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Data Element Name:  Inpatient Ancillary Total Non-Covered Charges
Format-Length:  N - 10 Required For:  IP
Effective Date:  1/1/94 Revision Date:  September 2003

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element

Code

Description
Version 4050R 2400 SV207 782 Inpatient Ancillary Total Non-Covered Charges

Paper Form Locator Code Qualifier
Institutional - UB-04 48 N/A

Definition:

The charges for Inpatient ancillary services which are not reimbursable by the primary payer.

Codes and Values:

  1. The amount must be entered in dollars and cents.

    Example:  $125.24 would be entered as: 125.24

Edit Applications:

  1. If Inpatient Ancillary Revenue Codes 0001 through 0099 are reported, any associated charges are NOT included in Inpatient Ancillary Total Non-Covered Charges.

  2. If Inpatient Ancillary Total Non-Covered Charges are entered, the associated Inpatient Ancillary Revenue Code and Inpatient Ancillary Total Charges must also be reported.

  3. Inpatient Ancillary Total Non-Covered Charges must be less than or equal to the corresponding Inpatient Ancillary Total Charges.

  4. SPARCS allows a maximum of 200 Ancillaries.
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