Pa. Code tit. 28, pt. VI, ch. 915, MISCELLANEOUS PROVISIONS, app B
Current through Register Vol. 54, No. 45, November 9, 2024
| Field Number | Data Element Name | |
| FRM | PRM | |
| (2*) | (4*) | Year of Birth/Age |
| 3 | 5 | Patient Sex |
| 4 | - | Patient Zip Code (first 5 digits) |
| 14e 1-4 | - | Estimated Responsibility |
| 14f 1-4 | - | Prior Payments-Payor and Patient |
| 14g 1-4 | - | Estimated Amount Due |
| 19 | 16 | Payor Group Number |
| 21e | 21 | Reserve Field |
| 28a-c | 19 | Patients' Relationship to Insured |
| 32 | - | Employer Name |
| 35 | - | Patient Race |
| - | 14 | Primary Payor Payments |
| - | 15 | Other Payments |
| * | * | Proxy Patient Identifier |
* constructed data element using submitted data elements
FRM-Facility Reporting Manual
PRM-Payor Reporting Manual
Pa. Code tit. 28, pt. VI, ch. 915, MISCELLANEOUS PROVISIONS, app B
This appendix cited in 28 Pa. Code § 915.3 (relating to definitions); 28 Pa. Code § 915.21 (relating to classes of data collected by the Council); and 28 Pa. Code § 915.23 (relating to release of protected data).