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Data Element Name:  Outpatient Ancillary Total Non-Covered Charges
Format-Length:  N - 10 Required For:  AS, ED
Effective Date:  1/1/94 Revision Date:  May 2008

NOTE: This is a composite data element, for mapping guidelines refer to the Inpatient and Outpatient 837 Addenda.

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element


Version 4050R 2400 SV207 782 Outpatient Ancillary Total Non-Covered Charge

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


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

It is necessary to report at least one Outpatient Ancillary with each claim. There must be at least one total and non-covered charge for all Outpatient ancillary codes reported except for the 036x, 045x, 048x, 049x, 051x, 052x, 075x, 076x or 079x categories. For these exceptions the total and non-covered charges may be rolled up to the first occurrence of the revenue code category with zero reported for subsequent occurrences on each claim.

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 Outpatient Ancillary Revenue Codes 0001 through 0099 are entered, any associated charges are NOT included in Outpatient Ancillary Total Non-Covered Charges.

  2. If Outpatient Ancillary Total Non-Covered Charge is entered, the associated Outpatient Ancillary Revenue Code and Outpatient Ancillary Total Charge must also be reported.

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

  4. SPARCS allows a maximum of 200 Ancillaries.
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