1 | Medical Care |
2 | Surgical |
3 | Consultation |
4 | Diagnostic X-Ray |
5 | Diagnostic Lab |
6 | Radiation Therapy |
7 | Anesthesia |
8 | Surgical Assistance |
9 | Other Medical |
10 | Blood Charges |
11 | Used Durable Medical Equipment |
12 | Durable Medical Equipment Purchase |
13 | Ambulatory Service Center Facility |
14 | Renal Supplies in the Home |
15 | Alternate Method Dialysis |
16 | Chronic Renal Disease (CRD) Equipment |
17 | Pre-Admission Testing |
18 | Durable Medical Equipment Rental |
19 | Pneumonia Vaccine |
20 | Second Surgical Opinion |
21 | Third Surgical Opinion |
22 | Social Work |
23 | Diagnostic Dental |
24 | Periodontics |
25 | Restorative |
26 | Endodontics |
27 | Maxillofacial Prosthetics |
28 | Adjunctive Dental Services |
30 | Health Benefit Plan Coverage |
31 | Benefit Disclaimer |
32 | Plan Waiting Period |
33 | Chiropractic |
34 | Chiropractic Office Visits |
35 | Dental Care |
36 | Dental Crowns |
37 | Dental Accident |
38 | Orthodontics |
39 | Prosthodontics |
40 | Oral Surgery |
41 | Routine (Preventive) Dental |
42 | Home Health Care |
43 | Home Health Prescriptions |
44 | Home Health Visits |
45 | Hospice |
46 | Respite Care |
47 | Hospital |
48 | Hospital - Inpatient |
49 | Hospital - Room and Board |
50 | Hospital - Outpatient |
51 | Hospital - Emergency Accident |
52 | Hospital - Emergency Medical |
53 | Hospital - Ambulatory Surgical |
54 | Long Term Care |
55 | Major Medical |
56 | Medically Related Transportation |
57 | Air Transportation |
58 | Cabulance |
59 | Licensed Ambulance |
60 | General Benefits |
61 | In-vitro Fertilization |
62 | MRI/CAT Scan |
63 | Donor Procedures |
64 | Acupuncture |
65 | Newborn Care |
66 | Pathology |
67 | Smoking Cessation |
68 | Well Baby Care |
69 | Maternity |
70 | Transplants |
71 | Audiology Exam |
72 | Inhalation Therapy |
73 | Diagnostic Medical |
74 | Private Duty Nursing |
75 | Prosthetic Device |
76 | Dialysis |
77 | Otological Exam |
78 | Chemotherapy |
79 | Allergy Testing |
80 | Immunizations |
81 | Routine Physical |
82 | Family Planning |
83 | Infertility |
84 | Abortion |
85 | AIDS |
86 | Emergency Services |
87 | Cancer |
88 | Pharmacy |
89 | Free Standing Prescription Drug |
90 | Mail Order Prescription Drug |
91 | Brand Name Prescription Drug |
92 | Generic Prescription Drug |
93 | Podiatry |
94 | Podiatry - Office Visits |
95 | Podiatry - Nursing Home Visits |
96 | Professional (Physician) |
97 | Anesthesiologist |
98 | Professional (Physician) Visit - Office |
99 | Professional (Physician) Visit - Inpatient |
A0 | Professional (Physician) Visit - Outpatient |
A1 | Professional (Physician) Visit - Nursing Home |
A2 | Professional (Physician) Visit - Skilled Nursing Facility |
A3 | Professional (Physician) Visit - Home |
A4 | Psychiatric |
A5 | Psychiatric - Room and Board |
A6 | Psychotherapy |
A7 | Psychiatric - Inpatient |
A8 | Psychiatric - Outpatient |
A9 | Rehabilitation |
AA | Rehabilitation - Room and Board |
AB | Rehabilitation - Inpatient |
AC | Rehabilitation - Outpatient |
AD | Occupational Therapy |
AE | Physical Medicine |
AF | Speech Therapy |
AG | Skilled Nursing Care |
AH | Skilled Nursing Care - Room and Board |
AI | Substance Abuse |
AJ | Alcoholism |
AK | Drug Addiction |
AL | Vision (Optometry) |
AM | Frames |
AN | Routine Exam |
AO | Lenses |
AP | Routine Eye Exam |
AQ | Nonmedically Necessary Physical These physicals are required by other entities e.g., insurance application, pilot license, employment or school |
AR | Experimental Drug Therapy |
B | Non-escrow or Non-impound Service |
B1 | Burn Care |
B2 | Brand Name Prescription Drug - Formulary |
B3 | Brand Name Prescription Drug - Non-Formulary |
BA | Independent Medical Evaluation |
BB | Partial Hospitalization (Psychiatric) |
BC | Day Care (Psychiatric) |
BD | Cognitive Therapy |
BE | Massage Therapy |
BF | Pulmonary Rehabilitation |
BG | Cardiac Rehabilitation |
BH | Pediatric |
BI | Nursery |
BJ | Skin |
BK | Orthopedic |
BL | Cardiac |
BM | Lymphatic |
BN | Gastrointestinal |
BP | Endocrine |
BQ | Neurology |
BR | Eye |
BS | Invasive Procedures |
BT | Gynecological |
BU | Obstetrical |
BV | Obstetrical/Gynecological |
BW | Mail Order Prescription Drug: Brand Name |
BX | Mail Order Prescription Drug: Generic |
BY | Physician Visit - Office: Sick |
BZ | Physician Visit - Office: Well |
C | Escrow or Impound Service |
C1 | Coronary Care |
CA | Private Duty Nursing - Inpatient |
CB | Private Duty Nursing - Home |
CC | Surgical Benefits - Professional (Physician) |
CD | Surgical Benefits - Facility |
CE | Mental Health Provider - Inpatient |
CF | Mental Health Provider - Outpatient |
CG | Mental Health Facility - Inpatient |
CH | Mental Health Facility - Outpatient |
CI | Substance Abuse Facility - Inpatient |
CJ | Substance Abuse Facility - Outpatient |
CK | Screening X-ray |
CL | Screening laboratory |
CM | Mammogram, High Risk Patient |
CN | Mammogram, Low Risk Patient |
CO | Flu Vaccination |
CP | Eyewear and Eyewear Accessories |
CQ | Case Management |
DG | Dermatology |
DM | Durable Medical Equipment |
DS | Diabetic Supplies |
GF | Generic Prescription Drug - Formulary |
GN | Generic Prescription Drug - Non-Formulary |
GY | Allergy |
IC | Intensive Care |
MH | Mental Health |
NI | Neonatal Intensive Care |
ON | Oncology |
PT | Physical Therapy |
PU | Pulmonary |
RN | Renal |
RT | Residential Psychiatric Treatment |
TC | Transitional Care |
TN | Transitional Nursery Care |
UC | Urgent Care |