complexType "ePayment"
Namespace:
http://www.nemsis.org
Content:
complex, 22 elements
Defined:
globally in ePayment_v3.xsd; see XML source
Includes:
definitions of 22 elements
Used:
at 1 location
Content Model Diagram
XML Representation Summary
<...>
   
Content: 
 ePayment.01, ePayment.CertificateGroup?, ePayment.08?, ePayment.InsuranceGroup*, ePayment.ClosestRelativeGroup?, ePayment.EmployerGroup?, ePayment.40?, ePayment.41*, ePayment.42*, ePayment.44*, ePayment.45?, ePayment.46?, ePayment.47*, ePayment.48?, ePayment.49?, ePayment.50, ePayment.51*, ePayment.52*, ePayment.53?, ePayment.54?, ePayment.SupplyItemGroup*, ePayment.57?
</...>
Content Model Elements (22):
ePayment.01 (in ePayment),
ePayment.08 (in ePayment),
ePayment.40 (in ePayment),
ePayment.41 (in ePayment),
ePayment.42 (in ePayment),
ePayment.44 (in ePayment),
ePayment.45 (in ePayment),
ePayment.46 (in ePayment),
ePayment.47 (in ePayment),
ePayment.48 (in ePayment),
ePayment.49 (in ePayment),
ePayment.50 (in ePayment),
ePayment.51 (in ePayment),
ePayment.52 (in ePayment),
ePayment.53 (in ePayment),
ePayment.54 (in ePayment),
ePayment.57 (in ePayment),
ePayment.CertificateGroup (in ePayment),
ePayment.ClosestRelativeGroup (in ePayment),
ePayment.EmployerGroup (in ePayment),
ePayment.InsuranceGroup (in ePayment),
ePayment.SupplyItemGroup (in ePayment)
All Direct / Indirect Based Elements (1):
ePayment (in PatientCareReport)
Known Usage Locations
XML Source (w/o annotations (62); see within schema source)
<xs:complexType name="ePayment">
<xs:sequence>
<xs:element id="ePayment.PrimaryMethodofPayment" name="ePayment.01" nillable="true">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="PrimaryMethodOfPayment">
<xs:attribute name="NV" use="optional">
<xs:simpleType>
<xs:union memberTypes="NV.NotApplicable NV.NotRecorded"/>
</xs:simpleType>
</xs:attribute>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.CertificateGroup" minOccurs="0" name="ePayment.CertificateGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.PhysicianCertificationStatement" minOccurs="0" name="ePayment.02" type="YesNoUnkValues"/>
<xs:element id="ePayment.DatePhysicianCertificationStatementSigned" minOccurs="0" name="ePayment.03" type="DateTimeType"/>
<xs:element id="ePayment.ReasonforPhysicianCertificationStatement" maxOccurs="unbounded" minOccurs="0" name="ePayment.04">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="Reason">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.HealthcareProviderTypeSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.05" type="HealthcareProviderType"/>
<xs:element id="ePayment.LastNameofIndividualSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.06" type="PersonLastName"/>
<xs:element id="ePayment.FirstNameofIndividualSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.07" type="PersonFirstName"/>
</xs:sequence>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.PatientResidesinServiceArea" minOccurs="0" name="ePayment.08" type="ResidencyStatusOfThePatient"/>
<xs:element id="ePayment.InsuranceGroup" maxOccurs="unbounded" minOccurs="0" name="ePayment.InsuranceGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.InsuranceCompanyID" minOccurs="0" name="ePayment.09" type="InsuranceCompanyID"/>
<xs:element id="ePayment.InsuranceCompanyName" minOccurs="0" name="ePayment.10" type="InsuranceCompanyName"/>
<xs:element id="ePayment.InsuranceCompanyBillingPriority" minOccurs="0" name="ePayment.11" type="InsuranceCompanyBillingPriority"/>
<xs:element id="ePayment.InsuranceCompanyAddress" minOccurs="0" name="ePayment.12">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="StreetAddress">
<xs:attribute name="StreetAddress2" type="StreetAddress" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.InsuranceCompanyCity" minOccurs="0" name="ePayment.13" type="CityGnisCodePayment"/>
<xs:element id="ePayment.InsuranceCompanyState" minOccurs="0" name="ePayment.14" type="ANSIStateCode"/>
<xs:element id="ePayment.InsuranceCompanyZIPCode" minOccurs="0" name="ePayment.15" type="ZIP"/>
<xs:element id="ePayment.InsuranceCompanyCountry" minOccurs="0" name="ePayment.16" type="ANSICountryCode"/>
<xs:element id="ePayment.InsuranceGroupID" minOccurs="0" name="ePayment.17" type="InsuranceGroupID"/>
<xs:element id="ePayment.InsurancePolicyIDNumber" minOccurs="0" name="ePayment.18" type="InsurancePolicyIDNumber"/>
<xs:element id="ePayment.LastNameoftheInsured" minOccurs="0" name="ePayment.19" type="PersonLastName"/>
<xs:element id="ePayment.FirstNameoftheInsured" minOccurs="0" name="ePayment.20" type="PersonFirstName"/>
<xs:element id="ePayment.MiddleInitialNameoftheInsured" minOccurs="0" name="ePayment.21" type="PersonMiddleName"/>
<xs:element id="ePayment.RelationshiptotheInsured" minOccurs="0" name="ePayment.22" type="RelationshipToInsured"/>
<xs:element id="ePayment.InsuranceGroupName" minOccurs="0" name="ePayment.58" type="InsuranceGroupName"/>
</xs:sequence>
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.ClosestRelativeGroup" minOccurs="0" name="ePayment.ClosestRelativeGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.ClosestRelativeGuardianLastName" minOccurs="0" name="ePayment.23" type="PersonLastName"/>
<xs:element id="ePayment.ClosestRelativeGuardianFirstName" minOccurs="0" name="ePayment.24" type="PersonFirstName"/>
<xs:element id="ePayment.ClosestRelativeGuardianMiddleInitialName" minOccurs="0" name="ePayment.25" type="PersonMiddleName"/>
<xs:element id="ePayment.ClosestRelativeGuardianStreetAddress" minOccurs="0" name="ePayment.26">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="StreetAddress">
<xs:attribute name="StreetAddress2" type="StreetAddress" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.ClosestRelativeGuardianCity" minOccurs="0" name="ePayment.27" type="CityGnisCodePayment"/>
<xs:element id="ePayment.ClosestRelativeGuardianState" minOccurs="0" name="ePayment.28" type="ANSIStateCode"/>
<xs:element id="ePayment.ClosestRelativeGuardianZIPCode" minOccurs="0" name="ePayment.29" type="ZIP"/>
<xs:element id="ePayment.ClosestRelativeGuardianCountry" minOccurs="0" name="ePayment.30" type="ANSICountryCode"/>
<xs:element id="ePayment.ClosestRelativeGuardianPhoneNumber" maxOccurs="unbounded" minOccurs="0" name="ePayment.31">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="PhoneNumber">
<xs:attribute name="PhoneNumberType" type="PhoneNumberType" use="optional"/>
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.ClosestRelativeGuardianRelationship" minOccurs="0" name="ePayment.32" type="ClosestRelativeGuardianRelationship"/>
</xs:sequence>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.EmployerGroup" minOccurs="0" name="ePayment.EmployerGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.PatientsEmployer" minOccurs="0" name="ePayment.33" type="EmployerName"/>
<xs:element id="ePayment.PatientsEmployersAddress" minOccurs="0" name="ePayment.34">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="StreetAddress">
<xs:attribute name="StreetAddress2" type="StreetAddress" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.PatientsEmployersCity" minOccurs="0" name="ePayment.35" type="CityGnisCodePayment"/>
<xs:element id="ePayment.PatientsEmployersState" minOccurs="0" name="ePayment.36" type="ANSIStateCode"/>
<xs:element id="ePayment.PatientsEmployersZIPCode" minOccurs="0" name="ePayment.37" type="ZIP"/>
<xs:element id="ePayment.PatientsEmployersCountry" minOccurs="0" name="ePayment.38" type="ANSICountryCode"/>
<xs:element id="ePayment.PatientsWorkPhoneNumber" minOccurs="0" name="ePayment.39">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="PhoneNumber">
<xs:attribute name="PhoneNumberType" type="PhoneNumberType" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
</xs:sequence>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.ResponseUrgency" minOccurs="0" name="ePayment.40" type="ResponseUrgency"/>
<xs:element id="ePayment.PatientTransportAssessment" maxOccurs="unbounded" minOccurs="0" name="ePayment.41">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="TransportAssessment">
<xs:attribute name="CorrelationID" type="CorrelationID"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.SpecialtyCareTransportCareProvider" maxOccurs="unbounded" minOccurs="0" name="ePayment.42">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="TransportCareProvider">
<xs:attribute name="CorrelationID" type="CorrelationID"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.AmbulanceTransportReasonCode" maxOccurs="unbounded" minOccurs="0" name="ePayment.44">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="AmbulanceReasonCode">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.RoundTripPurposeDescription" minOccurs="0" name="ePayment.45" type="TripPurposeDesciption"/>
<xs:element id="ePayment.StretcherPurposeDescription" minOccurs="0" name="ePayment.46" type="StretcherPurposeDesciption"/>
<xs:element id="ePayment.AmbulanceConditionsIndicator" maxOccurs="unbounded" minOccurs="0" name="ePayment.47">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="AmbulanceConditionsIndicator">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.MileagetoClosestHospitalFacility" minOccurs="0" name="ePayment.48" type="Mileage"/>
<xs:element id="ePayment.ALSAssessmentPerformedandWarranted" minOccurs="0" name="ePayment.49" type="YesNoValues"/>
<xs:element id="ePayment.CMSServiceLevel" name="ePayment.50" nillable="true">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="CMSServiceLevel">
<xs:attribute name="NV" use="optional">
<xs:simpleType>
<xs:union memberTypes="NV.NotApplicable NV.NotRecorded"/>
<!-- NV.NotReporting -->
</xs:simpleType>
</xs:attribute>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.EMSConditionCode" maxOccurs="unbounded" minOccurs="0" name="ePayment.51">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="icd10Code">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.CMSTransportationIndicator" maxOccurs="unbounded" minOccurs="0" name="ePayment.52">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="CMSTransportationIndicator">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.TransportAuthorizationCode" minOccurs="0" name="ePayment.53" type="AuthorizationCode"/>
<xs:element id="ePayment.PriorAuthorizationCodePayor" minOccurs="0" name="ePayment.54" type="PersonName"/>
<xs:element id="ePayment.SupplyItemGroup" maxOccurs="unbounded" minOccurs="0" name="ePayment.SupplyItemGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.SupplyItemUsedName" minOccurs="0" name="ePayment.55" type="SupplyUsed"/>
<xs:element id="ePayment.NumberofSupplyItemsUsed" minOccurs="0" name="ePayment.56" type="SupplyCount"/>
</xs:sequence>
<xs:attribute name="CorrelationID" type="CorrelationID"/>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.PayerType" minOccurs="0" name="ePayment.57" type="PayerType"/>
</xs:sequence>
</xs:complexType>
Content Element Detail (all declarations; defined in this component only; 22/22)
ePayment.01
Type:
anonymous (extension of PrimaryMethodOfPayment), simple content
Nillable:
(can be declared as nil using xsi:nil attribute in instance XML documents)
ePayment.01 Primary Method of Payment Yes Yes The primary method of payment or type of insurance associated with this EMS encounter E07_01 Required Airway Cardiac Arrest Pediatric Response STEMI Stroke Trauma
Simple Content
enumeration of xs:string
Enumeration:
"2601001"
 - 
 Insurance
"2601003"
 - 
 Medicaid
"2601005"
 - 
 Medicare
"2601007"
 - 
 Not Billed (for any reason)
"2601009"
 - 
 Other Government
"2601011"
 - 
 Self Pay
"2601013"
 - 
 Workers Compensation
"2601015"
 - 
 Payment by Facility
"2601017"
 - 
 Contracted Payment
"2601019"
 - 
 Community Network
"2601021"
 - 
 No Insurance Identified
"2601023"
 - 
 Other Payment Option
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.PrimaryMethodofPayment" name="ePayment.01" nillable="true">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="PrimaryMethodOfPayment">
<xs:attribute name="NV" use="optional">
<xs:simpleType>
<xs:union memberTypes="NV.NotApplicable NV.NotRecorded"/>
</xs:simpleType>
</xs:attribute>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.08
Type:
ResidencyStatusOfThePatient, simple content
ePayment.08 Patient Resides in Service Area No No An indication of whether the patient's current residence is within the EMS agency service area. Optional Added to assist in billing documentation.
Simple Content
enumeration of xs:string
Enumeration:
"2608001"
 - 
 Resident Within EMS Service Area
"2608003"
 - 
 Not a Resident Within EMS Service Area
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.PatientResidesinServiceArea" minOccurs="0" name="ePayment.08" type="ResidencyStatusOfThePatient"/>
ePayment.40
Type:
ResponseUrgency, simple content
ePayment.40 Response Urgency No No The urgency in which the EMS agency began to mobilize resources for this EMS encounter. E07_33 Optional This is for billing documentation.
Simple Content
enumeration of xs:string
Enumeration:
"2640001"
 - 
 Immediate
"2640003"
 - 
 Non-Immediate
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.ResponseUrgency" minOccurs="0" name="ePayment.40" type="ResponseUrgency"/>
ePayment.41
Type:
anonymous (extension of TransportAssessment), simple content
ePayment.41 Patient Transport Assessment No No Documentation of the patient's transport need based on mobility and/or physical capability. Optional Added to better justify the medical necessity of the transport. Based on CMS 42 CFR Ch IV (10-1-02 Edition) & 410.40 (d) medical necessity requirement (1)
Simple Content
enumeration of xs:string
Enumeration:
"2641001"
 - 
 Unable to sit without assistance
"2641003"
 - 
 Unable to stand without assistance
"2641005"
 - 
 Unable to walk without assistance
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.PatientTransportAssessment" maxOccurs="unbounded" minOccurs="0" name="ePayment.41">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="TransportAssessment">
<xs:attribute name="CorrelationID" type="CorrelationID"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.42
Type:
anonymous (extension of TransportCareProvider), simple content
ePayment.42 Specialty Care Transport Care Provider No No Documentation to show the patient care provided to the patient met the Specialty Care Transport Base Rate requirements. Optional Added to improve Specialty Care Transport billing justification. In accordance with CMS requirements Specialty Care Transport (SCT): ""Additional training" means the specific additional training that a State requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient during an SCT."
Simple Content
enumeration of xs:string
Enumeration:
"2642001"
 - 
 Advanced EMT-Paramedic
"2642003"
 - 
 Nurse
"2642005"
 - 
 Nurse Practitioner
"2642007"
 - 
 Physician (MD, DO)
"2642009"
 - 
 Physician Assistant
"2642011"
 - 
 2009 Emergency Medical Responder (EMR)
"2642013"
 - 
 2009 Emergency Medical Technician (EMT)
"2642015"
 - 
 2009 Advanced Emergency Medical Technician (AEMT)
"2642017"
 - 
 2009 Paramedic
"2642019"
 - 
 First Responder
"2642021"
 - 
 EMT-Basic
"2642023"
 - 
 EMT-Intermediate
"2642025"
 - 
 EMT-Paramedic
"2642027"
 - 
 Other Healthcare Professional
"2642029"
 - 
 Other Non-Healthcare Professional
"2642031"
 - 
 Respiratory Therapist
"2642033"
 - 
 Student
"2642035"
 - 
 Critical Care Paramedic
"2642037"
 - 
 Community Paramedicine
"2642039"
 - 
 Registered Nurse
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.SpecialtyCareTransportCareProvider" maxOccurs="unbounded" minOccurs="0" name="ePayment.42">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="TransportCareProvider">
<xs:attribute name="CorrelationID" type="CorrelationID"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.44
Type:
anonymous (extension of AmbulanceReasonCode), simple content
ePayment.44 Ambulance Transport Reason Code No No The CMS Ambulance Transport Reason Code for the transport. Optional Added to improve billing with electronic claims using the ASC X12 Standard. The Ambulance Transport Code values are those determined by US Dept of HHS for the "Code indicating the type of ambulance transport". The Accredited Standards Committee X12 organization maintains the standard. See the X12 website http://www.x12.org or United States Health Information Knowledgebase website for more information: https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133080000
Simple Content
enumeration of xs:string
Enumeration:
"A"
 - 
 Patient was transported to the nearest facility for care of symptoms, complaints, or both
"B"
 - 
 Patient was transported for the benefit of a preferred physician
"C"
 - 
 Patient was transported for the nearness of family members
"D"
 - 
 Patient was transported for the care of a specialist or for availability of equipment
"E"
 - 
 Patient was transferred to a Rehabilitation Facility
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.AmbulanceTransportReasonCode" maxOccurs="unbounded" minOccurs="0" name="ePayment.44">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="AmbulanceReasonCode">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.45
Type:
TripPurposeDesciption, simple content
ePayment.45 Round Trip Purpose Description No No Free text description providing the purpose of the round trip EMS transport based on CR109 field for CMS. Optional Added to improve billing documentation for CMS X12 based transactions. <br/> <br/>Ambulance providers can use this field to provide additional information regarding the circumstances of a round trip transport or for other medical necessity documentation. Added to improve billing with electronic claims using X12
Simple Content
xs:string
maxLength:
 80
minLength:
 2
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.RoundTripPurposeDescription" minOccurs="0" name="ePayment.45" type="TripPurposeDesciption"/>
ePayment.46
Type:
StretcherPurposeDesciption, simple content
ePayment.46 Stretcher Purpose Description No No Free Text Documentation providing the reason for use of a stretcher in the EMS patient transport. Optional Added to improve billing using CMS X12 transactions based on CR110. Documentation of Stretcher Purpose Description (ePayment.46) is required when needed to justify use of a stretcher. (X12 - Loop 2300 CR110).
Simple Content
xs:string
maxLength:
 80
minLength:
 2
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.StretcherPurposeDescription" minOccurs="0" name="ePayment.46" type="StretcherPurposeDesciption"/>
ePayment.47
Type:
anonymous (extension of AmbulanceConditionsIndicator), simple content
ePayment.47 Ambulance Conditions Indicator No No Documentation of the CRC03 through CRC07 requirements for CMS billing using X12 transactions. Optional Added to improve billing documentation and justification. Added to improve billing with electronic claims using X12. The Codes and Descriptors updated Sept 2013 to meet the X12 5010 standard.
Simple Content
enumeration of xs:string
Enumeration:
"01"
 - 
 Patient was admitted to a hospital
"04"
 - 
 Patient was moved by stretcher
"05"
 - 
 Patient was unconscious or in shock
"06"
 - 
 Patient was transported in an emergency situation
"07"
 - 
 Patient had to be physically restrained
"08"
 - 
 Patient had visible hemorrhaging
"09"
 - 
 Ambulance service was medically necessary
"12"
 - 
 Patient is confined to a bed or chair (Use code 12 to indicate patient was bedridden during transport.)
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.AmbulanceConditionsIndicator" maxOccurs="unbounded" minOccurs="0" name="ePayment.47">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="AmbulanceConditionsIndicator">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.48
Type:
Mileage, simple content
ePayment.48 Mileage to Closest Hospital Facility No No The mileage to the closest hospital facility from the scene. Documented only if the patient was transported to a facility farther away than the closest hospital. Optional Added to clarify billing mileage when the patient is not taken to the closest facility. Added for improved billing documentation.
Simple Content
xs:decimal
fractionDigits:
 2
maxInclusive:
 1000
minInclusive:
 1
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.MileagetoClosestHospitalFacility" minOccurs="0" name="ePayment.48" type="Mileage"/>
ePayment.49
Type:
YesNoValues, simple content
ePayment.49 ALS Assessment Performed and Warranted No No Documentation that the patient required an ALS assessment and it was performed. Optional Added to improve billing justification Added to improve billing justification
Simple Content
enumeration of xs:string
Enumeration:
"9923001"
 - 
 No
"9923003"
 - 
 Yes
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.ALSAssessmentPerformedandWarranted" minOccurs="0" name="ePayment.49" type="YesNoValues"/>
ePayment.50
Type:
anonymous (extension of CMSServiceLevel), simple content
Nillable:
(can be declared as nil using xsi:nil attribute in instance XML documents)
ePayment.50 CMS Service Level Yes Yes The CMS service level for this EMS encounter. E07_34 Required Airway Pediatric STEMI Stroke Trauma
Simple Content
enumeration of xs:string
Enumeration:
"2650001"
 - 
 ALS, Level 1
"2650003"
 - 
 ALS, Level 1 Emergency
"2650005"
 - 
 ALS, Level 2
"2650007"
 - 
 BLS
"2650009"
 - 
 BLS, Emergency
"2650011"
 - 
 Fixed Wing (Airplane)
"2650013"
 - 
 Paramedic Intercept
"2650015"
 - 
 Specialty Care Transport
"2650017"
 - 
 Rotary Wing (Helicopter)
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.CMSServiceLevel" name="ePayment.50" nillable="true">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="CMSServiceLevel">
<xs:attribute name="NV" use="optional">
<xs:simpleType>
<xs:union memberTypes="NV.NotApplicable NV.NotRecorded"/>
<!-- NV.NotReporting -->
</xs:simpleType>
</xs:attribute>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.51
Type:
anonymous (extension of icd10Code), simple content
ePayment.51 EMS Condition Code No No The condition code associated with the CMS EMS negotiated rule-making process. E07_35 Optional Airway Cardiac Arrest Pediatric STEMI Stroke Trauma Code list is represented in ICD-10-CM Codes: <br/>Website - <a href="http://uts.nlm.nih.gov" target="_blank">http://uts.nlm.nih.gov</a> <br/>Product - UMLS Metathesaurus
Simple Content
xs:string
Pattern:
 [A-Z][0-9][0-9A-Z]((\.[0-9A-Z]{1,3})?)
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.EMSConditionCode" maxOccurs="unbounded" minOccurs="0" name="ePayment.51">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="icd10Code">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.52
Type:
anonymous (extension of CMSTransportationIndicator), simple content
ePayment.52 CMS Transportation Indicator No No The CMS Ambulance Fee Schedule Transportation and Air Medical Transportation Indicators are used to better describe why it was necessary for the patient to be transported in a particular way or circumstance. E07_37 Optional Name changed from Condition Code Modifier to CMS Transportation Indicator Name changed from Condition Code Modifier to CMS Transportation Indicator
Simple Content
enumeration of xs:string
Enumeration:
"C1"
 - 
 Interfacility Transport (Requires Higher level of care)
"C2"
 - 
 Interfacility Transport (service not available)
"C3"
 - 
 Emergency Trauma Dispatch Condition Code (Major Incident or Mechanism of Injury)
"C4"
 - 
 Medically Necessary Transport (Facility on Divert or Services Unavailable)
"C5"
 - 
 BLS Transport of ALS Patient (ALS not available)
"C6"
 - 
 ALS Response (Based on Dispatch Info) to BLS Patient (Condition)
"C7"
 - 
 IV Medications required en route (ALS)
"D1"
 - 
 Long Distance-patient's condition requires rapid transportation over a long distance
"D2"
 - 
 Rare Circumstances, Traffic Patterns Precludes Ground Transport
"D3"
 - 
 Time to the closest appropriate hospital due to the patient's condition precludes ground transport; maximize clinical benefits
"D4"
 - 
 Pick up Point not Accessible by Ground Transport
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.CMSTransportationIndicator" maxOccurs="unbounded" minOccurs="0" name="ePayment.52">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="CMSTransportationIndicator">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
ePayment.53
Type:
AuthorizationCode, simple content
ePayment.53 Transport Authorization Code No No Prior authorization code provided by the insurance carrier/payer. Optional Added to improve billing documentation.
Simple Content
xs:string
maxLength:
 50
minLength:
 2
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.TransportAuthorizationCode" minOccurs="0" name="ePayment.53" type="AuthorizationCode"/>
ePayment.54
Type:
PersonName, simple content
ePayment.54 Prior Authorization Code Payer No No The Payer who has provided the Prior Authorization Code. Optional Added to document Prior Authorization Codes for an EMS Transport. Added to improve billing documentation.
Simple Content
xs:string
maxLength:
 255
minLength:
 1
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.PriorAuthorizationCodePayor" minOccurs="0" name="ePayment.54" type="PersonName"/>
ePayment.57
Type:
PayerType, simple content
ePayment.57 Payer Type No No Payer type according to X12 standard. Optional This element should only be used if Insurance, Medicare, Medicaid, Workers Compensation, or Other Government are selected in ePayment.01 - Primary Method of Payment. <v3Changes/>
Simple Content
enumeration of xs:string
Enumeration:
"11"
 - 
 Other Non-Federal Programs
"12"
 - 
 Preferred Provider Organization (PPO)
"13"
 - 
 Point of Service (POS)
"14"
 - 
 Exclusive Provider Organization (EPO)
"15"
 - 
 Indemnity Insurance
"16"
 - 
 Health Maintenance Organization (HMO) Medicare Risk
"17"
 - 
 Dental Maintenance Organization
"AM"
 - 
 Automobile Medical
"BL"
 - 
 Blue Cross/Blue Shield
"CH"
 - 
 Champus
"CI"
 - 
 Commercial Insurance Co.
"DS"
 - 
 Disability
"FI"
 - 
 Federal Employees Program
"HM"
 - 
 Health Maintenance Organization
"LM"
 - 
 Liability Medical
"MA"
 - 
 Medicare Part A
"MB"
 - 
 Medicare Part B
"MC"
 - 
 Medicaid
"OF"
 - 
 Other Federal Program
"TV"
 - 
 Title V
"VA"
 - 
 Veteran Affairs Plan
"WC"
 - 
 Workers' Compensation Health Claim
"ZZ"
 - 
 Mutually Defined
XML Source (w/o annotations (1); see within schema source)
<xs:element id="ePayment.PayerType" minOccurs="0" name="ePayment.57" type="PayerType"/>
ePayment.CertificateGroup
Type:
anonymous, complex content
Group Tag to hold Certification information
XML Source (w/o annotations (7); see within schema source)
<xs:element id="ePayment.CertificateGroup" minOccurs="0" name="ePayment.CertificateGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.PhysicianCertificationStatement" minOccurs="0" name="ePayment.02" type="YesNoUnkValues"/>
<xs:element id="ePayment.DatePhysicianCertificationStatementSigned" minOccurs="0" name="ePayment.03" type="DateTimeType"/>
<xs:element id="ePayment.ReasonforPhysicianCertificationStatement" maxOccurs="unbounded" minOccurs="0" name="ePayment.04">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="Reason">
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.HealthcareProviderTypeSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.05" type="HealthcareProviderType"/>
<xs:element id="ePayment.LastNameofIndividualSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.06" type="PersonLastName"/>
<xs:element id="ePayment.FirstNameofIndividualSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.07" type="PersonFirstName"/>
</xs:sequence>
</xs:complexType>
</xs:element>
ePayment.ClosestRelativeGroup
Type:
anonymous, complex content
Group Tag to hold information about patient's relative or guardian
XML Source (w/o annotations (11); see within schema source)
<xs:element id="ePayment.ClosestRelativeGroup" minOccurs="0" name="ePayment.ClosestRelativeGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.ClosestRelativeGuardianLastName" minOccurs="0" name="ePayment.23" type="PersonLastName"/>
<xs:element id="ePayment.ClosestRelativeGuardianFirstName" minOccurs="0" name="ePayment.24" type="PersonFirstName"/>
<xs:element id="ePayment.ClosestRelativeGuardianMiddleInitialName" minOccurs="0" name="ePayment.25" type="PersonMiddleName"/>
<xs:element id="ePayment.ClosestRelativeGuardianStreetAddress" minOccurs="0" name="ePayment.26">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="StreetAddress">
<xs:attribute name="StreetAddress2" type="StreetAddress" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.ClosestRelativeGuardianCity" minOccurs="0" name="ePayment.27" type="CityGnisCodePayment"/>
<xs:element id="ePayment.ClosestRelativeGuardianState" minOccurs="0" name="ePayment.28" type="ANSIStateCode"/>
<xs:element id="ePayment.ClosestRelativeGuardianZIPCode" minOccurs="0" name="ePayment.29" type="ZIP"/>
<xs:element id="ePayment.ClosestRelativeGuardianCountry" minOccurs="0" name="ePayment.30" type="ANSICountryCode"/>
<xs:element id="ePayment.ClosestRelativeGuardianPhoneNumber" maxOccurs="unbounded" minOccurs="0" name="ePayment.31">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="PhoneNumber">
<xs:attribute name="PhoneNumberType" type="PhoneNumberType" use="optional"/>
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.ClosestRelativeGuardianRelationship" minOccurs="0" name="ePayment.32" type="ClosestRelativeGuardianRelationship"/>
</xs:sequence>
</xs:complexType>
</xs:element>
ePayment.EmployerGroup
Type:
anonymous, complex content
Group Tag to hold information about patient's employer
XML Source (w/o annotations (8); see within schema source)
<xs:element id="ePayment.EmployerGroup" minOccurs="0" name="ePayment.EmployerGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.PatientsEmployer" minOccurs="0" name="ePayment.33" type="EmployerName"/>
<xs:element id="ePayment.PatientsEmployersAddress" minOccurs="0" name="ePayment.34">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="StreetAddress">
<xs:attribute name="StreetAddress2" type="StreetAddress" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.PatientsEmployersCity" minOccurs="0" name="ePayment.35" type="CityGnisCodePayment"/>
<xs:element id="ePayment.PatientsEmployersState" minOccurs="0" name="ePayment.36" type="ANSIStateCode"/>
<xs:element id="ePayment.PatientsEmployersZIPCode" minOccurs="0" name="ePayment.37" type="ZIP"/>
<xs:element id="ePayment.PatientsEmployersCountry" minOccurs="0" name="ePayment.38" type="ANSICountryCode"/>
<xs:element id="ePayment.PatientsWorkPhoneNumber" minOccurs="0" name="ePayment.39">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="PhoneNumber">
<xs:attribute name="PhoneNumberType" type="PhoneNumberType" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
</xs:sequence>
</xs:complexType>
</xs:element>
ePayment.InsuranceGroup
Type:
anonymous, complex content
Group Tag to hold information about the insurance company
XML Source (w/o annotations (16); see within schema source)
<xs:element id="ePayment.InsuranceGroup" maxOccurs="unbounded" minOccurs="0" name="ePayment.InsuranceGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.InsuranceCompanyID" minOccurs="0" name="ePayment.09" type="InsuranceCompanyID"/>
<xs:element id="ePayment.InsuranceCompanyName" minOccurs="0" name="ePayment.10" type="InsuranceCompanyName"/>
<xs:element id="ePayment.InsuranceCompanyBillingPriority" minOccurs="0" name="ePayment.11" type="InsuranceCompanyBillingPriority"/>
<xs:element id="ePayment.InsuranceCompanyAddress" minOccurs="0" name="ePayment.12">
<xs:complexType>
<xs:simpleContent>
<xs:extension base="StreetAddress">
<xs:attribute name="StreetAddress2" type="StreetAddress" use="optional"/>
</xs:extension>
</xs:simpleContent>
</xs:complexType>
</xs:element>
<xs:element id="ePayment.InsuranceCompanyCity" minOccurs="0" name="ePayment.13" type="CityGnisCodePayment"/>
<xs:element id="ePayment.InsuranceCompanyState" minOccurs="0" name="ePayment.14" type="ANSIStateCode"/>
<xs:element id="ePayment.InsuranceCompanyZIPCode" minOccurs="0" name="ePayment.15" type="ZIP"/>
<xs:element id="ePayment.InsuranceCompanyCountry" minOccurs="0" name="ePayment.16" type="ANSICountryCode"/>
<xs:element id="ePayment.InsuranceGroupID" minOccurs="0" name="ePayment.17" type="InsuranceGroupID"/>
<xs:element id="ePayment.InsurancePolicyIDNumber" minOccurs="0" name="ePayment.18" type="InsurancePolicyIDNumber"/>
<xs:element id="ePayment.LastNameoftheInsured" minOccurs="0" name="ePayment.19" type="PersonLastName"/>
<xs:element id="ePayment.FirstNameoftheInsured" minOccurs="0" name="ePayment.20" type="PersonFirstName"/>
<xs:element id="ePayment.MiddleInitialNameoftheInsured" minOccurs="0" name="ePayment.21" type="PersonMiddleName"/>
<xs:element id="ePayment.RelationshiptotheInsured" minOccurs="0" name="ePayment.22" type="RelationshipToInsured"/>
<xs:element id="ePayment.InsuranceGroupName" minOccurs="0" name="ePayment.58" type="InsuranceGroupName"/>
</xs:sequence>
<xs:attribute name="CorrelationID" type="CorrelationID" use="optional"/>
</xs:complexType>
</xs:element>
ePayment.SupplyItemGroup
Type:
anonymous, complex content
Group Tag to hold information about the supply used on the patient by the EMS Crew during the EMS event.
XML Source (w/o annotations (3); see within schema source)
<xs:element id="ePayment.SupplyItemGroup" maxOccurs="unbounded" minOccurs="0" name="ePayment.SupplyItemGroup">
<xs:complexType>
<xs:sequence>
<xs:element id="ePayment.SupplyItemUsedName" minOccurs="0" name="ePayment.55" type="SupplyUsed"/>
<xs:element id="ePayment.NumberofSupplyItemsUsed" minOccurs="0" name="ePayment.56" type="SupplyCount"/>
</xs:sequence>
<xs:attribute name="CorrelationID" type="CorrelationID"/>
</xs:complexType>
</xs:element>