This article documents the mappings between the base Group Medical custom form and the default Group Medical plan data capture form in both images and tables. It provides the PromptText for each mapped custom form field and the GUID for its data capture form counterpart.
Fields highlighted in red in the custom form images have no equivalent on the plan data capture form and cannot be mapped. Limitations and Exceptions fields on the custom form can be mapped to data capture form fields, but they only display conditionally on the data capture form (not by default). These fields display an asterisk (*) in the mapping tables.
Mappings are grouped by plan data capture section below. They display in the order in which they display in the data capture form. Only sections that contain mappings display.
| Number | Policy Data Capture GUID | Custom Form PromptText |
| 1 | GrpMed_GenInfo_AnnDedInd_In | GI-I-AnnDedInd |
| 2 | GrpMed_GenInfo_AnnDedInd_Out | GI-O-AnnDedInd |
| 3 | GrpMed_GenInfo_AnnDedFam_In | GI-I-AnnDedFam |
| 4 | GrpMed_GenInfo_AnnDedFam_Out | GI-O-AnnDedFam |
| 5 | GrpMed_GenInfo_Coinsurance_In | GI-I-Coinsurance |
| 6 | GrpMed_GenInfo_Coinsurance_Out | GI-O-Coinsurance |
| 7 | GrpMed_PhysSvc_PrimOfcVis_In | GI-I-OfcVst/Exam |
| 8 | GrpMed_PhysSvc_PrimOfcVis_Out | GI-O-OfcVst/Exam |
| 9 | GrpMed_PhysSvc_SpclOfcVis_In | GI-I-OPSpecVst |
| 10 | GrpMed_PhysSvc_SpclOfcVis_Out | GI-O-OPSpecVst |
| 11 | GrpMed_PhysSvc_PrevCare_In | GI-I-PrevCare |
| 12 | GrpMed_PhysSvc_PrevCare_Out | GI-O-PrevCare |
| Number | Policy Data Capture GUID | Custom Form PromptText |
| 1 | GrpMed_PhysSvc_PrimOfcVis_In | GI-I-OfcVst/Exam |
| 2 | GrpMed_PhysSvc_PrimOfcVis_Out | GI-O-OfcVst/Exam |
| 3 | GrpMed_PhysSvc_SpclOfcVis_In | GI-I-OPSpecVst |
| 4 | GrpMed_PhysSvc_SpclOfcVis_Out | GI-O-OPSpecVst |
| 5 | GrpMed_PhysSvc_PrevCare_In | GI-I-PrevCare |
| 6 | GrpMed_PhysSvc_PrevCare_Out | GI-O-PrevCare |
| * | GrpMed_PhysSvc_PrimOfcVis_Addl | GI-L&E-OfcVst/Exam |
| * | GrpMed_PhysSvc_SpclOfcVis_Addl | GI-L&E-OPSpecVst |
| * | GrpMed_PhysSvc_PrevCare_Addl | GI-L&E-PrevCare |
| Number | Policy Data Capture GUID | Custom Form PromptText |
| 1 | GrpMed_UrgSvc_UrgentCare_In | UC-I-UrgentCareFac |
| 2 | GrpMed_UrgSvc_UrgentCare_Out | UC-O-UrgentCareFac |
| 3 | GrpMed_UrgSvc_ER_In | ES-I-EmerRoom |
| 4 | GrpMed_UrgSvc_ER_Out | ES-O-EmerRoom |
| 5 | GrpMed_UrgSvc_EmrgyTrans_In | ES-I-EmerMedTrans |
| 6 | GrpMed_UrgSvc_EmrgyTrans_Out | ES-O-EmerMedTrans |
| * | GrpMed_UrgSvc_UrgentCare_Addl | UC-L&E-UrgentCareFac |
| * | GrpMed_UrgSvc_ER_Addl | ES-L&E-EmerRoom |
| * | GrpMed_UrgSvc_EmrgyTrans_Addl | ES-L&E-EmerMedTrans |
| Number | Policy Data Capture GUID | Custom Form PromptText |
| 1 | GrpMed_InSvc_FacilityFee_In | IHS-I-FacilityFee |
| 2 | GrpMed_InSvc_FacilityFee_Out | IHS-O-FacilityFee |
| 3 | GrpMed_InSvc_PhysFees_In | IHS-I-Phys/SurgFee |
| 4 | GrpMed_InSvc_PhysFees_Out | IHS-O-Phys/SurgFee |
| * | GrpMed_InSvc_FacilityFee_Addl | IHS-L&E-FacilityFee |
| * | GrpMed_InSvc_PhysFees_Addl | IHS-L&E-Phys/SurgFee |
| Number | Policy Data Capture GUID | Custom Form PromptText |
| 1 | GrpMed_OutSvc_FacilityFee_In | OHS-I-FacilityCharges |
| 2 | GrpMed_OutSvc_FacilityFee_Out | OHS-O-FacilityCharges |
| 3 | GrpMed_OutSvc_PhysFees_In | OHS-I-Phys/SurgFees |
| 4 | GrpMed_OutSvc_PhysFees_Out | OHS-O-Phys/SurgFees |
| 5 | GrpMed_OutSvc_HTImg_In | OHS-I-ImgCT/PET,MRI |
| 6 | GrpMed_OutSvc_HTImg_Out | OHS-O-ImgCT/PET,MRI |
| * | GrpMed_OutSvc_FacilityFee_Addl | OHS-L&E-FacilityCharges |
| * | GrpMed_OutSvc_PhysFees_Addl | OHS-L&E-Phys/SurgFees |
| * | GrpMed_OutSvc_HTImg_Addl | OHS-L&E-ImgCT/PET,MRI |
| Number | Policy Data Capture GUID | Custom Form PromptText |
| 1 | GrpMed_Rx_Ded-Ind_In | PDB-I-PrscDrgDed |
| 2 | GrpMed_Rx_Ded-Ind_Out | PDB-O-PrscDrgDed |
| 3 | GrpMed_Rx_AnnOOP-Ind_In | PDB-I-AnnOOPLimInd |
| 4 | GrpMed_Rx_AnnOOP-Ind_Out | PDB-O-AnnOOPLimInd |
| 5 | GrpMed_Rx_AnnOOP-Fam_In | PDB-I-AnnOOPLimFam |
| 6 | GrpMed_Rx_AnnOOP-Fam_Out | PDB-O-AnnOOPLimFam |
| 7 | GrpMed_Rx_MailOrder_In | PDB-I-MailOrder |
| 8 | GrpMed_Rx_MailOrder_Out | PDB-O-MailOrder |
| 9 | GrpMed_Rx_NumDaysSupply_In | PDB-I-NumDaysSply |
| 10 | GrpMed_Rx_NumDaysSupply_Out | PDB-O-NumDaysSply |
| Number | Policy Data Capture GUID | Custom Form PromptText |
| 1 | GrpMed_Notes_Notes | Notes1 |
| 2 | GrpMed_Notes_Notes | Notes2 |
| 3 | GrpMed_Notes_Notes | Notes3 |
| 4 | GrpMed_Notes_Notes | Notes4 |
| 5 | GrpMed_Notes_Notes | Notes5 |
| 6 | GrpMed_Notes_Notes | Notes6 |
| 7 | GrpMed_Notes_Notes | Notes7 |
| 8 | GrpMed_Notes_Notes | Notes8 |
| 9 | GrpMed_Notes_Notes | Notes9 |