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Classification Level Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Claim Service Start Date

Date on which services began.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Claim Service End Date

Date on which services ended.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Claim Paid Date

The date the claim was paid.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Modifier Code -4

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Modifier Code -3

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Modifier Code -2

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Modifier Code -1

Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Procedure Type

Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Procedure Code Type

Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Procedure Code Type

Principal medical procedure a patient received during inpatient stay. Current coding methods include: International Classification of Diseases Surgical Procedures (ICD-9). Information located on UB04 (Form Locator 74).
Additional surgical procedure surgical (ICD-9) administered during inpatient stay.
Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).
Additional surgical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10).

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Copay Amount

Medical: Amount an insured individual pays directly to a provider at the time the services or supplies are rendered. Usually, a copay will be a fixed amount per service, such as $15.00 per office visit.
Pharmacy: Amount to be collected from a patient that is included in the Patient Pay Amount that is due to a per prescription copay or coinsurance.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Amount Paid to Provider

The amount paid to the provider.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Patient Deductible

The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Other Payer Paid Amount

The reduction in the payment amount to reflect the current carrier as a secondary, tertiary, etc, payer. May be multiple occurrences if the current carrier is a tertiary, etc. carrier.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Coinsurance Amount

Medical: The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.
Pharmacy: Amount to be collected from a patient that is included in the Patient Pay Amount that is due to a per prescription copay or coinsurance.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Submitted Amount

Amount submitted by the provider for reimbursement of health care services. This amount includes non-covered services.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Allowed Amount

The contracted reimbursable amount for covered medical services or supplies or amount reflecting local methodology for noncontracted providers. Allowed amount should not include any COB adjustment. That is, the Allowed amount on a claim should be the same when the Plan is primary or secondary.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Line Member Liability

The amount of the member's liability.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Diagnosis Code Type

Indicates if the diagnosis is admitting, principal, other, an external cause of injury or secondary

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners
Level 0 Explanation of Benefit

Health data as reflected in a patient's Explanation of Benefits (EOB) statements, typically derived from claims and other administrative data.

 Diagnosis Type

ICD-10-CM code describing the condition chiefly responsible for a patient's admission to a facility. It may be different from the principal diagnosis, which is the diagnosis assigned after evaluation. Decimals will be included.
The member's principal condition treated during this service. This may or may not be different from the admitting diagnosis. Decimals will be included.
Additional diagnosis identified for this member. Decimals will be included.

NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes.

 Mark Roberts Leavitt Partners