Fields that Display by Default

Field on Transmission Page

Location of Data in EDI

Amount

2200D - STC04 - Line Item Charge Amount (Subscriber)

Assigned

From My Tasks page

Document Date

2200D - DTP03 - Claim Level Service Date if available

Otherwise BHT04 - Transaction Set Date + BHT05 - Transaction Set Time

Number of Errors

Count of errors with a severity greater than 2

Original File Date

Date supplied by the -m Instream command line parameter

Original File Name

Name supplied by the -m Instream command line parameter

Receiver

Criteria set up by TI administrator

Sender

Criteria set up by TI administrator

Status

From My Tasks page

Submitter Identifier

2200D - TRN02

277CA  fields that you can add with Choose Fields Link

Field on Transmission Page

Location of Data in EDI

Billing Provider Entity Type Qual

2100C - NM102

Billing Provider Id Code

2100C - NM109

Billing Provider Id Code Qual

2100C - NM108

Billing Provider Name First

2100C - NM104

Billing Provider Name Last

2100C - NM103

Claim Status Tracking Num

2200D - TRN02

Clearinghouse Claim Id

2200D - REF02 where REF01 =  D9

Info Receiver App Trace Num

2200B - TRN02

Info Receiver Entity Type Qual

2100B - NM102

Info Receiver Id Code

2100B - NM109

Info Receiver Name First

2100B - NM104

Info Receiver Name Last

2100B - NM103

Info Source Entity Id Code

2100A - NM101

Info Source Id Code

2100A - NM109

Info Source Id Code Qual

2100A - NM108

Info Source Name Last

2100A - NM103

Institutional Bill Type Id

2200D - REF02 where REF01 =  BLT

Patient Id Code

2100D - NM109

Patient Id Code Qual

2100D - NM108

Patient Name First

2100D - NM104

Patient Name Last

2100D - NM103

Payer Claim Control Num

2200D - REF02  where REF01 =  1K

Service Provider Trace Id

2200C - TRN02

Transmission Receipt Control Id

2200A - TRN02