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| Table of Contents |
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| Info |
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For fields with the number one (1) appended, the segment will display additional fields for sequential fields (ingredient 2, 3, etc). |
Field # | Field Name | Possible Value or Explanation of Field |
369-2Q | Additional Documentation Type ID | Type of additional documentation; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
374-2V | Request Period Begin Date | Date when the request is to begin, converted into YYYYMMDD format; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
375-2W | Request Period Recert Date | Date when the request is to be re-certified, converted into YYYYMMDD format; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
373-2U | Request Status | The request status; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
371-2S | Length of Need Qualifier | Indicates the qualifier for the length of time of the request; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
370-2R | Length of Need | Indicates the actual length of time for this request based on the qualifier above; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
372-2T | Prescriber/Supplier Date Signed | The date the request was approved by prescriber/supplier, converted into YYYYMMDD format; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
376-2X | Supporting Documentation | Supporting documentation attached to claim; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
378-4B | Question Number/Letter 1 | Inquiry entry number; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
379-4D | Question Percent Response 1 | Inquiry response, if responded with a percentage; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
380-4G | Question Date Response 1 | Inquiry response, if responded with a date; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
381-4H | Question Dollar Amount Response 1 | Inquiry response, if responded with a dollar amount; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
382-4J | Question Numeric Response 1 | Inquiry response, if responded with a numeric value; entered into the "More" button then "Additional Documentation" button located on the main processing screen |
383-4K | Question Alphanumeric Response 1 | Inquiry response, if responded with an alphanumeric value; entered into the "More" button then "Additional Documentation" button located on the main processing screen |