Plan Estimates
Patient (Standard) Estimates
| Name | Field | Required | In/Out |
|---|
| First Name | PID-5 | ✅ | In/Out |
| Last Name | PID-5 | ✅ | In/Out |
| Patient ID | PID-3 | ✅ | In/Out |
| Date of Birth | PID-7 | 🚫 | In/Out |
| Address Line 1 | PID-11 | 🚫 | In/Out |
| Address Line 2 | PID-11 | 🚫 | In/Out |
| City | PID-11 | 🚫 | In/Out |
| State | PID-11 | 🚫 | In/Out |
| ZIP Code | PID-11 | 🚫 | In/Out |
| Primary Phone Number | PID-13 | 🚫 | In/Out |
| Mobile Phone Number | PID-14 | 🚫 | In/Out |
| Email Address | PID-13 | 🚫 | In/Out |
Primary Insurance
| Name | Field | Required | In/Out |
|---|
| Payer Name/ID | IN1-3 | ✅ | In/Out |
| Plan Name/ID | IN1-2 | ✅ | In/Out |
| Member ID | IN1-36, IN1-49 | ✅ | In/Out |
| Group ID | IN1-8 | 🚫 | In/Out |
Note:
Use "SELF PAY" in IN1-2 to indicate self pay.
Encounters (This section is repeated once for each encounter)
| Name | Field | Required | In/Out |
|---|
| Service Date | PV1-44 | ✅ | In/Out |
| Provider NPI | PV1-7 | ✅ | In/Out |
| Encounter ID | PV1-19 | ✅ | In/Out |
| Facility | ROL-10 | 🚫 | In/Out |
| Self-Pay | PV1-29 | 🚫 | In/Out |
Procedures (This section is repeated once for each procedure within an encounter)
| Name | Field | Required | In/Out |
|---|
| Procedure Code | FT1-25.PR1-3 | ✅ | In/Out |
| Description | FT1-25.PR1-4 | 🚫 | In/Out |
| Quantity (Default 1) | FT1-10 | 🚫 | In/Out |
| Modifier 1 | FT1-26 | 🚫 | In/Out |
| Modifier 2 | GP2-8.PR1-16 | 🚫 | In/Out |
| Modifier 3 | GP2-8.PR1-16 | 🚫 | In/Out |
| Billed Amount | ZFT1-1 | | Out |
| Insurance Amount | FT1-15 | | Out |
| Allowed Amount | FT1-11 | | Out |
| In-Network | ZFT1-2 | | Out |
| Deductible Amount | FT1-6 DE or ZFT1-3 | | Out |
| Coinsurance Amount | FT1-6 CI or ZFT1-4 | | Out |
| Copay Amount | FT1-6 CO or ZFT1-5 | | Out |
Patient Eligibility
| Name | Field | Required | In/Out |
|---|
| Policy Scope | IN2-59 | | Out |
| Deductible Max | IN2-37 | | Out |
| Deductible Met | ZIN1-1 | | Out |
| Deductible Remaining | ZIN1-2 | | Out |
| Coinsurance Max | ZIN2-1 | | Out |
| Coinsurance Met | ZIN2-2 | | Out |
| Coinsurance Remaining | ZIN2-3 | | Out |
| Year Max | ZIN3-1 | | Out |
| Year Met | ZIN3-2 | | Out |
| Year Remaining | ZIN3-3 | | Out |
| Life Max | ZIN4-1 | | Out |
| Life Met | ZIN4-2 | | Out |
| Life Remaining | ZIN4-3 | | Out |
Policy Scope (IN2-59)
User defined table for ClearGage based on 0312 table as suggested by HL7 Specs. 6.4.7.59
| Values | Description |
|---|
| I-IND | In network individual |
| I-FAM | In network family |
| O-IND | Out-of-network individual |
| O-FAM | Out-of-network family |
Transaction Type (FT1-6)
User-defined for ClearGage based on 0017 Table as suggested by HL7 Specs. 6.5.1.6
| Values | Description |
|---|
| CG | Charge |
| CD | Credit |
| PY | Payment |
| AJ | Adjustment |
| CO | Co-payment |
| CI | Co-Insurance |
| DE | Deductible |