List of Data Elements for FISS Extract

Provider # 

Health Insurance Claim (HIC) Number 

Document Control Number (DCN) 

Type of Bill 

Original Paid Date 

Statement From Date 

Statement To Date 

Original Reimbursement Amount (claims page 10) 

Revised Reimbursement Amount (claim page 10) 

Difference between these amounts 

Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1) 

Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1) 

Difference between these amounts 

Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2) 

Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2) 

Difference between these amounts 

Original Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08) Revised Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08) Difference between these amounts 

Original Medicare Coinsurance Amount in the first calendar year period (Value Code 09) 

Revised Medicare Coinsurance Amount in the first calendar year period (Value Code 09) 

Difference between these amounts 

Original Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10) Revised Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10) Difference between these amounts 

Original Medicare Coinsurance Amount in the second calendar year period (Value code 11) 

Revised Medicare Coinsurance Amount in the second calendar year period (Value code 11) Difference between these amounts

Original Outlier Amount (Value Code 17) 

Revised Outlier Amount (Value Code 17)

Difference between these amounts Original DSH Amount (Value Code 18) 

Revised DSH Amount (Value Code 18) 

Difference between these amounts Original IME Amount (Value Code 19) 

Revised IME Amount (Value Code 19) 

Difference between these amounts Original New Tech Add-on (Value Code 77)

Revised New Tech Add-on (Value Code 77) 

Difference between these amounts 

Original Device Reductions (Value Code D4) 

Revised Device Reductions (Value Code D4) 

Difference between these amounts TOT CHRG – total billed charges (claim page 3) 

COV CHRG – total covered charges (claim page 3) 

Original Hospital Portion (claim page 14)

 Revised Hospital Portion (claim page 14) 

Difference between these amounts 

Original Federal Portion (claim page 14) 

Revised Federal Portion (claim page 14) 

Difference between these amounts

 Original C TOT PAY (claim page 14) Revised C TOT PAY (claim page 14) 

Difference between these amounts Original C FSP (claim page 14) 

Revised C FSP (claim page 14) Difference between these amounts 

Original C OUTLIER (claim page 14) 

Revised C OUTLIER (claim page 14)

 Difference between these amounts Original C DSH ADJ (claim page 14) 

Revised C DSH ADJ (claim page 14) 

Difference between these amounts Original C IME ADJ (claim page 14) 

Revised C IME ADJ (claim page 14) 

Difference between these amounts Original Pricer Amount Revised Pricer Amount 

Difference between these amounts Original PPS Payment (claim page 14) 

Revised PPS Payment (claim page 14) 

Difference between these amounts

Original PPS Return Code (claim page 14) 

Revised PPS Return Code (claim page 14)

 Original UNCOMP CARE AMT (claim page 40) 

Revised UNCOMP CARE AMT (claim page 40) 

Difference between these amounts Original VAL PURC ADJ AMT (claim page 40) 

Revised VAL PURC ADJ AMT (claim page 40) 

Difference between these amounts Original READMIS ADJ AMT (claim page 40) 

Revised READMIS ADJ AMT (claim page 40) 

Difference between these amounts Original HAC PAYMENT AMT (claim page 40) 

Revised HAC PAYMENT AMT (claim page 40) 

Difference between these amounts Original EHR PAY ADJ AMT (claim page 40) 

Revised EHR PAY ADJ AMT (claim page 40) 

Difference between these amounts Original PPS-ISLET-ADD-ON-AMT (Value Code Q7) 

Revised PPS-ISLET-ADD-ON-AMT (Value Code Q7) 

Difference between these amounts DRG 

MSP Indicator (Value Codes 12-16 & 41-43 – indicator indicating the claim is MSP; ‘Y’ = MSP, ‘blank’ = no MSP Reason Code 

HMO-IME Indicator 

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