code | I1.1 |
| Primary Carrier Copay | I1.16 |
| Primary Carrier Group Number | I1.5 |
| Primary Carrier Name | I1.0 |
| Primary Carrier Policy Number | I1.6 |
| Primary Carrier Spec Copay | I1.24 |
| Primary Carrier Verified By | I1.34 |
| Primary Carrier Verified By via CGM webVERIFY | I1.29 |
| Primary Carrier Verified Date | I1.33 |
| Primary Carrier Verified Date via CGM webVERIFY | I1.28 |
| Secondary Carrier Auth Required | I2.01 |
| Secondary Carrier Code | I2.1 |
| Secondary Carrier Copay | I2.16 |
| Secondary Carrier Group Number | I2.5 |
| Secondary Carrier Name | I2.0 |
| Secondary Carrier Policy Number | I2.6 |
| Secondary Carrier Spec Copay | I2.24 |
| Secondary Carrier Verified By | I2.34 |
| Secondary Carrier Verified By via CGM webVERIFY | I2.29 |
| Secondary Carrier Verified Date | I2.33 |
| Secondary Carrier Verified Date via CGM webVERIFY | I2.28 |
| Tertiary Carrier Auth Required | I3.01 |
| Tertiary Carrier Code | I3.1 |
| Tertiary Carrier Copay | I3.16 |
| Tertiary Carrier Group Number | I3.5 |
| Tertiary Carrier Name | I3.0 |
| Tertiary Carrier Policy Number | I3.6 |
| Tertiary Carrier Spec Copay | I3.24 |
| Tertiary Carrier Verified By | I3.34 |
| Tertiary Carrier Verified By via CGM webVERIFY | I3.29 |
| Tertiary Carrier Verified Date | I3.33 |
| Tertiary Carrier Verified Date via CGM webVERIFY | I3.28 |