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|TransactionControlNumber|ClaimType|InvoiceStartDateTime|InvoiceEndDateTime|CaregiverEvvId|CaregiverDob|CaregiverSsn|RecipientSsn|TransactionId|CaregiverEmail|SOCPaid|TPLPaidDate|TPLPayerType|TPLPayerName|TPLPayerID|TPLPayerAddress1|TPLPayerAddress2|TPLPayerCity|TPLPayerState|TPLPayerZip|TPLDeduct|TPLDeductDate|TPLDeniedAmount|TPLDeniedDate
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|TT|GY|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|17.53|PROV|AMBU,DRSL,IBOW|RELR|CAN|CAN|James|Smith|1234567890|123 FAU Blvd||Boca Raton|FL|33431|F|||8.00|102000-202A|TT|GY|||01/02/2018 07:54:00|01/02/2018 08:54:00|FL1234567890|01/29/1995|000112222|000112222|3675829b-ffb1-4f03-9ab5-a94982e0df1b|john.smith@johnhomecare.com|35.00|02/15/2020|Primary|United|234242545|22702 SW 125th Ave||Miami|FL|331780000|50.00|03/15/2020|50.00|04/12/2020