ANSI to MicroMD Mapping Troubleshooting Guide
This document contains a basic reference for those trying to troubleshoot ANSI claim files. We have organized
these tables by ANSI loop and element. Users will also find directions for finding the appropriate location within
MicroMD® where the system actually pulls information to create the claim file.
NOTE | Use the ANSI Ripper application developed by our
programmers to help you read the ANSI file in a human-friendly
format.
Overall Notes
For Tricare through ENS or PI, and for New York Medicaid direct, the system removes all leading zeros from
dollar amounts on claims.
Enveloping
Element
Location in MicroMD (window and field)
ISA01
ISA02
ISA04
EB Setup Screen - Author Information qualifier
EB Setup Screen - Author Information
EB Setup Screen – Password
If EB Type is ALPR or PerSe, MicroMD leaves this element blank.
EB Setup Screen – Sender ID qualifier
EB Setup Screen – Sender ID
EB Setup Screen – Interchng Recv ID qualifier
EB Setup Screen – Interchng Recv ID
EB Setup Screen – Submission Number
Claims Processing – EB –
If EB Type is MDWV, MicroMD sets this to 1. Otherwise, the system sends a 0.
EB Setup Screen – Submission Test
Defaults to ‘:’. You can change it in the eb.ini file.
EB Setup Screen – Application Sender ID
If Application Sender ID is blank, MicroMD pulls the value from the EB Setup Screen - Sender
ID field.
EB Setup Screen – Application Receiver ID
If Application Receiver ID is blank, MicroMD pulls the value from the EB Setup Screen Interchng Recv ID.
EB Setup Screen – Group Control
EB Setup Screen – Claim File Type
EB Setup Screen – Claim File Type
(If EB Type section of the eb.ini file has a key called dtest with a value of 1, and the EB Setup
Screen – Submission Test field is set to Test, MicroMD adds a D to the value. This is only to
be used for Pilot Testing.)
ISA05
ISA06
ISA07
ISA08
ISA13
ISA14
ISA15
ISA16
GS02
GS03
GS06
GS08
REF(87)02
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1
Loop 1000A
Element
Location in MicroMD (window and field)
NM1(41)03
EB Setup Screen – Sub Org/Last Name
If this field is blank, MicroMD uses the practice name.
EB Setup Screen – First Name
Only if the practice name is not used.
EB Setup Screen – MI
Only if the practice name is not used.
EB Setup Screen – Source ID
If it exists. Sender ID otherwise
EB Setup Screen – Contact
EB Setup Screen – Primary Contact No. Qualifier (TE if it does not exist)
EB Setup Screen – Primary Contact No. (Uses practice phone if it does not exist)
EB Setup Screen – Sec. Contact No. Qualifier
EB Setup Screen – Sec. Contact No.
NM1(41)04
NM1(41)05
NM1(41)09
PER02
PER03
PER04
PER05
PER06
Loop 1000B
Element
Location in MicroMD (window and field)
NM1(40)03
If EB Setup Screen – Batch By Plan is checked, MicroMD pulls the value for this element
from the Plan Detail – ID/Anesthesia tab, Org Name (1000B). Otherwise, the system pulls
the information from the EB Setup Screen – Receiver Name
If EB Setup Screen – Batch By Plan is checked, MicroMD pulls the value for this element
from the Plan Detail – ID/Anesthesia tab, Org ID (1000B). Otherwise, the system pulls the
information from the EB Setup Screen – Recv ID
NM1(40)09
Loop 2000A
Element
Location in MicroMD (window and field)
PRV03
If EB Setup Screen – Organization is not checked, or if Taxonomy 2000a drop-down EB
Setup has a selection made then this PRV segment is created. If it exists and depending on
the choice in the Taxonomy 2000a drop-down, MicroMD pulls the value for this element from
Provider Detail – Taxonomy field or from the Taxonomy Code column on the practice
Location tab. If the client needs to have Organization checked, they can check the
Taxonomy 2000a checkbox on the EB Setup window. You must also turn on Batch by
Provider in this case so the loop is created for each provider.
Loop 2010AA
Element
Location in MicroMD (window and field)
NM102
If there is a checkmark in the Non-Person Entity checkbox on the provider’s detail window,
the system populates this segment with a “2”. The non-person entity whole name must also
appear in the Last Name field. (Enter a dummy first name, as this is a required field.) If there
is no check mark, the system enters a “1” in this segment.
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
2
Element
Location in MicroMD (window and field)
NM1(85)03
If EB Setup Screen – Organization is checked, MicroMD first looks at the name on the
Practice Detail – Provider tab, Box 33 Information. If this name exists, the system uses that
information. If the Box 33 information is blank, MicroMD uses the Name from the Practice
Detail. Otherwise if Organization is not checked, the system uses the Rendering Provider
Last Name from the Provider Detail.
If EB Setup Screen – Organization is not checked, the Rendering Provider First Name will be
used from Provider Detail.
If EB Setup Screen – Organization is not checked, the Rendering Provider MI will be used
from Provider Detail.
If a qualifier is entered on the EB Setup Screen – Provider Qualifier, then that value is
entered here. If not, then the value of the Tax Type on the Practice Detail – Practice tab is
used to determine the value. If Tax Type = S, a 34 is entered here. If Tax Type = E, a 24 is
entered here. If none of the above, an XX is entered here.
If NM1(85)08 = ‘34’, the SSN from the Provider Detail will be used. If NM1(85)08 = ‘24’, then
the Federal Tax ID from the Provider tab of Practice Detail will be used if it exists, otherwise,
the Federal Tax ID from the Practice Detail, Practice tab will be used.
If NM1(85)08 = XX and Organization is checked on the EB Setup window, then the value will
be pulled from:
Practice Detail – Practice Insurance ID Tab – NPI
Practice Detail - Providers Tab – NPI
Practice Detail - Practice Tab - Practice NPI
Practice Detail - Provider Insurance ID Tab – NPI
Provider Detail - NPI.
If NM1(85)08 = XX and Organization is not checked on the EB Setup window, then the value
will be pulled from:
Practice Detail – Provider Tab - Provider Insurance ID Tab - NPI
Provider Detail – NPI
Practice Detail – Practice Insurance ID Tab – NPI
Practice Detail – Provider Tab – NPI
Practice Detail – Practice NPI
The Box 33 information on Practice Detail, Provider tab will be used if it exists to send
Address line 1, otherwise, the practice address line 1 will be sent.
The Box 33 information on Practice Detail, Provider tab will be used if it exists to send
Address line 2, otherwise, the practice address line 2 will be sent.
The Box 33 information on Practice Detail, Provider tab will be used if it exists to send city,
otherwise, the practice city will be sent.
The Box 33 information on Practice Detail, Provider tab will be used if it exists to send state,
otherwise, the practice state will be sent.
The Box 33 information on Practice Detail, Provider tab will be used if it exists to send zip
code, otherwise, the practice zip code will be sent.
If NM1(85)08 = XX then this REF segment will be created. This is the value of the Tax Type
on the Practice Detail – Practice tab is used to determine the value. If Tax Type = S, then SY
is entered here. If Tax Type = E, then EI is entered here.
If NM1(85)08 = XX and if REF01 = SY then the SSN from the Provider Detail will be used.
Otherwise, if NM1(85)08 = XX and REF01 = EI then the Federal Tax ID from the Provider tab
of Practice Detail will be used if it exists; otherwise, the Federal Tax ID from the Practice
Detail, Practice tab will be used.
NM1(85)04
NM1(85)05
NM1(85)08
NM1(85)09
N301
N302
N401
N402
N403
REF01
REF02
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
3
Element
Location in MicroMD (window and field)
REF01
If EB Setup – Provider Qualifier is set to XX-NPI w/o Insurance ID, then this REF segment
will NOT be created. Otherwise, the billing qualifier from the Practice Insurance ID tab from
Practice Detail will be used first. If it does not exist, the billing qualifier from the Provider
Insurance ID tab from Practice Detail will be used. If that does not exist, the Source of
Payment from Plan Detail will be used to determine what qualifier to send.
If a value is chosen in EB Setup – 2010AA, then the value from that location will be used for
the ID. The values for 2010AA are Practice Insurance ID, Plan Practice ID, and Provider
Insurance ID.
If none of those are chosen, then MicroMD uses IDs in the following order. If none exists in
the field, then the system moves to the next field in this list:
Plan Detail, ID/Anesthesia tab – Plan Practice ID
Practice Detail, Practice Insurance ID tab – Practice Insurance ID
Practice Detail, Provider Insurance ID tab – Provider Insurance No
A second REF segment will be created in the 2010AA loop if EB Type is BSGA (G5), ALPR
(G5), MDNY (LU), ENS for payor ID NYMCD (LU), PRIN for payor ID MCDNY (LU)or PerSe
(LU).
If EB Type is ALPR or PerSe, the value is taken from EB Setup – Password (the value
explicitly not put in the ISA segment). If EB Type is BSGA, the value is taken from EB Setup
– Contact No. If EB Type is MDNY, the value is taken from Practice Detail – Location tab,
Location Code based on the location on the sequence.
REF02
REF01
REF02
Loop 2010AB
MicroMD can create this loop if there is no checkmark in the Suppress 2010AB checkbox on the EB Setup
window on the ANSI tab.
STOP | BE CAREFUL: The difference that triggers this loop can be a
matter of a single character, including spaces and punctuation.
Element
Location in MicroMD (window and field)
NM1(87)03
First, MicroMD looks at Practice Detail – Provider tab, Pay-To Name and Pay-To Address 1. If
these are different than the 2010AA Name and Address 1 and EB Setup – Organization is
checked, then the Provider Pay-To Name will be put in this element; if Organization is
unchecked, the Provider Last Name will be entered here.
NM1(87)04
NM1(87)05
NM1(87)08
If those items are the same, MicroMD looks at the Practice Detail – Practice tab, Pay-To
Name and Pay-To Address 1. If either is different than the 2010AA Name and Address 1 and
EB Setup – Organization is checked, then the Practice Pay-To Name will be entered in this
element; if Organization is unchecked, the Provider Last Name will be entered here. If both
Name and Address 1 match, this loop will not be created.
If Provider Last Name is entered in NM1(87)03, then Provider First Name will be entered here.
If Provider Last Name is entered in NM1(87)03, then Provider Middle Initial will be entered
here.
If a qualifier is entered on the EB Setup Screen – Provider Qualifier, then that value is entered
here. If not, then the value of the Tax Type on the Practice Detail – Practice tab is used to
determine the value. If Tax Type = S, a 34 is entered here. If Tax Type = E, a 24 is entered
here. If none of the above, an XX is entered here.
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
4
Element
Location in MicroMD (window and field)
NM1(87)09
If NM1(85)08 = ‘S’, the SSN from the Provider Detail will be used. If NM1(85)08 = ‘E’, then the
Federal Tax ID from the Provider tab of Practice Detail will be used if it exists, otherwise, the
Federal Tax ID from the Practice Detail, Practice tab will be used. If NM1(85)08 = XX, then the
value will be pulled from Provider Detail – NPI field.
Address 1 from the corresponding name in NM1(87)03 will be entered here.
Address 2 from the corresponding name in NM1(87)03 will be entered here.
The city from the corresponding name in NM1(87)03 will be entered here.
The state from the corresponding name in NM1(87)03 will be entered here.
The zip code from the corresponding name in NM1(87)03 will be entered here.
If EB Setup – ANSI tab has a value in 2010AB, then the billing qualifier from the Practice
Insurance ID tab from Practice Detail will be used first. If it does not exist, the billing qualifier
from the Provider Insurance ID tab from Practice Detail will be used. If that does not exist, the
Source of Payment from Plan Detail will be used to determine what qualifier to send. If no
value is set in EB Setup – ANSI tab in the 2010AB field, then this REF segment will not be
created.
If a value is chosen in EB Setup – 2010AB, then the value from that location will be used for
the ID. The values for 2010AB are Practice Insurance ID, Plan Practice ID, and Provider
Insurance ID.
N301
N302
N401
N402
N403
REF01
REF02
Loop 2000B
Element
Location in MicroMD (window and field)
SBR01
Patient Detail – Plan Sets tab – Plan Type. P for Primary, S for Secondary, and T for
Tertiary.
If Patient Detail – Plan Sets tab – Relation is Self, then 18 is entered here; otherwise, this
element is left blank.
If EB type is MCVA and SBR01 = P and, on the Source of Payment field on the Plan Detail is
Medicare, then this element will be left blank. If EB Type is PRWA and Plan Detail –
ID/Anesthesia tab Payer ID is 00882, then this element will be left blank. Otherwise, Patient
Detail – Plan Sets tab – Group No (unless the EB type is ALPR. If it is, and Plan Detail –
ID/Anesthesia tab, Payer Type = BNC and there is no Group Number, 999999 will be entered
here).
If EB type is MCVA and SBR01 = P and Plan Detail – Source of Payment is Medicare, then
this element will be left blank. If EB Type is PRWA and Plan Detail – ID/Anesthesia tab Payer
ID is 00882, then this element will be left blank. Otherwise, if SBR03 is not empty, the Plan
Name will be pulled from Plan Detail – Plan tab.
If Plan Detail – Source of Payment is Medicare, and SBR01 = S or T, then the value is pulled
from Claim Modification – Ins Type field.
Plan Detail – Plan tab – Source of Payment
(Element created only if a self-insured claim, and if patient is deceased or patient is marked
with the pregnancy indicator). If a patient deceased date exists on Patient Detail – Detail tab,
it is entered here.
(6.0 and above) If DME CMN, Patient Weight from Claim Transactions Window
Segment is created when Pregnancy indicator is checked and there is no check mark in Auto
Accident or Other Accident. Date must also be included in Injury/LMP field to create
segment. System includes a Y in this segment when created.
SBR02
SBR03
SBR04
SBR05
SBR09
PAT06
PAT08
PAT09
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
5
Loop 2010BA
Element
Location in MicroMD (window and field)
NM1(IL)02
If there is a checkmark in the NP Entity checkbox on the patient’s plan sets tab (in the
Policyholder section if the relation is other than self), the system populates this segment with a
“2”. The non-person entity whole name must also appear in the Last Name field. (Enter a
dummy first name, as this is a required field.) If there is no check mark, the system enters a
“1” in this segment.
If patient is self insured, the last name is pulled from Patient Detail, Detail tab – Last Name. If
patient is not self insured, and the insured is a guarantor in the system, the last name is pulled
from Patient Detail – Detail tab of the insured account. If the insured is not a patient in the
system, then the last name is pulled from the Insured Box on Patient Detail – Plan Sets tab.
Pulls the first name from the same place as the last name is pulled for NM1(IL)03
Pulls the middle initial from the same place as the last name is pulled for NM1(IL)03
Pulls the generation from the same place as the last name is pulled for NM1(IL)03
Patient Detail, Plan Sets tab – Policy Qualifier
If EB Type is SCMI, then MicroMD first looks at Claim Transactions – Block 10D; otherwise, it
uses the policy number. If EB Type is anything else, it uses Patient Detail, Plan Sets tab –
Policy.
(Segment is created if the person is self-insured, or if Plan Detail – ID/Anesthesia tab –
Insured Address is checked.) Address 1 is pulled from the same place as last name is pulled
for NM1(IL)03.
Address 2 is pulled from the same place as last name is pulled for NM1(IL)03.
(Segment is created if the person is self insured, or if Plan Detail – ID/Anesthesia tab, Insured
Address is checked.) City is pulled from the same place as last name is pulled for NM1(IL)03.
State is pulled from the same place as last name is pulled for NM1(IL)03.
Zip code is pulled from the same place as last name is pulled for NM1(IL)03.
(Segment is created if the person is self insured, or if Plan Detail – ID/Anesthesia tab, Insured
Address is checked.) DOB is pulled from the same place as last name is pulled for NM1(IL)03.
Insured sex is pulled from the same place as last name is pulled for NM1(IL)03.
This segment is only populated if the EB type is MACSIS..
This is the patient social security number, pulled from Patient Detail – Detail tab.
NM1(IL)03
NM1(IL)04
NM1(IL)05
NM1(IL)07
NM1(IL)08
NM1(IL)09
N301
N302
N401
N402
N403
DMG02
DMG03
REF(SY)01
REF(SY)02
Loop 2010BB
Element
Location in MicroMD (window and field)
NM1(PR)03
NM1(PR)08
NM1(PR)09
Plan Detail, Plan tab – Plan Name
Plan Detail, ID/Anesthesia tab – Payer ID Qualifier
Plan Detail, ID/Anesthesia tab – Payer ID
If EB type is MDWV, then the value WV_MMIS_4UNISYS is entered here. Otherwise if EB
type is THIN, a letter based on the Source of Payment for the plan is placed in front of the
payer ID (C for Medicare, D for Medicaid, F for Commercial, G for Blue Shield).
Plan Detail, Plan tab – Address line 1
Plan Detail, Plan tab – Address line 2
Plan Detail, Plan tab – City
Plan Detail, Plan tab – State
Plan Detail, Plan tab – Zip code
N301
N302
N401
N402
N403
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
6
Element
Location in MicroMD (window and field)
REF01
(Segment is only created if a value exists on Plan Detail – ID/Anesthesia tab, Claim Office ID)
An FY is entered here.
Plan Detail, ID/Anesthesia tab – Claim Office ID
REF02
Loop 2000C
(Only created if patient is not the insured)
Element
Location in MicroMD (window and field)
PAT01
PAT06
PAT09
Patient Detail, Plan Sets tab – Relation
If a patient deceased date exists on Patient Detail – Detail tab, it is entered here
If claim is not accident related, Claim Transactions Window – Pregnancy indicator
Loop 2010CA
(Only created if patient is not the insured)
Element
Location (Screen – Field) in MicroMD
NM1(QC)03
NM1(QC)04
NM1(QC)05
NM1(QC)08
Patient Detail, Detail tab – Last Name
Patient Detail, Detail tab – First Name
Patient Detail, Detail tab – MI
If Plan Detail – ID/Anesthesia tab, Insured Policy is checked, this value is pulled from Patient
Detail, Plan Sets tab – Policy Qualifier
If Plan Detail – ID/Anesthesia tab, Insured Policy is checked, this value is pulled from Patient
Detail, Plan Sets tab – Policy
If the EB Type is IHNY or PRWA and the group number is 11 digits, the system places the
group number in this segment.
Patient Detail, Detail tab – Address line 1
Patient Detail, Detail tab – Address line 2
Patient Detail, Detail tab – City
Patient Detail, Detail tab – State
Patient Detail, Detail tab – Zip code
Patient Detail, Detail tab – DOB
Patient Detail, Detail tab – Sex
“QC” (Created for Texas Workers Comp)
“1” (Created for Texas Workers Comp)
Last Name (Created for Texas Workers Comp)
First Name (Created for Texas Workers Comp)
Patient Plan Policy Qualifier (should be “MI”) (Created for Texas Workers Comp)
Patient Plan Policy (Created for Texas Workers Comp)
“Y4” (Created for Texas Workers Comp)
Claim Number (on the Extra button on the Texas Workers Comp form)
NM1(QC)09
N301
N302
N401
N402
N403
DMG02
DMG03
NM101
NM102
NM103
NM104
NM108
NM109
Ref01
Ref02
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
7
Loop 2300
Element
Location (Screen – Field) in MicroMD
CLM01
Patient Detail, Detail tab – Patient ID in the form of practice ID-guarantor id.patient nosequence no. e.g. 1-1001.0-1 Or, if EB Setup – ANSI tab – Format Ctrl Number is not
checked then the control number is entered in the form of:
PracticeID(space)guarantorID(space)patientNo(space)sequenceNo e.g., 1 1001 0 1
Claim Transactions – Fee (Summed for all line items)
Claim Transactions – POS
Claim Adjustment Information – Claim Frequency Type Code (Claim Level)
Claim Transactions – Assignment
Patient Detail, Plan Sets Tab– Assign Benefits
Patient Detail, Plan Sets tab – Release Code
If CLM09 does not equal N, then Patient Detail, Plan Sets tab – Signature Code
Claim Transactions – Accident Related
Claim Transactions – State
If EPSDT is checked in Claim Transactions, a 01 is entered here
If a Delay Reason Code is selected from Claim Transactions, More screen, that code is
entered here
(Segment only created if EB Setup – Claim Indicator is set to Chiropractic or if Claim
Transactions – Pregnancy is not checked, and claim is not accident-related.) If Claim
Indicator is Chiropractic, then the date is pulled from Chiropractic Information Screen –
Treatment. If not pregnancy-related, the date is pulled from Claim Transactions – Injury/LMP
(if a date exists).
(Segment only created if Claim Transactions, Lst Seen is populated) Claim Transactions –
Lst Seen (if a date exists)
(Segment only created if Claim Transactions – Conslt/Illness is populated) Claim
Transactions – Conslt/Illness (if a date exists)
(Segment only created if EB Setup – Claim Indicator is set to Chiropractic and Chiropractic
Information Screen – Nature of Condition is set to A or M) Chiropractic Information Screen –
Manifestation Date (if a date exists)
(Segment only created if accident-related) Claim Transactions – Injury/LMP (if a date exists)
(Segment only created if Claim Transactions – Pregnancy is checked, and the sequence is
not accident-related) Claim Transactions – Injury/LMP (if a date exists)
(Segment only created if EB Setup – Claim Indicator is set to Chiropractic) Chiropractic
Information Screen – X-Ray Date (if a date exists)
Claim Transactions – Admission (if a date exists)
Claim Transactions – Discharge (if a date exists)
(Segment only created if Practice Preferences – Billing Preferences, Show Patient Payment
is checked) Patient Paid amount from Sequence
Claim Adjustment Information – Service Authorization Exception Code
(Segment only created if Plan Detail – Plan tab, Source of Payment is set to Medicare)
Service Facility Detail, Service Facility tab – Mammo. Cert (If a value exists)
Claim Transactions – Prior Authorization # (If a value exists)
CLM02
CLM05-1
CLM05-3
CLM07
CLM08
CLM09
CLM10
CLM11-1
CLM11-4
CLM12
CLM20
DTP(454)03
DTP(304)03
DTP(431)03
DTP(453)03
DTP(439)03
DTP(484)03
DTP(455)03
DTP(435)03
DTP(096)03
AMT(F5)02
REF(4N)02
REF(EW)02
REF(G1)02
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
8
Element
Location (Screen – Field) in MicroMD
REF(9F)02
(Segment only created if EB type is MDGA, MDFL, or MDIN) If type is MDIN (including
clearinghouses), the value is pulled from Claim Transactions – Block 19. If type is MDGA,
the value is pulled from Claim Transactions – Block 10d. If type is MDFL and a referring
doctor is assigned to the sequence, the referring doctor insurance ID is used (First looks at
Referring Doctor – Insurance ID tab, Referring Insurance No. If that doesn’t exist, it looks at
Referring Doctor – Detail tab, UPIN).
Claim Modification – Original-Ref No/CRN. If, however, there is data in the Override ICN
field (click Adj. Codes button), the system uses this data instead for this segment.
(Segment only created if Plan Detail – Plan tab, Source of Payment is set to Medicare or
Medicaid and Procedure Detail – Detail tab, CLIA Flag is checked) *Order of CLIA priority:
Provider Detail – CLIA No
Practice Detail, Location Tab
Practice Detail, Practice Tab
Claim Transactions – Claim level notes qualifier taken from drop-down of Clm Doc button
Claim Transactions – Clm Doc button
(Segment only created if Ambulance Related Claim) Ambulance Addtl Info, Weight (lbs)
Ambulance Addtl Info, Transport Code
Ambulance Addtl Info, Transport Reason Code
Ambulance Addtl Info, Miles
If CR103 = X, then Ambulance Addtl Info, Round Trip Description
Ambulance Addtl Info, Stretcher Description
(Segment only created if EB Setup – Claim Indicator is set to Chiropractic) Chiropractic
Information – Number in Series (4010 only)
Chiropractic Information – Total in Series (4010 only)
Chiropractic Information – Begin Level of Subluxation (4010 only)
Chiropractic Information – End Level of Subluxation (4010 only)
Chiropractic Information – Treatment Period Qualifier (4010 only)
Chiropractic Information – Treatment Period (4010 only)
Chiropractic Information – Number in Treatment (4010 only)
Chiropractic Information – Nature of Condition
Chiropractic Information – Complication Indicator (4010 only)
Chiropractic Information – Symptoms Description
Chiropractic Information – Symptoms Description
Chiropractic Information – X-Ray Availability
(Segment only created if the CR1 segment exists and Condition Codes exist) Ambulance
Addtl Info, Condition Codes Apply
Ambulance Addtl Info, Condition Code 1
Ambulance Addtl Info, Condition Code 2
Ambulance Addtl Info, Condition Code 3
Ambulance Addtl Info, Condition Code 4
Ambulance Addtl Info, Condition Code 5
(Segment only created if Claim Transactions – EPSDT is checked) If Claim Transactions –
More Screen, Visit Code 2 (first row only) is empty, or has a value of NU, then an N is
entered here; otherwise, a Y is entered
If Claim Transactions – More Screen, Visit Code 2 (first row only) is empty, an NU is entered
here, otherwise, the code in the field is entered.
REF(F8)02
REF(X4)02
NTE01
NTE02
CR102
CR103
CR104
CR106
CR109
CR110
CR201
CR202
CR203
CR204
CR205
CR206
CR207
CR208
CR209
CR210
CR211
CR212
CRC(07)02
CRC(07)03
CRC(07)04
CRC(07)05
CRC(07)06
CRC(07)07
CRC(ZZ)02
CRC(ZZ)03
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
9
Element
Location (Screen – Field) in MicroMD
HI01-2
HI02-2
HI03-2
HI04-2
AMT(NE)
Claim Transactions – Diagnosis 1
Claim Transactions – Diagnosis 2
Claim Transactions – Diagnosis 3
Claim Transactions – Diagnosis 4
(Segment only created if Outside Lab checked on Claim Modification window) Total
purchased service amount. System adds the line level charge amounts to reach the claim
level amount.
Attachment Code (Created for Texas Workers Comp). Located on the CLAIM
ATTACHMENT INFORMATION window in MicroMD.
Transmission Method Code (Created for Texas Workers Comp). Located on the CLAIM
ATTACHMENT INFORMATION window in MicroMD.
“AC” (Created for Texas Workers Comp). Located on the CLAIM ATTACHMENT
INFORMATION window in MicroMD.
Attachment Control Number (Created for Texas Workers Comp). Located on the CLAIM
ATTACHMENT INFORMATION window in MicroMD.
Resubmission Condition Indicator (when sending a bill that is a duplicate or an appeal)
(Created for Texas Workers Comp)
PWK01
PWK02
PWK05
PWK06
K301
Loop 2310A
(Only created if a referring doctor is on the sequence)
Element
Location (Screen – Field) in MicroMD
NM1(DN)02
NM1(DN)03
NM1(DN)04
NM1(DN)05
NM1(DN)08
Referring Doctor Detail, Detail tab – Non-Person Entity
Referring Doctor Detail, Detail tab – Last Name
Referring Doctor Detail, Detail tab – First Name
Referring Doctor Detail, Detail tab – MI
Referring Doctor Detail, Detail tab – SSN/FID Qualifier (Only required if no UPIN or
insurance ID is in the system)
Referring Doctor Detail, Detail tab – SSN/FID (Only required if no UPIN or insurance ID is in
the system)
(Segment will not be created if EB type is MDFL, Referring Doctor ID will be added in the
2300 loop, in the REF(9F) segment) Referring Doctor Detail, Insurance ID tab – Qualifier
(If it doesn’t exist, the UPIN qualifier will be sent)
Referring Doctor Detail, Insurance ID tab – Referring Insurance No
(If it doesn’t exist, UPIN from Detail tab will be sent)
If “Remove Tax ID” is chosen from the 2310A drop-down in EB Setup, the system does not
create this REF segment.
(Segment created for MDFL and MDLA EB Types) Provider Taxonomy Code.
NM1(DN)09
REF01
REF02
PRV03
Loop 2310B
(Only created if Organization is checked on EB Setup)
This loop is completely removed even if Organization is checked on EB Setup for MACSIS of Ohio. MicroMD can
remove this loop if there is a check mark in the Suppress 2310B checkbox on the EB Setup window on the ANSI
tab.
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10
Element
Location (Screen – Field) in MicroMD
NM102
If there is a checkmark in the Non-Person Entity checkbox on the provider’s detail window,
the system populates this segment with a “2”. The non-person entity whole name must also
appear in the Last Name field. (Enter a dummy first name, as this is a required field.) If there
is no check mark, the system enters a “1” in this segment.
Provider Detail – Last Name
Provider Detail – First Name
Provider Detail – MI
If a value exists on EB Setup – Provider Qualifier, it will be entered here. If it does not exist,
Practice Detail – Practice tab, Tax Type will determine the value. If Tax Type is E, a 24 will
be entered here. If Tax Type is S, a 34 will be entered here. In all other cases, an XX will be
entered here.
If NM1(82)08 = 24, The Federal Tax ID will be entered. First from Practice Detail – Provider
tab, then from Practice Detail – Practice tab. If NM1(82)08 = 34, the SSN from Provider
Detail will be entered. If NM1(82)08 = XX, then the NPI from Practice Detail, Provider
Insurance ID Tab, then from Provider Detail, then from Practice Detail, Practice Insurance ID
Tab, NPI column, then from Practice Detail, Providers Tab, NPI field, then from Practice
Detail, Practice Tab, Practice NPI.
Provider Detail – Taxonomy Code
Practice Detail, Provider Insurance ID tab – Rend Qual
Practice Detail, Practice Insurance ID tab – Rend Qual
If a value is chosen in EB Setup – 2310B, then the value from that location will be used for
the ID. The values for 2310B are Practice Insurance ID, Plan Practice ID, and Provider
Insurance ID.
If none of those are chosen, then MicroMD uses IDs in the following order. If none exists in
the field, then the system moves to the next field in this list:
Practice Detail, Provider Insurance ID tab – Provider Insurance No
Plan Detail, ID/Anesthesia tab – Plan Practice ID
Practice Detail, Practice Insurance ID tab – Practice Insurance ID
If “Remove Tax ID” is chosen from the 2310B drop-down, the system does not create this
REF segment.
A second REF segment will be created if there is an ID under Maint, Practice, Provider
Network ID tab – Network ID for the plan attached to the patient.
Practice Detail, Provider Network ID tab – Network ID.
NM1(82)03
NM1(82)04
NM1(82)05
NM1(82)08
NM1(82)09
PRV03
REF01
REF02
REF(N5)01
REF(N5)02
Loop 2310C
(Only created if there is a check mark in the Outside Lab checkbox on Claim Modification window and the
purchased service provider and charge amount are entered on the line level adjudication box. System also
creates 2400 loop with PS1 segment, 2420B Loop with NM1 segment and 2300 loop with AMT segment.)
Element
Location (Screen – Field) in MicroMD
NM1(QB)
Claim level provider info pulls first purchased service provider from first line
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11
Loop 2310D
(Only created if an ambulance claim and service facility address 1 is filled in on Ambulance Addt’l Info screen)
Element
Location (Screen – Field) in MicroMD
NM1(77)03
N301
N302
N401
N402
N403
POINT OF PICK UP
Ambulance Add’l Info screen – Service Facility Address 1
Ambulance Add’l Info screen – Service Facility Address 2
Ambulance Add’l Info screen – Service Facility City
Ambulance Add’l Info screen – Service Facility State
Ambulance Add’l Info screen – Service Facility Zip code
Loop 2310D
(Only created if a service facility is on the sequence)
MicroMD will only create this loop if there has been no 2310D created yet.
Element
Location (Screen – Field) in MicroMD
NM1(FA)03
N301
N302
N401
N402
N403
REF01
Service Facility Detail, Service Facility tab – Description
Service Facility Detail, Service Facility tab – Address 1
Service Facility Detail, Service Facility tab – Address 2
Service Facility Detail, Service Facility tab – City
Service Facility Detail, Service Facility tab – State
Service Facility Detail, Service Facility tab – Zip code
(Segment only created if an ID exists for the service facility) Service Facility Detail, ID tab –
Qualifier
Service Facility Detail, ID tab – Facility Insurance ID
REF02
Loop 2310D
(Only if EB Type is ALPR, and Plan Detail – ID/Anesthesia Tab, Emdeon 2310D is not checked – Replaces
regular 2310D)
MicroMD will only create this loop if there has been no 2310D created yet.
Element
Location (Screen – Field) in MicroMD
NM1(77)03
N301
N302
N401
N402
N403
Hard coded to be “Rendering Provider”
If Pay-To address 1 is filled in, it will use that; otherwise, it will use Practice Address 1
If Pay-To address 2 is filled in, it will use that; otherwise, it will use Practice Address 2
If Pay-To city is filled in, it will use that; otherwise, it will use Practice city
If Pay-To state is filled in, it will use that; otherwise, it will use Practice state
If Pay-To zip code is filled in, it will use that; otherwise, it will use Practice zip code
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
12
Loop 2310E
(Only created if a supervising physician exists on the sequence)
(Supervising Provider pulls from Referring Doctor list)
Element
Location (Screen – Field) in MicroMD
NM1(DQ)02
NM1(DQ)03
NM1(DQ)04
NM1(DQ)05
NM1(DQ)08
NM1(DQ)09
REF01
Referring Doctor Detail, Detail tab – Non-Person Entity
Referring Doctor Detail, Detail tab – Last Name
Referring Doctor Detail, Detail tab – First Name
Referring Doctor Detail, Detail tab – MI
Referring Doctor Detail, Detail tab – SSN/FID Qualifier
Referring Doctor Detail, Detail tab – SSN/FID
Referring Doctor Detail, Insurance ID tab – Qualifier
(If it doesn’t exist, the UPIN qualifier will be sent)
Referring Doctor Detail, Insurance ID tab – Referring Insurance No
(If it doesn’t exist, UPIN from Detail tab will be sent)
REF02
Loop 2320
(Only created if either EB Setup – ANSI tab – Include Other Ins is checked, or if sending a non-primary claim to
report previous payers)
Element
Location (Screen – Field) in MicroMD
SBR01
Patient Detail – Plan Sets tab – Plan Type. P for Primary, S for Secondary, and T for
Tertiary.
Patient Detail – Plan Sets tab – Relation
Patient Detail – Plan Sets tab – Group No
Plan Detail – Plan tab – Plan Name
Patient Detail – Plan Sets tab – Ins Type Code
Plan Detail – Plan tab – Source of Payment
(Segment created only if the payer has already paid on the claim)
Claim Adjustment Information – Adjudication section – Group Code
Claim Adjustment Information – Adjudication section – Reason Code
Claim Adjustment Information – Adjudication section – Amount. If the payers are Tricare
(through ENS or PI) or New York Medicaid direct, and the amount is less than $1.00,
MicroMD automatically removes the leading zero.
Claim Adjustment Information – Adjudication section – Quantity
(Segment created only if the payer has already paid on the claim) Payer amount paid on the
claim
(Segment created only if the payer has already paid on the claim, even if the amount is 0)
Payer amount allowed on the claim
(Segment created only if the payer has already paid on the claim)
Coinsurance amount on the claim.
(Segment created only if the payer has already paid on the claim, and if Practice
Preferences – Billing Preferences, Show Patient Payment is checked) Amount patient paid
on the claim
DOB is pulled from the Patient Detail – Detail tab – DOB.
SBR02
SBR03
SBR04
SBR05
SBR09
CAS01
CAS02
CAS03
CAS04
AMT(D)02
AMT(B6)02
AMT(F2)02
AMT(F5)02
DMG02
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
13
Element
Location (Screen – Field) in MicroMD
DMG03
OI03
OI04
OI06
Insured sex is pulled from the Patient Detail – Detail tab – Sex.
Patient Detail – Plan Sets tab – Assignment
If OI06 does not equal N, then Patient Detail – Plan Sets tab – Signature Source
Patient Detail – Plan Sets tab – Release of Information
Loop 2330A
(Only created if either EB Setup – ANSI tab – Include Other Ins is checked, or if sending a non-primary claim to
report previous payers)
Element
Location (Screen – Field) in MicroMD
NM1(IL)03
If patient is self-insured, the last name is pulled from Patient Detail, Detail tab – Last Name.
If patient is not self-insured, and the insured is a guarantor in the system, the last name is
pulled from Patient Detail – Detail tab of the insured account. If the insured is not a patient in
the system, then the last name is pulled from the Insured Box on Patient Detail – Plan Sets
tab.
Pulls the first name from the same place as the last name is pulled for NM1(IL)03
Pulls the middle initial from the same place as the last name is pulled for NM1(IL)03
Pulls the generation from the same place as the last name is pulled for NM1(IL)03
Patient Detail, Plan Sets tab – Policy Qualifier
If EB Type is SCMI, then MicroMD first looks at Claim Transactions – Block 10D; otherwise,
it uses the policy number. If EB Type is anything else, it uses Patient Detail, Plan Sets tab –
Policy
If EB Type is MSOH, then Claim Modification – Visit1 is entered here; otherwise, this
segment does not get created.
NM1(IL)04
NM1(IL)05
NM1(IL)07
NM1(IL)08
NM1(IL)09
REF(IG)02
Loop 2330B
(Only created if either EB Setup – ANSI tab – Include Other Ins is checked, or if sending a non-primary claim to
report previous payers)
Element
Location (Screen – Field) in MicroMD
NM1(PR)03
NM1(PR)08
NM1(PR)09
Plan Detail, Plan tab – Plan Name
Plan Detail, ID/Anesthesia tab – Payer ID Qualifier
If EB Type is BSFL, then this element will first look at the NAIC code on Plan Detail –
ID/Anesthesia tab. If that is blank, it will use the Payer ID. If the current payer Ins Type on
Patient Detail – Plan Sets tab is set to MI, then this element will try to use the Medigap ID on
Plan Detail – ID/Anesthesia tab, or if that is blank, it will use the Payer ID. Or if the source of
payment on the primary plan is Medicare and the Ins Type is blank, it will also try to use the
Medigap ID. Otherwise, it uses the Payer ID. In all other cases, MicroMD uses the value
from Plan Detail, ID/Anesthesia tab – Payer ID
The payment date recorded in MicroMD. The date will first be looked at on the Claim
Adjustment Information – Adjudication section – Payment Date; otherwise, it uses the Date
Paid on the claim.
For BCBSFL, Claim Adjustment Information window - Override ICN. ***Note the payer id
needs to be correct in the plan in order for the REF F8 segment to be created. They are
different if the practice uses ENS vs. Practice Insight. ***
DTP(573)02
REFF8
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
14
Loop 2400
(Each line item on a sequence will create a separate 2400 loop)
Element
Location (Screen – Field) in MicroMD
SV101-1
SV101-2
SV101-3
SV101-4
SV101-5
SV102
SV103
SV104
SV105
Procedure Detail – Procedure tab, Qualifier
Claim Transactions – Code
Claim Transactions – M1
Claim Transactions – M2
Claim Transactions – M3
Claim Transactions – Fee (For Availity claims, the system removes the leading zero)
Plan Detail – ID/Anesthesia tab, Print Units or Minutes
Claim Transactions – Unit
(Segment only created if POS is different from CLM05, or if EB Setup – Line level Pos is
checked) Claim Transactions – POS
Claim Transactions – Diag (Pointers)
Claim Transactions – Emergency Indication
If Claim Transactions – EPSDT is checked, a Y is entered here
If Claim Transactions – Family Planning is checked, a Y is entered here
(Segment only created in PM 6.0 and above, and DME CMN) Same as SV101-1
Same as SV101-2
DME Form, Length of Need multiplied by 30.42 because days is required here
DME Form, Rental Price
DME Form, Purchase Price
DME Form, Rental Unit
(Segment only created in PM 6.0 and above, and DME CMN) DME Form, Attachment
Code
(Segment only created in PM 6.0 and above, and DME CMN) DME Form, Certification
Code
DME Form, Length of Need
(Segment will only be created if sequence is marked as a Hospice Employed Provider) If
Claim Transactions – Hospice Employed Provider is checked, a Y will be entered here
(Segment only created in PM 6.0 and above, and DME CMN) DME Form, Condition
Applies
DME Form, Condition Indicator 1
DME Form, Condition Indicator 2
DME Form, Condition Indicator 3
DME Form, Condition Indicator 4
DME Form, Condition Indicator 5
If the EPSDT checkbox is marked on the Claims Transaction window and a value appears
in the Vist2 field of the More window, then in addition to the 2300 loop information, the
2400 loop Segment CRC Element 02 has a Y and Element 03 has the Vist2 value.
If the EPSDT checkbox is marked on the Claims Transaction window and a value appears
in the Vist2 field of the More window, then in addition to the 2300 loop information, the
2400 loop Segment CRC Element 02 has a Y and Element 03 has the Vist2 value.
Claim Transactions – From, To
SV107
SV109
SV111
SV112
SV501-1
SV501-2
SV503
SV504
SV505
SV506
PWK02
CR301
CR303
CRC(70)02
CRC(09)02
CRC(09)03
CRC(09)04
CRC(09)05
CRC(09)06
CRC(09)07
CRC(ZZ)02
CRC(ZZ)03
DTP03(472)
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
15
Element
Location (Screen – Field) in MicroMD
DTP03(463)
(Segment only created in PM 6.0 and above, and DME CMN) DME Form, Begin Therapy
Date
(Segment only created in PM 6.0 and above, and DME CMN) DME Form, Recertification
(Segment only created for DME CMS form and when CR301 = R or S)
DME Form, Revised Date
(Segment only created in PM 5.2 and above) If line level documentation includes the value:
HCT# where # is the result of the Hematocrit test. No spaces or other characters can exist
between HCT and #. # is expected to be a number of any length. As soon as a nonnumeric character (spaces, letters, etc) is read, the value is entered in this element.
(Segment only created in PM 6.0 and above, and DME CMN) DME Form, Patient Height
Where 01=EW segment. (Segment only created if Plan Detail – Plan tab, Source of
Payment is set to Medicare) Service Facility Detail, Service Facility tab – Mammo. Cert (If
a value exists)
MicroMD practice, guarantor, patient, sequence, line number
(Segment only created if Plan Detail – Plan tab, Source of Payment is set to Medicare or
Medicaid and Procedure Detail – Detail tab, CLIA Flag is checked and Suppress Clia in
2400 in EB Setup is not checked) *Order of CLIA priority:
Provider Detail – CLIA No
Practice Detail, Location Tab
Practice Detail, Practice Tab
If the service line exists with a 90 modifier and it is a CLIA procedure, the system creates
REF*F4 instead of this X4 segment.
(Segment only created if the pending payer is secondary) Claim Modification Window,
Allowed amount based on the line item
Documentation Window - Qualifier
Documentation Window
(Segment only created if Outside Lab checked. See loop 2310C.)
Provider NPI and charge amount
Segment only created in PM 6.5 and above when sending claims to SCCMH. Service
times must be entered in the line level notes in the following format.
An asterisk, followed by the keyword SVCTIME, then two (2) spaces, a four (4) digit start
time in 24 hour format, a hyphen, a four (4) digit end time in 24 hour format, and ended
with an asterisk. So, if your appointment time was from 1:15PM to 2:15 PM, you would
enter:
*SVCTIME 1315-1415*
DTP03(461)
DTP03(607)
MEA03
MEA03
REF02
REF02(6R)
REF02(X4)
AMT(AAE)02
NTE01
NTE02
PS1
K301
Loop 2410
(Created if NDC information exists on the sequence and the Claim File Type on the EB Setup window is set to
ANSI 4010X098A1)
Element
Location (Screen – Field) in MicroMD
LIN03
CTP03
CTP04
CTP05-1
REF(XZ)02
Claim Adjustment Information, NDC Code (Line Level)
Claim Adjustment Information, Unit Price (Line Level)
Claim Adjustment Information, Units (Line Level)
Claim Adjustment Information, Measurement (Line Level)
Claim Adjustment Information, Rx Number (Line Level)
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
16
Loop 2420B
(Only created if there are multiple purchased service providers per claim)
Element
Location (Screen – Field) in MicroMD
NM1(QB)
Loop 2420C
(Created if EB Type is ALPR and POS is not 11 or 12, and Plan Detail – ID/Anesthesia Tab, Emdeon 2310D is
not checked)
Element
Location (Screen – Field) in MicroMD
NM1(FA)03
N301
N302
N401
N402
N403
Service Facility Detail, Service Facility tab – Description
Service Facility Detail, Service Facility tab – Address 1
Service Facility Detail, Service Facility tab – Address 2
Service Facility Detail, Service Facility tab – City
Service Facility Detail, Service Facility tab – State
Service Facility Detail, Service Facility tab – Zip code
Loop 2420E
(Created if EB Type is DMRA, DMRB, DMRC, DMRD or if EB Type is THIN (Payer IDs 00885, 05655, 19003) or
if EB Type is ENS (Payer IDs DMERA, DMERB, DMERC, DMERD) or if EB Type is Practice Insight (Payer IDs
811, 635, DMED))
Element
Location (Screen – Field) in MicroMD
NM1(DK)02
NM1(DK)03
NM1(DK)04
NM1(DK)05
NM1(DK)08
Referring Doctor Detail, Detail tab – Non-Person Entity
Referring Doctor Detail, Detail tab – Last Name
Referring Doctor Detail, Detail tab – First Name
Referring Doctor Detail, Detail tab – MI
Referring Doctor Detail, Detail tab – SSN/FID Qualifier (Only required if no UPIN or
insurance ID is in the system)
Referring Doctor Detail, Detail tab – SSN/FID (Only required if no UPIN or insurance ID is in
the system)
Referring Doctor Detail – Detail tab, Address 1
Referring Doctor Detail – Detail tab, Address 2
Referring Doctor Detail – Detail tab, City
Referring Doctor Detail – Detail tab, State
Referring Doctor Detail – Detail tab, Zipcode
Referring Doctor Detail, Insurance ID tab – Qualifier
(If it doesn’t exist, the UPIN qualifier will be sent. If the EB Setup indicates to send NPI w/o
Ins Id, the system does not create this ref segment.)
Referring Doctor Detail, Insurance ID tab – Referring Insurance No
(If it doesn’t exist, UPIN from Detail tab will be sent. If the EB Setup indicates to send NPI
w/o Ins Id, the system does not create this ref segment.)
NM1(DK)09
N301
N302
N401
N402
N403
REF01
REF02
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
17
Loop 2430
(Created if a previous payer has already adjudicated the claim, and there are line level adjustments posted
against the claim)
Element
Location (Screen – Field) in MicroMD
SVD01
If EB Type is BSFL, then this element will first look at the NAIC code on Plan Detail –
ID/Anesthesia tab. If that is blank, it will use the Payer ID. If the current payer Ins Type on
Patient Detail – Plan Sets tab is set to MI, then this element will try to use the Medigap ID on
Plan Detail – ID/Anesthesia tab, or if that is blank, it will use the Payer ID. Or if the source of
payment on the primary plan is Medicare and the Ins Type is blank, it will also try to use the
Medigap ID, otherwise the Payer ID. In all other cases, MicroMD uses the value from Plan
Detail, ID/Anesthesia tab – Payer ID
Payment made on the claim
Is set to the same value as SV101
Is set to the same value as SV104
(Segment created only if the payer has already paid on the claim) Claim Adjustment
Information – Adjudication section – Group Code
Claim Adjustment Information – Adjudication section – Reason Code
Claim Adjustment Information – Adjudication section – Amount
Claim Adjustment Information – Adjudication section – Quantity
The payment date recorded in MicroMD. The date will first be looked at on the Claim
Adjustment Information – Adjudication section – Payment Date; otherwise, it uses the Date
Paid on the claim.
SVD02
SVD03
SVD05
CAS01
CAS02
CAS03
CAS04
DTP(573)02
Loop 2440
(Created in PM 6.0 and above, and DME CMN. The information contained in this loop will change based on which
CMN is being sent. In the example below, the DME 06.03B TENS form is being sent)
Element
Location (Screen – Field) in MicroMD
LQ02
FRM01
FRM02
FRM03
FRM04
DME Form number (example 06.03B)
DME Form Question number (examples 1, 2, 3, 4, 5, 6)
DME Form, answers to Yes or No Questions (examples, 1, 4, 5)
DME Form, answers to Text Questions (examples 2, 3)
DME Form, answers to Date Questions (example 6)
760 Boardman-Canfield Rd. Boardman  OH 44512  P: 330-758-8832  F: 330-758-0182  micromd.com
18