To populate line level REF IDs in electronic claims, enter the ID in Line Notes in the given format

Format

REF:<Qualifier>:<ID> 

Permitted Qualifiers 

9B’,’9D’,’G1′,’2U’,’6R’,’EW’,’X4′,’F4′,’BT’.

For eg. in order to populate Additional/Referring CLIA# on electronic claim should enter the ID in format REF:F4:<CLIA#> to the Line Note. Table describes the qualifiers used.

Qualifier Description
9B REPRICED LINE ITEM REFERENCE NUMBER
9D ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER
G1 PRIOR AUTHORIZATION
6R LINE ITEM CONTROL NUMBER
EW MAMMOGRAPHY CERTIFICATION NUMBER
X4 CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) IDENTIFICATION
F4 REFERRING CLINICAL LABORATORY IMPROVEMENT AMENDMENT (CLIA) FACILITY IDENTIFICATION
BT IMMUNIZATION BATCH NUMBER
9F REFERRAL NUMBER