***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