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Field labels

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Updated on August 31, 2021

This section defines the fields on the claim screen user interface. The fields within each core section outlined below are identified and defined; note that some fields are accessed via hyperlink.

Unless otherwise noted, each field in the list appears on all claim types.

Member information section
SectionField nameDescription
Member informationView submitted member informationThe View submitted member information hyperlink opens the Submitted member information pop up, displaying the subscriber and patient information as it was submitted on the claim. Note: when only subscriber information is submitted, only subscriber information is displayed.
Member informationNameThe matched patient's first and last name.
Member informationPatient IDThe patient’s identification number for the matched policy. The Patient ID hyperlink opens the Member details pop up.
Member informationGenderThe matched patient's gender.
Member informationDate of birthThe date of birth of the matched patient.
Member informationPolicy role/relationshipThe matched patient’s relationship to the subscriber.
Member informationPlan nameThe matched plan name. The Plan name hyperlink provides access to details from PHFC regarding the patient's plan.
Member informationPayerThe name of the payer.
Member informationIDThe identification number of the payer.
Member informationPolicy numberThe member's policy number.
Member informationSubscriber IDThe identification number of the subscriber. The Subscriber ID hyperlink opens the Member details pop up.
Member informationPayer responsibility sequence number codeThe policy’s order of responsibility for adjudicating the claim.
Submitted member information pop upIDThe identification number of the subscriber as submitted on the claim.
Submitted member information pop upDate of birthThe subscriber's date of birth as submitted on the claim.
Submitted member information pop upNameThe subscriber's first name, middle initial, and last name as submitted on the claim.
Submitted member information pop upAddressThe subscriber's address as submitted on the claim.
Submitted member information pop upGenderThe subscriber's gender as submitted on the claim.
Submitted member information pop upPolicy role/relationshipThe subscriber's relationship code as submitted on the claim.
Submitted member information pop upIDThe identification number of the patient as submitted on the claim.
Submitted member information pop upDate of birthThe patient's date of birth as submitted on the claim.
Submitted member information pop upNameThe patient's first name, middle initial, and last name as submitted on the claim.
Submitted member information pop upAddressThe patient's address as submitted on the claim.
Submitted member information pop upGenderThe patient's gender as submitted on the claim.
Submitted member information pop upPolicy role/relationshipThe patient's relationship code as submitted on the claim.
Member details pop upMaster IDThe master identification number associated to the patient.
Member details pop upFirst nameThe patient's first name.
Member details pop upMiddle nameThe patient's middle name.
Member details pop upLast nameThe patient's last name.
Member details pop upSuffixThe patient's suffix.
Member details pop upAddress line 1The first line of the patient's address.
Member details pop upAddress line 2The second line of the patient's address.
Member details pop upCityThe patient's city of residence.
Member details pop upStateThe patient's state of residence.
Member details pop upZip codeThe patient's zip code.
Member details pop upGenderThe patient's gender.
Member details pop upDate of birthThe patient's date of birth.
Member details pop upCategoryIndicates the type of policy - medical, dental, etc.
Member details pop upIDThe patient's identification number for the policy.
Member details pop upEffective dateThe effective date of the policy.
Member details pop upEnd dateThe end date of the policy.
Member details pop upIdentifierThe identification number for the policy type.
Member details pop upTypeThe type of policy.
Member details pop upNameThe name of the patient's primary care provider. Displayed only if member has a PCP on record.
Member details pop upSpecialtyThe specialty of the patient's primary care provider. Displayed only if member has a PCP on record.
Member details pop upEffective dateThe effective date of the patient's primary care provider relationship. Displayed only if member has a PCP on record.
Member details pop upEnd dateThe end date of the patient's primary care provider relationship. Displayed only if member has a PCP on record.
OTHER POLICIES (COB)PayerThe name of the other payer(s) for the member
OTHER POLICIES (COB)Other subscriber IDThe identification number of the other insurance subscriber.
OTHER POLICIES (COB)Last name/organization nameThe last name or organization name of the other insurance subscriber.
OTHER POLICIES (COB)Individual relationship codeThe other insurance subscriber's individual relationship code.
OTHER POLICIES (COB)AddressThe other subscriber's address.
OTHER POLICIES (COB)Benefit assignment certification indicatorThe benefit assignment certification indicator of the other subscriber.
OTHER POLICIES (COB)Release of informationThe release of information indicator for the other subscriber.
OTHER POLICIES (COB)Other payer IDThe identifier for the other insurance payer.
OTHER POLICIES (COB)Other payer organization nameThe name of the other insurance payer.
OTHER POLICIES (COB)Claim control numberThe claim number associated with the other insurance payment.
OTHER POLICIES (COB)Payer responsibility sequence numberThe other insurance policy’s order of responsibility for adjudicating the claim.
OTHER POLICIES (COB)AddressThe address of the other insurance payer.
OTHER POLICIES (COB)Paid amountThe total paid amount the other payer paid for the claim.
OTHER POLICIES (COB)Paid dateThe date the other payer paid the claim.
OTHER POLICIES (COB)Patient's remaining liabilityThe remaining patient liability after the other payer paid the claim.
OTHER POLICIES (COB)Non covered amountThe amount not covered when the other payer paid the claim.
OTHER POLICIES (COB)Check numberThe check number associated with the other payer's claim payment.
OTHER POLICIES (COB)Adjustment group codeThe adjustment group code used by the other payer to indicate liability for non-paid amounts on the claim.
OTHER POLICIES (COB)Reason codeThe reason code used by the other payer to explain non-paid amounts on the claim.
OTHER POLICIES (COB)DescriptionThe description associated with the reason code used by the other payer to explain non-paid amounts on the claim.
OTHER POLICIES (COB)AmountThe dollar amount of the adjustment.
OTHER POLICIES (COB)QuantityThe quantity of the adjustment.

Provider information section
SectionField nameDescription
BILLING PROVIDERNameThe name of the billing provider.
BILLING PROVIDERTax identification numberThe billing provider's tax identification number. The Tax identification number hyperlink leads to detailed billing provider information.
BILLING PROVIDERCapitation flagThe capitation flag indicates whether the provider is subject to a capitation agreement.
BILLING PROVIDERAddressThe full address of the billing provider.
BILLING PROVIDERPAY TO ADDRESSThe pay to address of the billing provider. The Pay to address hyperlink opens a pop up displaying the address entered.
RENDERING PROVIDERNameThe name of the rendering provider.
RENDERING PROVIDERProvider NPIThe rendering provider's National Provider Identifier (NPI). The Provider NPI hyperlink leads to detailed rendering provider information.
RENDERING PROVIDERSpecialtyThe specialty of the rendering provider.
OTHER PROVIDERSProvider typeWhen provider types other than billing and rendering are submitted on the claim, SCE displays the provider type (for example, operating provider or service facility) above a hyperlink that leads to detailed information about the other provider(s).

Claim lines section
SectionField nameDescription
Claim linesNo.The claim line number.
Claim linesService from

Professional, outpatient, and inpatient claims only - The Service from date indicates the starting month, day, and year the service(s) was

provided.

Claim linesService to

Professional, outpatient, and inpatient claims only - The Service to date indicates the ending month, day, and year the service(s) was

provided.

Claim linesProcedure dateDental claims only - The procedure date indicates the starting month, day, and year the service(s) was provided.
Claim linesProcedure codeProfessional and dental claims only - The procedure code identifies the medical services and procedures provided to the patient.
Claim linesProcedure modifiersProfessional claims only - The procedure code modifier provides supplemental information for the procedure code billed.
Claim linesArea of oral cavityDental claims only - The area of oral cavity is a code which reports what part of the mouth the procedure billed on the claim line applies to.
Claim linesTooth surfaceDental claims only - The tooth surface is a code which reports which part of the tooth the procedure billed on the claim line applies to.
Claim linesUnitsProfessional, outpatient, and inpatient claims only - The units field captures the count of the services reported on the claim line.
Claim linesBilled amountThe billed amount indicates the total charged by the provider for the claim line.
Claim linesApproved amountThe approved amount is the amount due to the payee for all the services on the claim.
Claim linesStatusThe adjudication status of the claim line.
Claim linesRevenue codeOutpatient and inpatient claims only - The revenue code is used to identify specific accommodations and/or ancillary charges.
Claim line detailsService from

The Service from date indicates the starting month, day, and year the service(s) was

provided.

Claim line detailsService to

The Service to date indicates the ending month, day, and year the service(s) was

provided.

Claim line detailsTreatment start dateDental claims only - The beginning date of treatment for the service billed on the claim line.
Claim line detailsTreatment completion dateDental claims only - The end date of treatment for the service billed on the claim line.
Claim line detailsOrthodontic banding dateDental claims only - The date orthodontic banding was performed.
Claim line detailsReplacement dateDental claims only - The date the appliance or prosthesis was replaced.
Claim line detailsPredetermination of benefits identifierDental claims only - The identification or reference number of the predetermination of benefits submission.
Claim line detailsAdj repriced line reference numberDental claims only - The line number of an adjusted repriced line item adjusted from an original amount.
Claim line detailsProsthesis crown or inlay codeDental claims only - The code specifying the placement status for the dental work.
Claim line detailsPrior placement dateDental claims only - The date of the prior placement of the prosthesis, crown, or inlay.
Claim line detailsPlace of serviceFor professional and dental claims only - The place of service code and description submitted on the claim line.
Claim line detailsOral cavity designation codeDental claims only - The oral cavity designation code indicates the area of the oral cavity associated with the service submitted on the claim line.
Claim line detailsTooth codeDental claims only - The tooth code indicates the tooth associated with the service submitted on the claim line.
Claim line detailsTooth surface codeDental claims only - The tooth surface code indicates the part of the tooth associated with the service submitted on the claim line.
Claim line detailsRevenue codeOutpatient and inpatient claims only - The revenue code is used to identify specific accommodations and/or ancillary charges.
Claim line detailsNational drug codeProfessional, outpatient, and inpatient claims only - The National Drug Code (NDC) is a unique, three-segment number which serves as an identifier for drugs.
Claim line detailsProcedure codeThe procedure code identifies the medical services and procedures provided to the patient.
Claim line detailsProcedure code qualifierOutpatient and inpatient claims only - Identifies an additional attribute of the procedure reported.
Claim line detailsUnit qualifierThe units qualifier further describes the units billed, denoting, days, units, etc.
Claim line detailsProcedure modifiersThe procedure code modifier provides supplemental information for the procedure code billed.
Claim line detailsService unitOutpatient and inpatient claims only - The service unit field captures the count of the services reported on the claim line.
Claim line detailsNon covered chargesOutpatient and inpatient claims only - Non-covered charges for the claim service line as submitted by the provider.
Claim line detailsClaim approved unitsThe number of units approved for payment on the claim service line.
Claim line detailsBenefitThe benefit matched to the claim line based on the service, diagnosis and other factors billed on the claim.
Claim line detailsPrior authorizationThe prior authorization number, referral number, mammography pre-certification number, or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service.
Claim line detailsAdjudicated authorizationThe actual prior authorization number, referral number, mammography pre-certification number, or Clinical Laboratory Improvement Amendments (CLIA) number applied during claim adjudication.
Claim line detailsPROVIDERSWhen claim line level providers are reported, SCE displays the provider type (for example, operating provider or service facility) above a hyperlink that leads to detailed information about the other provider(s).
Claim line detailsUnit of serviceFor professional and dental claims only - The unit of service field captures the count of the services reported on the claim line.
Execution resultBilled claim amountThe billed claim amount indicates the total charged by the provider for the services on the claim line.
Execution resultApproved amountThe approved amount is the amount due to the payee for the services billed on the claim line.
Execution resultStatusThe adjudication status of the claim line.
Execution resultAllowed amountThe initial maximum dollar amount a payer would pay for a given service line on the claim.
Execution resultCalculated allowed amountThe final amount payable for the claim line. Factors such as surcharge amount and billed amount (when lesser than the allowed amount) are taken into consideration.
Execution resultSurcharge amountThe surcharge amount applicable to the claim line.
Execution resultGME %The percentage applied for the graduate medical expense surcharge.
Execution resultPricing sourceThe source for the price applied to the claim service line.
Execution resultPricing methodThe method for calculating the price applied to the claim service line.
DeductibleThe deductible amount due from the member for the services on the claim line.
CoinsuranceThe coinsurance amount due from the member for the services on the claim line.
Execution resultMember penaltyThe amount of any penalty applied to the member.
CopayThe copay amount due from the member for the services on the claim line.
Execution resultAdditional liabilityCaptures any additional member liability for the services billed on the claim line
Execution resultCopay calculation methodIndicates how the copay is calculated by the benefit plan.
Execution resultFinalized paid dateThe date the check/EFT was issued by the payer.
Check or EFT numberThe check or Electronic Funds Transfer (EFT) number associated with the payment.
Execution resultAdjudication dateThe date the adjudication of the claim line was completed.
Execution resultNetwork IDThe identifier for the network matched to drive payment calculations.
Execution resultTotal patient liabilityThe total patient liability for the services submitted on the claim line.
Execution resultNon-covered patient liabilityThe patient liability for non-covered services submitted on the claim line.
Execution resultPaid amountThe amount paid for services submitted on the claim line.
Execution resultCapitation flag for APIAn indicator for capitation.
Execution resultRatesheet IDThe identifier for the provider ratesheet.
Execution resultDOFR indicatorIndicates that the claim line is subject to a Division of Financial Responsibility (DOFR) provision.
Execution resultParticipating networkThe indicator of whether the provider is participating or non-participating.
Execution resultContract IDThe provider's contract identifier.
Execution resultInfo from external systemThe Info from external system hyperlink provides access to information from external systems (for example, ClaimsXten or NetworX Pricer) used in the claim line adjudication.
Execution resultPricing SourcesThe Pricing Sources hyperlink provides access to the pricing sources, methodologies, and dollar amounts generated during claim line adjudication.
Adjustment detailsOther payerThe other insurance payer identifier for other insurance payments associated to the claim line. This field is expandable for access to details regarding the adjustment group code, reason code, description, amount, and quantity associated with the claim line.
Adjustment detailsPaid amountThe amount paid by the other insurance payer for the claim line.
Adjustment detailsRemaining patient liabilityThe remaining patient liability amount for the claim line after adjudication by the other payer.
Adjustment detailsPaid service unit countThe service unit count of services paid on the claim line by the other payer.
Adjustment detailsProcedure codeThe procedure code submitted by the other insurance payer for the claim line.
Adjustment detailsAdjustment group codeThe adjustment group code used to indicate liability for non-paid amounts on the claim line.
Adjustment detailsReason codeThe reason code used to explain non-paid amounts on the claim line.
Adjustment detailsDescriptionThe description associated with the reason code used to explain non-paid amounts on the claim line.
Adjustment detailsAmountThe amount of the claim line adjustment.
Adjustment detailsQuantityThe quantity associated with the claim line adjustment.
Adjustment detailsRemittance advice remark codeThe code used to further explain the adjustment to the claim line.
Adjustment detailsDescriptionThe description associated with the code used to further explain the adjustment to the claim line.
Pulse section

Pulse provides the ability for you to post messages and receive replies.

Summary section
SectionField nameDescription
SummaryBilled claim amountThe billed claim amount indicates the total charged by the provider for all the services on the claim.
SummaryApproved amountThe approved amount is the amount due to the payee for the claim line.
SummaryClaim age (Days)The age of the claim calculated based on the submitted date of the claim.
SummaryRelated claim detailsThe Related claim details hyperlink appears when there are automatically or manually related claims.

Claim header section
SectionField nameDescription
Claim headerClaim typeThe claim type of the claim.
Claim headerStatusThe current adjudication status of the claim.
Claim headerLine of businessThe line of business associated with the policy.
Claim headerReceived onThe date the claim was received by the EDI gateway.
Claim headerUpdated onThe date of the most recent update to the claim.
Claim headerRouted toDisplayed on unresolved claims only, the routed to field indicates the work queue or work list to which the claim is routed.
Claim headerAuthorizationThe authorization submitted by the provider at the claim header level.
Claim headerSubmitted onThe date the claim was submitted into the SCE.
Claim headerTooth numbers/lettersDental claims only - The Tooth numbers/letters chart indicates missing teeth and/or teeth to be extracted. You can choose to view a maxillary or mandibular tooth chart.
Claim informationService date from-toProfessional and dental claims only - The date span of the services submitted on the claim.
Claim informationPlace of serviceProfessional and dental claims only - The claim level place of service code and description.
Claim informationAccident typeProfessional and dental claims only - The type of accident associated with the services rendered on the claim.
Claim informationAccident countryProfessional and dental claims only - The country where the accident associated with the services rendered on the claim occurred.
Claim informationAccident stateProfessional and dental claims only - The state where the accident associated with the services rendered on the claim occurred.
Claim informationDate of accidentProfessional and dental claims only - The date the accident associated with the services rendered on the claim occurred.
Claim informationOther insurance indicatorProfessional and dental claims only - Indicates whether other insurance coverage for the accident exists.
Claim informationClaim referral numberProfessional and dental claims only - The referral number associated with the services rendered on the claim.
Claim informationICNDental claims only - The internal control number for the claim.
Claim informationSubmitter claim numberProfessional, outpatient, and inpatient claims only - The claim number provided by the submitter of the claim.
Claim informationClaim identifierThe claim identifier for the claim.
Claim informationTransaction typeThe transaction type for the claim.
Claim informationMedia typeProfessional and dental claims only - The media type of the claim submission.
Claim informationCapitation flagIndicates whether the claim was processed as capitated.
Claim informationLine of businessThe line of business associated with the policy.
Claim informationObject IDThe work object identifier for the claim work object.
Claim informationDiagnosis typeThe type of diagnosis submitted for the claim.
Claim informationPrincipal diagnosis codeThe principal diagnosis related to the services submitted on the claim.
Claim informationPresent on admissionAn indicator of whether the diagnosis was present upon the patient's hospital admission date.
Claim informationOther diagnosis codesProfessional and dental claims only - Additional diagnosis codes associated with the patient.
Claim informationIs predetermination of benefitsDental claims only - Indicates whether the submitted claim is for predetermination of benefits.
Claim informationPrior authorization numberOutpatient, inpatient, and dental claims only - The prior authorization number assigned by the payer for the current service.
Claim informationPredetermination of benefits identifierDental claims only - The identification or reference number of the predetermination of benefits submission.
Claim informationIs treatment for orthodonticsDental claims only - Indicates whether services billed were for orthodontic treatment.
Payment information section
SectionField nameDescription
Payment informationSurcharge amountThe total dollar amount of any surcharges applied to the claim.
Payment informationAllowed amountThe initial maximum dollar amount a payer would pay for all service lines on the claim.
Payment informationPatient liabilityThe total patient liability for the services submitted on the claim.
Payment informationLPI amountThe total late payment interest amount paid for the claim.
Payment detailsBilled claim amountThe billed claim amount indicates the total charged by the provider for all the services on the claim.
Payment detailsApproved amountThe approved amount is the amount due to the payee for all the services on the claim.
Payment detailsStatusThe overall claim status.
Payment detailsAllowed amountThe initial maximum dollar amount a payer would pay for all service lines on the claim.
Payment detailsSurcharge amountThe total dollar amount of any surcharges applied to the claim.
Payment detailsSurcharge %The surcharge percentage applied to the claim.
Payment detailsAdjudication dateThe date the adjudication of the claim was completed.
Payment detailsCheck or EFT numberThe check or Electronic Funds Transfer (EFT) number associated with the payment.
Payment detailsMember penaltyThe dollar amount of any penalty due from the member.
Payment detailsCoinsuranceThe total coinsurance amount due from the member.
Payment detailsCopayThe total copay amount due from the member.
Payment detailsDeductibleThe total deductible amount due from the member.
Payment detailsAdditional liabilityCaptures any additional member liability for the services billed on the claim.
Payment detailsLPI amountThe amount of late payment interest paid.
Payment detailsLPI number of daysThe number of days used to calculate late payment interest.
Payment detailsLPI decisioningThe LPI decisioning hyperlink opens the decision table used to calculate late payment interest.
Payment detailsCalculated allowed amountThe final amount payable for the claim.
Payment detailsTotal patient estimated liabilityProfessional and inpatient claims only - The estimate of the patient's liability submitted by the provider.
Payment detailsTotal patient liabilityThe total patient liability for the services submitted on the claim.
Payment detailsPaid amountThe total amount paid for the claim.
Payment detailsPaid dateThe date payment was issued for the claim.
Payment detailsNetwork codeThe code indicating the network.
Payment detailsInfo from external systemThe Info from external system hyperlink provides access to information from external systems (for example, ClaimsXten or NetworX Pricer) used in the claim adjudication.
Payment detailsAdjustment group codeThe adjustment group code used to indicate liability for non-paid amounts on the claim.
Payment detailsReason codeThe reason code used to explain non-paid amounts on the claim.
Payment detailsDescriptionThe description associated with the reason code used to explain non-paid amounts on the claim.
Payment detailsAmountThe amount of the claim adjustment.
Payment detailsQuantityThe quantity associated with the claim adjustment.
Payment detailsRemittance advice remark codeThe code used to further explain the adjustment to the claim.
Payment detailsDescriptionThe description associated with the remittance advice code on the claim.
Payment detailsNetworkThe network name.
Payment detailsOOP totalThe out of pocket (OOP) total for the network.
Payment detailsOOP yearly maxThe out of pocket (OOP) yearly maximum defined for the network.
Case details section
SectionField nameDescription
Case detailsLast updated byThe name and timeframe of the last update made to the claim.
Case detailsCreated byThe name and timeframe of the creation of the claim.
Case detailsTagsAllows you to choose an existing tag or create a new one(s) in order to tag the claim work object.
Attachments section

The Attachments slot provides the ability to add, delete or download attachments, based on the user role and privileges.

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