Grouping

  Elements

  ePayment.01 - Primary Method of Payment

  ePayment.02 - Physician Certification Statement

  ePayment.03 - Date Physician Certification Statement Signed

  ePayment.04 - Reason for Physician Certification Statement

  ePayment.05 - Healthcare Provider Type Signing Physician Certification Statement

  ePayment.06 - Last Name of Individual Signing Physician Certification Statement

  ePayment.07 - First Name of Individual Signing Physician Certification Statement

  ePayment.08 - Patient Resides in Service Area

  ePayment.09 - Insurance Company ID

  ePayment.10 - Insurance Company Name

  ePayment.11 - Insurance Company Billing Priority

  ePayment.12 - Insurance Company Address

  ePayment.13 - Insurance Company City

  ePayment.14 - Insurance Company State

  ePayment.15 - Insurance Company ZIP Code

  ePayment.16 - Insurance Company Country

  ePayment.17 - Insurance Group ID

  ePayment.18 - Insurance Policy ID Number

  ePayment.19 - Last Name of the Insured

  ePayment.20 - First Name of the Insured

  ePayment.21 - Middle Initial/Name of the Insured

  ePayment.22 - Relationship to the Insured

  ePayment.23 - Closest Relative/Guardian Last Name

  ePayment.24 - Closest Relative/ Guardian First Name

  ePayment.25 - Closest Relative/ Guardian Middle Initial/Name

  ePayment.26 - Closest Relative/ Guardian Street Address

  ePayment.27 - Closest Relative/ Guardian City

  ePayment.28 - Closest Relative/ Guardian State

  ePayment.29 - Closest Relative/ Guardian ZIP Code

  ePayment.30 - Closest Relative/ Guardian Country

  ePayment.31 - Closest Relative/ Guardian Phone Number

  ePayment.32 - Closest Relative/ Guardian Relationship

  ePayment.33 - Patient's Employer

  ePayment.34 - Patient's Employer's Address

  ePayment.35 - Patient's Employer's City

  ePayment.36 - Patient's Employer's State

  ePayment.37 - Patient's Employer's ZIP Code

  ePayment.38 - Patient's Employer's Country

  ePayment.39 - Patient's Employer's Primary Phone Number

  ePayment.40 - Response Urgency

  ePayment.41 - Patient Transport Assessment

  ePayment.42 - Specialty Care Transport Care Provider

  ePayment.44 - Ambulance Transport Reason Code

  ePayment.45 - Round Trip Purpose Description

  ePayment.46 - Stretcher Purpose Description

  ePayment.47 - Ambulance Conditions Indicator

  ePayment.48 - Mileage to Closest Hospital Facility

  ePayment.49 - ALS Assessment Performed and Warranted

  ePayment.50 - CMS Service Level

  ePayment.51 - EMS Condition Code

  ePayment.52 - CMS Transportation Indicator

  ePayment.53 - Transport Authorization Code

  ePayment.54 - Prior Authorization Code Payer

  ePayment.55 - Supply Item Used Name

  ePayment.56 - Number of Supply Item(s) Used

  ePayment.57 - Payer Type

  ePayment.58 - Insurance Group Name