Pos |
Segment |
M/C |
Repeat |
Repr. |
Notes |
010 |
|
E206 |
OBJECT IDENTIFICATION |
M |
3 |
|
|
|
|
7402 |
Object identifier |
M |
|
an..35 |
|
|
|
7405 |
Object identification code qualifier |
C |
|
an..3 |
|
|
|
4405 |
Status description code |
C |
|
an..3 |
|
020 |
|
E021 |
SERVICE |
C |
3 |
|
|
|
|
7135 |
Product identifier |
M |
|
an..35 |
|
|
|
1131 |
Code list identification code |
C |
|
an..3 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
030 |
|
1229 |
Action request/notification description code |
C |
1 |
an..3 |
|
040 |
|
E017 |
MONETARY AMOUNT |
C |
15 |
|
|
|
|
5025 |
Monetary amount type code qualifier |
C |
|
an..3 |
|
|
|
5004 |
Monetary amount |
C |
|
n..35 |
|
|
|
6345 |
Currency identification code |
C |
|
an..3 |
|
|
|
6343 |
Currency type code qualifier |
C |
|
an..3 |
|
|
|
4405 |
Status description code |
C |
|
an..3 |
|
050 |
|
6060 |
Quantity |
C |
3 |
an..35 |
|
060 |
|
E030 |
ADJUSTMENT INFORMATION |
C |
15 |
|
|
|
|
9619 |
Adjustment category code |
M |
|
an..3 |
|
|
|
4465 |
Adjustment reason description code |
M |
|
an..3 |
|
|
|
5004 |
Monetary amount |
C |
|
n..35 |
|
070 |
|
9620 |
Policy limitation identifier |
C |
4 |
an..10 |
|
080 |
|
5389 |
Product group name code |
C |
1 |
an..25 |
|
090 |
|
E507 |
DATE/TIME/PERIOD |
C |
1 |
|
|
|
|
2005 |
Date or time or period function code qualifier |
M |
|
an..3 |
|
|
|
2380 |
Date or time or period value |
C |
|
an..35 |
|
|
|
2379 |
Date or time or period format code |
C |
|
an..3 |
|
100 |
|
9639 |
Diagnosis category code |
C |
1 |
an..3 |
|
110 |
|
5482 |
Percentage |
C |
1 |
n..10 |
|