| | | | | | | | | | | |
| | _Ref_ | Id | _________Element Name__________ | Req | Type | Min/Max | | |
| | AMT01 | 522 | Amount Qualifier Code | M | ID | 1/3 | | |
| | | | Description: Code to qualify amount |
| | | | | Code | Name_______________________________ |
| | | | | I | Interest |
| | | | | T | Tax |
| | | | | AU | Coverage Amount |
| | | | | | Description: The dollar amount of property coverage provided by a specific policy contract |
| | | | | D8 | Discount Amount |
| | | | | | Description: A reduction from the usual price |
| | | | | DY | Per Day Limit |
| | | | | F5 | Patient Amount Paid |
| | | | | | Description: Monetary amount value already paid by one receiving medical care |
| | | | | NL | Negative Ledger Balance |
| | | | | T2 | Total Claim Before Taxes |
| | | | | | Description: The total monies requested for a single claim before any taxes were included |
| | | | | ZK | Federal Medicare or Medicaid Payment Mandate - Category 1 |
| | | | | ZL | Federal Medicare or Medicaid Payment Mandate - Category 2 |
| | | | | ZM | Federal Medicare or Medicaid Payment Mandate - Category 3 |
| | | | | ZN | Federal Medicare or Medicaid Payment Mandate - Category 4 |
| | | | | ZO | Federal Medicare or Medicaid Payment Mandate - Category 5 |
| | | | | ZZ | Mutually Defined |
| | AMT02 | 782 | Monetary Amount | M | R | 1/18 | | |
| | | | Description: Monetary amount |
