The Supplemental Information section displays additional information relating to the claim. The Supplemental Information fields are defined by section below:
Service Line Ambulance Information: This section provides information related to the ambulance service rendered to a patient.
Transport Reason CodeTransport Reason Code
Code indicating the reason for ambulance transport. Options are:
| A | Patient was transported to 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 specialized equipment. |
| E | Patient transferred to rehabilitation facility. |
The weight of the patient at the time of transport.
The distance traveled during the transport of the patient.
Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services.
Purpose of Round TripPurpose of Round Trip
A free-form description to clarify the purpose for the round trip ambulance service.
Purpose of Stretcher Purpose of Stretcher
A free-form description to clarify the purpose for the use of a stretcher during ambulance service. Required if needed to justify use of a stretcher.
Service Line Ambulance Pick-Up Location: This section is used to specify the geographic location of the named party.
Address Line 1 & 2Address Line 1 & 2
Ambulance pick-up address.
Ambulance pick-up postal zone zip code. When a user enters a zip code in a zip code field and clicks tab to move to the next field, the city and state fields are automatically generated based on data received from the USPS. Note: This replaces any data already entered in the city/state fields.
Ambulance pick-up city name.
Ambulance pick-up state or province code.
Ambulance pick-up country code.
Subdivision CodeSubdivision Code
Ambulance pick-up country subdivision code.
Service Line Ambulance Drop-Off Location: This section is used to specify the geographic location of the named party.
Address Line 1 & 2Address Line 1 & 2
Ambulance drop-off address.
Ambulance drop-off postal zone zip code. When a user enters a zip code in a zip code field and clicks tab to move to the next field, the city and state fields are automatically generated based on data received from the USPS. Note: This replaces any data already entered in the city/state fields.
Ambulance drop-off city name.
Ambulance drop-off state or province code.
Ambulance drop-off country code.
Subdivision CodeSubdivision Code
Ambulance drop-off country subdivision code.
Service Line Additional Supplemental Information: This section includes fields for entering and displaying supplemental data for a specific service line.
Line Item Ctrl NbrLine Item Ctrl Nbr
Identifier assigned by the submitter/provider to this line item. When keying a new claim, this field populates once a claim is saved.
OB Anesth Add UnitsOB Anesth Add Units
Obstetric Anesthesia Additional Units. Required in conjunction with anesthesia for obstetric services when the anesthesia provider chooses to report additional complexity beyond the normal services reflected by the procedure base units and anesthesia time.
Mammography Cert NbrMammography Cert Nbr
CMS assigned certification number of the certified mammography screening center.
Clinical Laboratory Improvement Amendment (CLIA) Number. Required on Medicare and Medicaid claims for any laboratory performing tests covered by the CLIA Act.
Referring CLIA NbrReferring CLIA Nbr
Referred CLIA facility identification. Required for Medicare claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line.
Immunization Batch NbrImmunization Batch Nbr
The manufacturer’s lot number for vaccine used in immunization.
Required if sales tax applies to the service line and the submitter is required to report that information to the receiver.
Postage Claimed AmtPostage Claimed Amt
Value of postage claimed for this service line. Required if the service line charge includes a postage amount claimed in this service line.
Purchased Serv Prov AmtPurchased Serv Prov Amt
Cost of the purchased service.
Prior Authorization NbrPrior Authorization Nbr
A number or other indicator that designates that the treatment covered by this bill has been authorized by the payer.
Reference information as defined for a particular transaction set or as specified by the reference identification qualifier. Available for primary, secondary, and tertiary numbers.
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