| Element ID | Label | Section | Type | Card. | Nat'l | Rules | States |
|---|---|---|---|---|---|---|---|
| ePayment.01 | Primary Method of Payment | Payment | CodedValue | 1:1 | 11 | 11 / 51 | |
| ePayment.02 | Physician Certification Statement | Payment | CodedValue | 0:1 |
| 1 / 51 |
| ePayment.03 | Date Physician Certification Statement Signed | Payment | DateTime | 0:1 | 0 | 0 / 51 |
| ePayment.04 | Reason for Physician Certification Statement | Payment | CodedValue | 0:M | 0 | 0 / 51 |
| ePayment.05 | Healthcare Provider Type Signing Physician Certification Statement | Payment | CodedValue | 0:1 | 0 | 0 / 51 |
| ePayment.06 | Last Name of Individual Signing Physician Certification Statement | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.07 | First Name of Individual Signing Physician Certification Statement | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.08 | Patient Resides in Service Area | Payment | CodedValue | 0:1 | 0 | 0 / 51 |
| ePayment.09 | Insurance Company ID | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.10 | Insurance Company Name | Payment | String | 0:1 | 1 | 1 / 51 |
| ePayment.11 | Insurance Company Billing Priority | Payment | CodedValue | 0:1 | 0 | 0 / 51 |
| ePayment.12 | Insurance Company Address | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.13 | Insurance Company City | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.14 | Insurance Company State | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.15 | Insurance Company ZIP Code | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.16 | Insurance Company Country | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.17 | Insurance Group ID | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.18 | Insurance Policy ID Number | Payment | Integer | 0:1 | 0 | 0 / 51 |
| ePayment.19 | Last Name of the Insured | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.20 | First Name of the Insured | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.21 | Middle Initial/Name of the Insured | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.22 | Relationship to the Insured | Payment | CodedValue | 0:1 | 0 | 0 / 51 |
| ePayment.23 | Closest Relative/Guardian Last Name | Payment | String | 0:1 | 1 | 1 / 51 |
| ePayment.24 | Closest Relative/ Guardian First Name | Payment | String | 0:1 | 1 | 1 / 51 |
| ePayment.25 | Closest Relative/ Guardian Middle Initial/Name | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.26 | Closest Relative/ Guardian Street Address | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.27 | Closest Relative/ Guardian City | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.28 | Closest Relative/ Guardian State | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.29 | Closest Relative/ Guardian ZIP Code | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.30 | Closest Relative/ Guardian Country | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.31 | Closest Relative/ Guardian Phone Number | Payment | String | 0:M | 0 | 0 / 51 |
| ePayment.32 | Closest Relative/ Guardian Relationship | Payment | CodedValue | 0:1 | 1 | 1 / 51 |
| ePayment.33 | Patient's Employer | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.34 | Patient's Employer's Address | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.35 | Patient's Employer's City | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.36 | Patient's Employer's State | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.37 | Patient's Employer's ZIP Code | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.38 | Patient's Employer's Country | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.39 | Patient's Employer's Primary Phone Number | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.40 | Response Urgency | Payment | CodedValue | 0:1 | 2 | 2 / 51 |
| ePayment.41 | Patient Transport Assessment | Payment | CodedValue | 0:M | 0 | 0 / 51 |
| ePayment.42 | Specialty Care Transport Care Provider | Payment | CodedValue | 0:M | 1 | 1 / 51 |
| ePayment.44 | Ambulance Transport Reason Code | Payment | CodedValue | 0:M | 0 | 0 / 51 |
| ePayment.45 | Round Trip Purpose Description | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.46 | Stretcher Purpose Description | Payment | String | 0:1 | 1 | 1 / 51 |
| ePayment.47 | Ambulance Conditions Indicator | Payment | CodedValue | 0:M | 0 | 0 / 51 |
| ePayment.48 | Mileage to Closest Hospital Facility | Payment | Decimal | 0:1 | 0 | 0 / 51 |
| ePayment.49 | ALS Assessment Performed and Warranted | Payment | CodedValue | 0:1 | 0 | 0 / 51 |
| ePayment.50 | CMS Service Level | Payment | CodedValue | 1:1 | 11 | 11 / 51 |
| ePayment.51 | EMS Condition Code | Payment | String | 0:M | 0 | 0 / 51 |
| ePayment.52 | CMS Transportation Indicator | Payment | CodedValue | 0:M | 0 | 0 / 51 |
| ePayment.53 | Transport Authorization Code | Payment | CodedValue | 0:1 | 0 | 0 / 51 |
| ePayment.54 | Prior Authorization Code Payer | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.55 | Supply Item Used Name | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.56 | Number of Supply Item(s) Used | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.57 | Payer Type | Payment | CodedValue | 0:1 | 0 | 0 / 51 |
| ePayment.58 | Insurance Group Name | Payment | String | 0:1 | 0 | 0 / 51 |
| ePayment.59 | Insurance Company Phone Number | Payment | String | 0:M | 0 | 0 / 51 |
| ePayment.60 | Date of Birth of the Insured | Payment | DateTime | 0:1 | 0 | 0 / 51 |