Gap Assist

Data Element Name	4050 Version	5010 Version
Submitter Information
Submitter Name	yes	yes
Submitter Identifier	yes	yes
Submitter Fax	yes	yes
Submitter Telephone	yes	yes
Processing Date	yes	yes
Input/Tape Supplier Number (TSN)	yes	yes
Receiver Information
Receiver Name	yes	yes
Receiver Identification	yes	yes
Provider Information
Service Provider Name	yes	yes
Service Provider Identification Number	yes	yes
Patient Information
Patient's Last Name	yes	yes
Patient's First Name	yes	yes
Patient's Middle Name	yes	yes
Patient's Control Number	yes	yes
Medical Record Number	yes	yes
Unique Personal Identifier/Social Security Number	yes	yes
Patient's Marital Status	no	yes
Patient's Race	yes	yes
Patient's Ethnicity	yes	yes
Patient's Address Line - 1	yes	yes
Patient's Address Line - 2	yes	yes
Patient's City	yes	yes
Patient's County Code	yes	yes
Patient's State	yes	yes
Patient's Postal Service Zip Code and Extension Code	yes	yes
Patient's Sex	yes	yes
Patient's Birth Date	yes	yes
Newborn Birth Weight	yes	yes
Mother's Medical Record Number for Newborn Child	yes	yes
Expected Patient Responsibility	yes	yes
Claim Information
Type of Admission	yes	yes
Source of Admission	yes	yes
Admission Date/Start of Care	yes	yes
Admission Hour	yes	yes
Statement Covers Period - From Date	yes	yes
Statement Covers Period - Thru Date	yes	yes
Service Date	yes	yes
Discharge Date - Derived from Statement From Date & Type of Bill	yes	yes
Discharge Hour	yes	yes
Patient Status or Disposition	yes	yes
Facility Type Code	yes	yes
Claim Frequency Code	yes	yes
Accident Related Codes & Dates	yes	yes
Auto Accident State	no	yes
ALC Span Dates	yes	yes
LOA Span Dates	yes	yes
Do Not Resuscitate Indicator	yes	yes
Homeless Patient Indicator	yes	yes
Non-US Resident Patient Indicator	yes	yes
Readmission Code	yes	yes
Medicaid Special Program (PHC) Indicator	yes	yes
Medicaid Special Program (SFP) Indicator	yes	yes
Medicaid Special Program (FP) Indicator	yes	yes
Medicaid Special Program (DIS) Indicator	yes	yes
Workers' Compensation Indicator and Amount	yes	yes
No Fault Indicator and Amount	yes	yes
Mcaid Surplus, Catastrophic, Recurring Monthly Amount	yes	yes
Blood Furnished Indicator and Amount	yes	yes
Insurance Information
Source of Payment Code	yes	yes
Payer Identification	yes	yes
Policy Number	yes	yes
Covered Days	yes	yes
Non-Covered Days	yes	yes
Payer Estimated Amount Due	yes	yes
Payer Prior Payment	yes	yes
Service Line Information
UB-92 Accommodation Code	yes	yes
Accommodations Rate	yes	yes
Accommodations Days	yes	yes
Accommodations Total Charges	yes	yes
Accommodations Total Non-Covered Charges	yes	yes
Ancillary Revenue Code	yes	yes
Ancillary Units of Service	yes	yes
Ancillary Total Charges	yes	yes
Ancillary Total Non-Covered Charges	yes	yes
Total Charges	yes	yes
Procedure Code - HCPCS or CPT4	yes	yes
Modifier 1 (HCPC & CPT4)	yes	yes
Modifier 2 (HCPC & CPT4)	yes	yes
Modifier 3 (HCPC & CPT4)	no	yes
Modifier 4 (HCPC & CPT4)	no	yes
Drug Information - Line Level Detail
National Drug Code	no	yes
National Drug Unit Count	no	yes
Prescription or Compound Drug Association Number	no	yes
Physician Information - Line Level Detail
Operating Physician License Number	no	yes
Other Operating Physician License Number	no	yes
Medical Information
Principal Diagnosis Code	yes	yes
Principal Diagnosis Present on Admission Indicator	no	yes
Other Diagnosis Code	yes	yes
Other Diagnosis Present on Admission Indicator	yes	yes
Principal Procedure Code	yes	yes
Principal Procedure Date	yes	yes
Other Procedure Code	yes	yes
Other Procedure Date	yes	yes
Admitting Diagnosis Code	yes	yes
Patient's Reason for Visit	yes	yes
External Cause-of-Injury Code	yes	yes
External Cause-of-Injury Present on Admission Indicator	no	yes
Diagnosis Related Group	no	yes
Physician Information
Attending Provider License Number	yes	yes
Operating Physician License Number	yes	yes
Other Operating Physician License Number	no	yes
Rendering Provider License Number	no	yes
Other Physician License Number	yes	no
Referring Provider License Number	yes	yes