SourceSystem|Jurisdiction|Payer|Plan|Program|DeliverySystem|ProviderName|ProviderMedicaidId|ProviderNpi|ProviderNPITaxonomy|ProviderNPIZipCode|ProviderEin|CaregiverFirstName|CaregiverLastName|CaregiverLicenseNumber|RecipientMedicaidId|RecipientMemberId|RecipientFirstName|RecipientLastName|RecipientDob|ServiceAddress1|ServiceAddress2|ServiceCity|ServiceState|ServiceZip|VisitId|ServiceCode|ServiceCodeMod1|ServiceCodeMod2|DiagnosisCode1|DiagnosisCode2|DiagnosisCode3|DiagnosisCode4|StartVerificationType|EndVerificationType|ScheduledStartDateTime|ScheduledEndDateTime|ScheduledLatitude|ScheduledLongitude|ActualStartDateTime|ActualEndDateTime|ActualStartLatitude|ActualStartLongitude|ActualEndLatitude|ActualEndLongitude|UserField1|UserField2|UserField3|ReasonCode1|ReasonCode2|ReasonCode3|ReasonCode4|TimeZone|VisitNote|EndAddress1|EndAddress2|EndCity|EndState|EndZip|VisitStatus|MissedVisitReason|MissedVisitActionTaken|InvoiceUnits|InvoiceAmount|ScheduledEndLatitude|ScheduledEndLongitude|PaidAmount|CareDirectionType|Tasks|CaregiverType|StartAddressType|EndAddressType|ReferringPhysicianFirstName|ReferringPhysicianLastName|ReferringPhysicianNpi|ProviderAddress|ProviderAddress2|ProviderCity|ProviderState|ProviderZip|RecipientGender|AuthorizationID|ICNPayerClaimNumber|TPLPaid|ProviderInvoiceNumber|ServiceCodeMod3|ServiceCodeMod4
AETN|FL|AETN|FMSP|PACE|FFFS|Friendly Home Care||1234567890|251E00000X|33436|123456789|john|smith||1234567890|123456789|Jane|Doe|01/01/1950|123 Main St||Deerfield Beach|FL|32779|123456789|T1019|||G30.9||||GPS|GPS|11/22/2019 17:00:00|11/22/2019 19:00:00|28.122456|-81.121234|11/22/2019 17:00:00|11/22/2019 19:00:00|28.000000|-81.000000|28.000000|-81.000000||||||||NEWY||123 Main St||Deerfield|FL|32779|COMP|||8.00|36.00|28.000000|-81.000000|||||||||||||||||||||