BPM007093_IMPAXX_Attachment - Proprietary File Specifications.pdf

IMPAXX Proprietary Confidential

Field No. Field Name Data Type Max Length

Starting Position

Ending Position

Optional/Mandatory Description

1 Sequence Id Numeric 8 1 8 Mandatory Unique sequence number.

Will be used to associate errors to a specific record within the file.

2 Claim Control Number (ICN) Alphanumeric 50 9 58 Mandatory Company specific key that will uniquely identify the Injured Party. System will identify claim as New or Old with the combination of Account Id, RREID, and Claim Control Number.

3 Action Type Alphabetic 6 59 64 Mandatory Action to be performed. Valid values:

SUBMIT

ONHOLD

DELETE

4 MBI Alphanumeric 12 65 76 Optional Medicare Beneficiary Identifier (MBI)/Medicare Health Insurance Claim Number (HICN).

Leave it blank, if unknown and SSN provided.

5 Injured Party SSN Numeric 9 77 85 Mandatory Social Security Number.

May contain only numbers. Leave it blank, if unknown and HICN provided. No dashes, hyphens, or special characters allowed. Required if HICN not provided.

Following make SSN Invalid:

First 3 digits greater than or equal to 90 First 3 digits equal to 000 First 3 digits equal to 666 6th to 9th position of SSN contain 0000, 4th and 5th position contain 00

6 Injured Party Last Name Alphabetic 40 86 125 Mandatory Surname of Injured Party.

Name should be submitted as it appears on the individual’s Social Security or Medicare Insurance card. First position must be an alphabetic character. Other positions may contain a letter, hyphen, apostrophe or space.

7 Injured Party First Name Alphabetic 30 126 155 Mandatory Given or first name of Injured Party.

Name should be submitted as it appears on the individual’s Social Security or Medicare Insurance card. May only contain letters.

8 Injured Party Middle Initial Alphabetic 1 156 156 Optional First letter of Injured Party middle name. Name should be submitted as it appears on the individual’s Social Security or Medicare Insurance card. Leave blank, if unknown.

9 Injured Party Gender Numeric 1 157 157 Mandatory Code to reflect the gender of the Injured Party.

Valid values:

0 = Unknown 1 = Male 2 = Female

10 Injured Party DOB Numeric (Date) 8 158 165 Mandatory Date of Birth of Injured Party.

Must be numeric and contain a valid date prior to the current date.

Format: CCYYMMDD

11 Injured Party DOD Numeric (Date) 8 166 173 Optional Date of Death of Injured Party.

Must be numeric and contain a valid date prior to the current date.

Format: CCYYMMDD

12 Injured Party Address1 AlphaNumeric 50 174 223 Optional Injured Party Address1.

Leave it blank, if unknown.

13 Injured Party Address2 AlphaNumeric 50 224 273 Optional Injured Party Address2.

14 Injured Party City AlphaNumeric 30 274 303 Optional Injured Party City.

15 Injured Party State Alphabetic 2 304 305 Optional Injured Party State.

16 Injured Party Zip Code Numeric 5 306 310 Optional Injured Party Zip code.

17 Injured Party Zip+4 AlphaNumeric 4 311 314 Optional Injured Party Zip Extension.

18 Injured Party Phone AlphaNumeric 10 315 324 Optional Injured Party Phone Number.

19 Injured Party Phone Extension AlphaNumeric 5 325 329 Optional Injured Party Phone Extension.

20 CMS Date of Incident (DOI):

DOI as defined by CMS

Numeric (Date) 8 330 337 Mandatory Date of Incident (DOI) as defined by CMS:

For an automobile wreck or other accident, the date of incident is the date of the accident.

For claims involving exposure (including, for example, occupational disease and any associated cumulative injury) the DOI is the date of first exposure.

For claims involving ingestion (for example, a recalled drug), it is the date of first ingestion. For claims involving implants, it is the date of the implant (or date of the first implant if there are multiple implants).

For claims involving cumulative injury, the DOI is the earlier of the date that treatment for any manifestation of the cumulative injury began, when such treatment preceded formal diagnosis; or the first date that formal diagnosis was made by any medical practitioner.

NOTE: CMS’ definition of DOI generally differs from the definition routinely used by the insurance/workers’ compensation industry only for claims involving exposure, ingestion, or implants.

Must be numeric and a valid date prior to or equal to the current COBC processing date.

Format: CCYYMMDD

21 Industry Date of Incident Numeric (Date) 8 338 345 Optional Date of Incident (DOI) used by the insurance/workers’ compensation industry:

For an automobile wreck or other accident, the date of incident is the date of the accident. For claims involving exposure, ingestion, or implantation, the date of incident is the date of last exposure, ingestion, or implantation.

NOTE: The definition of DOI routinely used by the insurance/workers’ compensation industry DOI generally differs from the definition which CMS must use only for claims involving exposure, ingestion, or implants. Field should contain a valid date prior to or equal to the current COBC processing date. Leave blank, if unknown.

Format: CCYYMMDD

22 Alleged Cause of Injury, Incident, or Illness

Alphanumeric 7 346 352 Optional External Cause of Injury Code describing the alleged cause of injury/illness.

See the NGHP User Guide for complete information. In this field only, an ICD-9 code must begin with the letter “E,” and an ICD-10 code must begin with “V”, “W”, “X”, or “Y”. Codes in this field must NOT be on the list of Excluded ICD9/ICD-10 Diagnosis Codes found in Appendix I. Leave blank if unknown.

23 State of Venue Alphabetic 2 353 354 Mandatory US postal abbreviation corresponding to the US State (including Guam, Puerto Rico, Washington DC and the US Virgin Islands) whose state law controls resolution of the claim.

If the applicable law that controls the resolution of the claim is federal law (such as the Federal Tort Claim Act or the Federal Employee Compensation Act), then submit ‘US’. Otherwise if the applicable law is state law, supply the code for that state. Insert ‘FC’ in the case where the state of venue is outside the United States.

If the state of venue is in dispute at the time an RRE reports acceptance of ongoing responsibility for medicals, the RRE should use its best judgment regarding the state of venue and submit updated information, if applicable, when the ongoing responsibility is terminated or further reporting is required because of a settlement, judgment, award or payment other than payment made under the ongoing responsibility for medicals.

24 ICD Indicator Alphanumeric 1 355 355 Mandatory Code to reflect the type of ICD diagnosis codes submitted on the record.

9 or blank = ICD9

0 = ICD10

If ICD indicator is ICD9, all ICD code 1 thru 19 must be ICD 9 codes. If ICD indicator is ICD10, all ICD code 1 thru 19 must be ICD 10 codes.

25 ICD Diagnosis Code 1 Alphanumeric 7 356 362 Mandatory

CM (International Classification of Diseases, Ninth Revision, Clinical Modification) Diagnosis Code describing the alleged injury/illness.

Required for add and update records (Action Type = 0 or 2).

Do not include decimal point. Must exactly match a code on the list of valid diagnosis codes posted under the Reference Materials menu option on the Section 111 COBSW at http://www.section111.cms.hhs.gov. See Section 11.2.5 for complete information. No “E Codes” or “V Codes” permitted (Cannot begin with the letter ‘E’ and cannot begin with the letter ‘V’).

Must NOT be on the list of Excluded Diagnosis Codes found in Appendix I.

Special default for D22 reporting: If, and only if:

1) The ORM Indicator is N, the Plan Insurance Type is L.

2) Claim for loss of consortium, an errors and omissions liability insurance claim, a directors and officers liability insurance claim, or a claim resulting from a wrongful action related to employment status action was/is alleged.

3) There is no allegation of a situation involving medical care or a physical or mental injury.

4) The settlement, judgment, award or other payment releases or has the effect of releasing medicals; then a value of ‘NOINJ’ may be submitted. If ‘NOINJ’ is submitted in Field 27 then ‘NOINJ’ must be submitted in Field 24. If ‘NOINJ’ is submitted in Field 27 then all remaining Diagnosis Code 2-19 must be filled with spaces.

26 ICD Diagnosis Code 2 Alphanumeric 7 363 369 Optional Required when multiple body parts are affected.

27 ICD Diagnosis Code 3 Alphanumeric 7 370 376 Optional Required when multiple body parts are affected.

28 ICD Diagnosis Code 4 Alphanumeric 7 377 383 Optional Required when multiple body parts are affected.

29 ICD Diagnosis Code 5 Alphanumeric 7 384 390 Optional Required when multiple body parts are affected.

30 ICD Diagnosis Code 6 Alphanumeric 7 391 397 Optional Required when multiple body parts are affected.

31 ICD Diagnosis Code 7 Alphanumeric 7 398 404 Optional Required when multiple body parts are affected.

32 ICD Diagnosis Code 8 Alphanumeric 7 405 411 Optional Required when multiple body parts are affected.

33 ICD Diagnosis Code 9 Alphanumeric 7 412 418 Optional Required when multiple body parts are affected.

34 ICD Diagnosis Code 10 Alphanumeric 7 419 425 Optional Required when multiple body parts are affected.

35 ICD Diagnosis Code 11 Alphanumeric 7 426 432 Optional Required when multiple body parts are affected.

36 ICD Diagnosis Code 12 Alphanumeric 7 433 439 Optional Required when multiple body parts are affected.

37 ICD Diagnosis Code 13 Alphanumeric 7 440 446 Optional Required when multiple body parts are affected.

38 ICD Diagnosis Code 14 Alphanumeric 7 447 453 Optional Required when multiple body parts are affected.

39 ICD Diagnosis Code 15 Alphanumeric 7 454 460 Optional Required when multiple body parts are affected.

40 ICD Diagnosis Code 16 Alphanumeric 7 461 467 Optional Required when multiple body parts are affected.

41 ICD Diagnosis Code 17 Alphanumeric 7 468 474 Optional Required when multiple body parts are affected.

42 ICD Diagnosis Code 18 Alphanumeric 7 475 481 Optional Required when multiple body parts are affected.

43 ICD Diagnosis Code 19 Alphanumeric 7 482 488 Optional Required when multiple body parts are affected.

44 Product Liability Indicator AlphaNumeric 1 489 489 Optional Leave blank.

45 Product Generic Name AlphaNumeric 40 490 529 Optional Leave blank.

46 Product Brand Name AlphaNumeric 40 530 569 Optional Leave blank.

47 Product Manufacturer AlphaNumeric 40 570 609 Optional Leave blank.

48 Product Alleged Harm AlphaNumeric 200 610 809 Optional Leave blank.

49 Self-Insured Indicator Alphabetic 1 810 810 Mandatory Indication of whether the reportable event involves self-insurance as defined by CMS.

Valid values:

Y = Yes N = No Required. If Plan Insurance Type is E or L, this field must equal Y or N. If Plan Insurance Type is D, this field must equal N or blank.

50 Self-Insured Type Alphabetic 1 811 811 Mandatory Identifies whether the self-insured is an organization or individual.

Valid values:

I = Individual O = Other than Individual (e.g. business, corporation, organization, company, etc.)

Blank = Not applicable (Self-Insured Indicator Field is N or space Required and must contain a value of I or O if the Self- Insured Indicator is Y. If the Self-Insured Indicator is N or blank, the Self-Insured type must be kept blank.

51 Policyholder Last Name Alphabetic 40 812 851 Required if Self-Insured Type=I

Surname of policyholder or self-insured individual.

Embedded hyphens (dashes), apostrophes and spaces accepted. If Self-Insured Type = I, first position must be an alphabetic character and other positions may contain a letter, hyphen, apostrophe or space. If Self-Insured Type is not equal to I, must be blank.

52 Policyholder First Name Alphabetic 30 852 881 Required if Self-Insured Type=I

Given/First name of policyholder or self-insured individual.

May only contain letters. If Self-Insured Type = I, must contain only letters. If Self-Insured Type is not equal to I, must be blank.

53 DBA Name AlphaNumeric 70 882 951 Required if Self-Insured Type=O

"Doing Business As” Name of Self-Insured organization/business.

Required if Self-Insured Type = O and Legal Name not provided. If supplied, must be at least 2 characters long. If Self- Insured Type = I, must be blank.

54 Legal Name AlphaNumeric 70 952 1021 Required if Self-Insured Type=O

Legal Name of Self-Insured organization/business.

Required if Self-Insured Type = O and DBA Name not provided. If supplied, must be at least 2 characters long. If Self-Insured Type = I, must be blank.

55 Plan Insurance Type Alphabetic 1 1022 1022 Mandatory Type of insurance coverage or line of business provided by the plan policy or self-insurance.

Valid values:

D = No-Fault E = Workers’ Compensation L = Liability

56 TIN Numeric 9 1023 1031 Mandatory Federal Tax Identification Number of the “applicable plan” used by the RRE, whether liability insurance (including self-insurance), no-fault insurance or a workers’ compensation law or plan.

Must contain a valid 9-digit IRS- assigned Federal Tax Identification Number or foreign RRE pseudo-TIN. Must be numeric.

Include leading zeroes. Do not include hyphens. In the case of a foreign RRE without a valid IRS-assigned TIN, supply the pseudo-TIN created during Section 111 registration. Must have a corresponding entry with associated Office Code/Site ID on the TIN Reference File.

57 Office Code/Site ID AlphaNumeric 9 1032 1040 Optional RRE-defined 9-digit number to uniquely identify variations in insurer addresses/claim offices/Plan Contact Addresses under the same TIN. Defined by RRE. Used to uniquely specify different addresses associated with one TIN.

If only one address will be used per reported TIN, leave blank. Must have a corresponding entry with associated TIN on the TIN Reference File. A record must be submitted on the TIN Reference File for each unique TIN/Office Code combination. If not used, leave blank. If used, must be a non-zero 9-digit number. No letters or special Characters are accepted.

58 Policy Number AlphaNumeric Plus Parens

30 1041 1070 Mandatory The unique identifier for the policy under which the underlying claim was filed.

RRE defined. If liability self-insurance or workers’ compensation self- insurance, leave it blank if you do not have or maintain a specific number reference. Must be at least 3 characters in length.

59 Claim Number AlphaNumeric Plus Parens

30 1071 1100 Mandatory The unique claim identifier by which the primary plan identifies the claim.

If liability self-insurance or workers’ compensation self-insurance, leave it blank, if you do not have or maintain a claim number reference. May not be equal to all spaces.

60 Plan Contact Department Name

AlphaNumeric Plus Parens

70 1101 1170 Optional Name of department for the Plan Contact to which claim-related communication and correspondence should be sent.

Note that this name is used for informal communications and not used for recovery demand notifications.

61 Plan Contact Last Name Alphabetic 40 1171 1210 Optional Surname of individual that should be contacted at the Plan for claim-related communication and correspondence.

Note that this name is used for informal communications and not used for recovery demand notifications. If not left blank, first position must be an alphabetic character. Other positions may contain a letter, hyphen, apostrophe, or space.

62 Plan Contact First Name Alphabetic 30 1211 1240 Optional Given or first name of individual that should be contacted at the Plan for claim-related communication and correspondence.

Note that this name is used for informal communications and not used for recovery demand notifications. May only contain letters. If not left blank, first position must be an alphabetic character. Other positions must contain letters or spaces.

63 Plan Contact Phone Numeric 10 1241 1250 Optional Telephone number of individual that should be contacted at the Plan for claim-related communication.

Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation. Must contain 10-digit numeric value.

64 Plan Contact Phone Extension AlphaNumeric 5 1251 1255 Optional Telephone extension number of individual that should be contacted at the Plan for claim-related communication.

65 No-Fault Insurance Limit Numeric 11 1256 1266 Required if Plan Insurance Type=D (No- Fault Insurance)

Dollar amount of limit on no-fault insurance.

Specify dollars and cents. Required if Plan Insurance Type is D (No-Fault Insurance). If Plan Insurance Type is D and there is no such dollar limit, leave blank, otherwise specify Amount If Plan Insurance Type is E (Workers’ Compensation) or L (Liability Insurance), must be blank.

66 Exhaust Date for Dollar Limit for No-Fault Insurance

Numeric (Date) 8 1267 1274 If Plan Insurance Type is D (No- Fault Insurance) and the limit has not yet been reached, leave blank. Otherwise, specify the date the limit was reached and the same date in the ORM Termination Date. If Plan Insurance Type is E (Workers’

Date on which limit was reached or benefits exhausted for No-Fault Insurance Limit.

Field may not be blank (all spaces). Must contain a valid date or all zeroes as specified below. When a valid date is supplied, the same date should be supplied in the ORM Termination Date. If Plan Insurance Type is D (No-Fault Insurance) and the limit has not yet been reached, fill with all zeroes. Otherwise, specify the date the limit was reached and the same date in the ORM Termination Date. If Plan Insurance Type is E (Workers’ Compensation) or L (Liability Insurance), leave blank.

Format: CCYYMMDD

67 Injured Party Representative Indicator

Alphabetic 1 1275 1275 Required if Injured Party has a Representative.

Code indicating the type of Attorney/Other Representative information provided.

Valid values:

A = Attorney G = Guardian/Conservator P = Power of Attorney O = Other If the injured party has more than one representative, provide the injured party’s attorney information if available.

68 Representative Last Name Alphabetic 40 1276 1315 Required if Injured Party has a Representative.

Surname of representative. Embedded hyphens, apostrophes are accepted.

Either Representative Last Name and First Name OR Representative Firm Name is required if Injured Party has a representative. Must be blank if Injured Party Representative Indicator is blank.

69 Representative First Name Alphabetic 30 1316 1345 Required if Injured Party has a Representative.

Given or first name of representative. May only contain letters.

Either Representative Last Name and First Name OR Representative Firm Name is required if Injured Party has a representative. Must be blank if Injured Party Representative Indicator is blank.

70 Representative Firm Name AlphaNumeric 70 1346 1415 Required if Injured Party has a Representative.

Representative’s Firm Name.

Either Representative Last Name and First Name OR Representative Firm Name is required if Injured Party has a representative. Must be blank if Injured Party Representative Indicator is blank.

71 Representative TIN AlphaNumeric 9 1416 1424 Optional Representative’s Federal Tax Identification Number (TIN).

If representative is part of a firm, supply the firm’s Employer Identification Number (EIN), otherwise supply the representative’s Social Security Number (SSN). May contain only numbers. If no Representative TIN is available, Leave blank. Must be blank if Injured Party Representative Indicator is blank.

72 Representative Mailing Address1

Alphanumeric 50 1425 1474 Required if Injured Party has a Representative.

First line of the mailing address for the representative named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Must be blank if Injured Party Representative Indicator is blank.

73 Representative Mailing Address2

Alphanumeric 50 1475 1524 If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party has a representative. Must be blank if Injured Party

Second line of the mailing address of the representative named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Must be blank if Injured Party Representative Indicatoris blank.

74 Representative City AlphaNumeric 30 1525 1554 If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party has a representative. Must be blank if Injured Party

Mailing address city for the representative named above.

Field may contain only alphabetic, Space, Comma, & - ' . @ # / ; : characters. No numeric characters allowed. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Must be blank if Injured Party Representative Indicator is blank.

75 Representative State Alphabetic 2 1555 1556 Required if Injured Party has a Representative.

If no US address is available, supply ‘FC’. Guam, Puerto Rico, and the US Virgin Islands are considered to have US addresses. Must be blank if Injured Party Representative Indicator is blank.

76 Representative Mail Zip Code AlphaNumeric 5 1557 1561 Required if Injured Party has a Representative.

5-digit Zip Code for the representative named above.

If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Must be blank if Injured Party Representative Indicator is blank.

77 Representative Mail Zip+4 AlphaNumeric 4 1562 1565 Optional 4-digit Zip+4 Code for the representative named above.

If not applicable or unknown, leave blank. Must be blank if Injured Party Representative Indicator is blank.

78 Representative Phone AlphaNumeric 10 1566 1575 Required if Injured Party has a Representative.

Telephone number of the representative named above.

Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation. If no US phone number is available, leave blank and supply ‘FC’ in the corresponding State Code. Must be blank if Injured Party Representative Indicator is blank.

79 Representative Phone Extension

AlphaNumeric 5 1576 1580 Optional Telephone extension number of Representative named above.

Leave blank if unknown or not applicable. Must be blank if Injured Party Representative Indicator is blank.

80 ORM Indicator Alphabetic 1 1581 1581 Mandatory Indication of whether there is on-going responsibility for medicals (ORM).

Valid values:

Y = Yes N = No The Y value remains in this field even when an ORM Termination Date is submitted in this same record or a subsequent record.

81 ORM Termination Date Numeric (Date) 8 1582 1589 When an ORM termination date is submitted, the ORM indicator must remain as Y.

Leave blank if ORM Indicator is N, or if a date

Date ongoing responsibility for medicals ended, where applicable.

Only applies to records previously submitted (or submitted in this record where ongoing responsibility for medicals and termination of such responsibility are reported in this same submission) with ORM Indicator of Y. Future dates are accepted but not more than 6 months greater than the file submission date. When an ORM termination date is submitted, the ORM indicator must remain as Y.

Format: CCYYMMDD

82 TPOC Date 1 Numeric (Date) 8 1590 1597 Should not be blank if TPOC Amount 1 is present. Must be greater than the CMS Date of Incident and less or equal to the current COB processing date. No future dates allowed.

Leave blank if TPOC Amount 1 is not supplied.

Date of associated Total Payment Obligation to the Claimant (TPOC) without regard to ongoing responsibility for medicals

(ORM).

Not required for the initial report of a claim reflecting ongoing responsibility for medicals. If there is a TPOC amount/date reportable at the same time ORM termination is being reported, report the TPOC fields on the second (final) report for the ongoing responsibility for medicals. Leave blank if there is no TPOC to report. Required for all other claim reports. Should not be blank if TPOC Amount 1 is present. Must be greater than the CMS Date of Incident and less or equal to the current COB processing date. No future dates allowed. Leave blank if TPOC Amount 1 is all not supplied. Use the additional TPOC fields to report additional separate TPOCs as required.

Format: CCYYMMDD

83 TPOC Amount 1 Numeric 11 1598 1608 Required if applicable Total Payment Obligation to the Claimant (TPOC) amount: Dollar amount of the total payment obligation to the claimant. If there is a structured settlement, the amount is the total payout amount.

Not required for the initial report of a claim reflecting ongoing responsibility for medicals. If there is a TPOC amount/date reportable at the same time ORM termination is being reported, report the TPOC fields on the second (final) report for the ongoing responsibility for medicals. Keep it blank if there is no TPOC to report. Required for all other claim reports. Must be non-zero if a non-zero value is submitted in TPOC Date 1. Leave blank if TPOC Date 1 is not supplied. Use the TPOC fields to report additional, separate TPOCs as required. No formatting ( no $ , . ).

For example, a TPOC amount of $20,500.55 should be formatted: 2050055

84 Funding Delayed Beyond TPOC Start Date 1

Numeric (Date) 8 1609 1616 Required if applicable If funding for the TPOC Amount 1 is delayed, provide actual or estimated date of funding.

Leave blank if not applicable.

Format: CCYYMMDD

85 Claimant 1 Relationship Alphabetic 1 1617 1617 Optional Relationship of the claimant to the injured party/Medicare beneficiary.

This field also indicates whether the claimant’s name refers to an individual or an entity/organization.

Valid values:

E = Estate, Individual Name Provided F = Family Member, Individual Name Provided O = Other, Individual Name Provided X = Estate, Entity Name Provided Y = Family, Entity Name Provided Z = Other, Entity Name Provided Space or Blank = Not applicable Required if injured party is deceased and claimant is not the injured party.

86 Claimant 1 TIN AlphaNumeric 9 1618 1626 Optional Federal Tax Identification Number (TIN), Employer Identification Number (EIN) or Social Security Number (SSN) of Claimant 1.

May contain only numbers. Must not match other claimant(s). Required if Injured Party is deceased and claimant is not the injured party. If Claimant 1 Relationship is equal to a space or blank, leave blank.

87 Claimant 1 Last Name Alphabetic 40 1627 1666 Optional Surname of Claimant 1. Embedded hyphens, apostrophes and spaces accepted.

Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 1 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 1 Relationship is equal to a space or blank, leave blank.

88 Claimant 1 First Name Alphabetic 30 1667 1696 Optional Given/First name of Claimant 1.

May only contain letters and spaces. Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 1 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 1 Relationship is equal to a space or blank, leave blank.

89 Claimant 1 Middle Initial Alphabetic 1 1697 1697 Optional First letter of Claimant 1’s Middle Name.

Use only if Claimant 1 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 1 Relationship is equal to a space or blank, leave blank.

90 Claimant 1 Entity/Organization Name

AlphaNumeric 71 1698 1768 Optional Name of Claimant 1 Entity/Organization.

Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 1 Relationship is ‘X’, ‘Y’ or ‘Z’. If Claimant 1 Relationship is equal to a space or blank, leave blank.

91 Claimant 1 Mailing Address1 AlphaNumeric 50 1769 1818 Optional First line of the mailing address for the claimant named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party is deceased and claimant is not the Injured Party. If Claimant 1 Relationship is equal to a space or blank, leave blank.

92 Claimant 1 Mailing Address2 AlphaNumeric 50 1819 1868 Optional Second line of the mailing address of the claimant named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. If Claimant 1 Relationship is equal to a space or blank, leave blank.

93 Claimant 1 City AlphaNumeric 30 1869 1898 Optional Mailing address city for the claimant named above.

Field may contain only alphabetic, space, comma, & - ' . @ # / ; : characters. No numeric characters allowed. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code.

Required if Injured Party is deceased and claimant is not the Injured Party. If Claimant 1 Relationship is equal to a space or blank, leave blank.

94 Claimant 1 State Alphabetic 2 1899 1900 Optional US Postal abbreviation State Code for the claimant named above.

See http://www.usps.com. If no US address is available, supply ‘FC’. Guam, Puerto Rico, and the US Virgin Islands are considered to have US addresses. Required if injured party is deceased and claimant is not the Injured Party. If Claimant 1 Relationship is equal to a space or blank, leave blank.

95 Claimant 1 Zip AlphaNumeric 5 1901 1905 Optional 5-digit Zip Code for the claimant named above.

If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party is deceased claimant is not the Injured Party. If Claimant 1 Relationship is equal to a space or blank, leave blank.

96 Claimant 1 Zip+4 AlphaNumeric 4 1906 1909 Optional 4-digit Zip Code Extension for the claimant named above.

If not applicable or unknown, leave blank. If Claimant 1 Relationship is equal to a space or blank, leave blank.

97 Claimant 1 Phone AlphaNumeric 10 1910 1919 Optional Telephone number of the claimant named above.

Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation. If no US phone number is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party is deceased and claimant is not the injured party. If Claimant 1 Relationship is equal to a space or blank, leave blank.

98 Claimant 1 Phone Extension AlphaNumeric 5 1920 1924 Optional Telephone extension number of the claimant named above.

Leave blank if unknown or not applicable. If Claimant 1 Relationship is equal to a space or blank, leave blank.

99 Claimant 1 Representative Indicator

Alphabetic 1 1925 1925 Optional Code indicating the type of Attorney/Other Representative information provided for Claimant 1.

Valid values:

A = Attorney G = Guardian/Conservator P = Power of Attorney O = Other Space or blank = Not applicable If Claimant 1 has more than one representative, provide information for his/her attorney if available. Required if Claimant 1 has a representative.

100 Claimant 1 Representative Last Name

Alphabetic 40 1926 1965 Optional Surname of Claimant 1 Representative.

Embedded hyphens, apostrophes and spaces accepted. Either Claimant 1 Representative Last Name and First Name OR Claimant 1 Representative Firm Name is required.

101 Claimant 1 Representative First Name

Alphabetic 30 1966 1995 Optional Given or first name of Claimant 1 Representative.

May only contain letters. Either Claimant 1 Representative Last Name and First Name OR Claimant 1 Representative Firm Name is required if Claimant 1 has a Representative. If supplied, must contain at least 2 characters. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

102 Claimant 1 Representative Firm Name

AlphaNumeric 70 1996 2065 Optional Claimant 1 Representative’s Firm Name.

Either Claimant 1 Representative Last Name and First Name OR Claimant 1 Representative Firm Name is required if Claimant 1 has a Representative. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

103 Claimant 1 Representative TIN AlphaNumeric 9 2066 2074 Optional Claimant 1 Representative’s Federal Tax Identification Number (TIN).

If Claimant 1 Representative is part of a Firm, supply the Firm’s Employer Identification Number (EIN), otherwise supply Claimant 1’s Representative’s Social Security Number (SSN). May contain only numbers. If no Claimant 1 Representative TIN is available, leave blank . If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

104 Claimant 1 Representative Mailing Address1

AlphaNumeric 50 2075 2124 Optional First line of the mailing address for the Claimant 1 Representative named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 1 has a Representative. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

105 Claimant 1 Representative Mailing Address2

AlphaNumeric 50 2125 2174 Optional Second line of the mailing address of the Claimant 1 Representative named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

106 Claimant 1 Representative Mailing City

AlphaNumeric 30 2175 2204 Optional Mailing address city for the Claimant 1 Representative named above.

Field may contain only alphabetic, space, comma, & - ' . @ # / ; : characters. No numeric characters allowed. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 1 has a representative. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

107 Claimant 1 Representative State

Alphabetic 2 2205 2206 Optional US Postal abbreviation State Code for the Claimant 1 Representative named above.

See http://www.usps.com. If no US address is available, supply ‘FC’. Guam, Puerto Rico, and the US Virgin Islands are considered to have US addresses. Required if Claimant 1 has a representative. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

108 Claimant 1 Representative Zip AlphaNumeric 5 2207 2211 Optional 5-digit Zip Code for the Claimant 1 Representative named above.

If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 1 has a representative. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

109 Claimant 1 Representative Zip+4

AlphaNumeric 4 2212 2215 Optional 4-digit Zip Code Extension for the Claimant 1 Representative named above.

If not applicable or unknown, leave blank. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

110 Claimant 1 Representative Phone

AlphaNumeric 10 2216 2225 Optional Telephone number of the Claimant 1 Representative named above.

Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation. If no US phone number is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 1 has a Representative. If Claimant 1 Representative Indicator is equal to a space or blank, leave blank.

111 Claimant 1 Representative Phone Extension

AlphaNumeric 5 2226 2230 Optional Telephone extension number of the Claimant 1 Representative named above.

Leave blank if unknown or not applicable. If Claimant 1 Representative Indicator is equal to a space, leave blank.

112 Claimant 2 Relationship Alphabetic 1 2231 2231 Optional Relationship of the claimant to the injured party/Medicare beneficiary.

This field also indicates whether the claimant’s name refers to an individual or an entity/organization.

Valid values:

E = Estate, Individual Name Provided F = Family Member, Individual Name Provided O = Other, Individual Name Provided X = Estate, Entity Name Provided Y = Family, Entity Name Provided Z = Other, Entity Name Provided Space or Blank = Not applicable Required if injured party is deceased and claimant is not the injured party.

113 Claimant 2 TIN AlphaNumeric 9 2232 2240 Optional Federal Tax Identification Number (TIN), Employer Identification Number (EIN) or Social Security Number (SSN) of Claimant 2.

May contain only numbers. Must not match other claimant(s). Required if Injured Party is deceased and claimant is not the injured party. If Claimant 2 Relationship is equal to a space or blank, leave blank.

114 Claimant 2 Last Name Alphabetic 40 2241 2280 Optional Surname of Claimant 2. Embedded hyphens (dashes), apostrophes and spaces accepted.

Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 2 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 2 Relationship is equal to a space or blank, leave blank.

115 Claimant 2 First Name Alphabetic 30 2281 2310 Optional Given/First name of Claimant 2.

May only contain letters and spaces. Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 2 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 2 Relationship is equal to a space or blank, leave blank.

116 Claimant 2 Middle Initial Alphabetic 1 2311 2311 Optional First letter of Claimant 2’s middle name.

Use only if Claimant 2 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 2 Relationship is equal to a space or blank, leave blank.

117 Claimant 2 Entity/Organization Name

AlphaNumeric 71 2312 2382 Optional Name of Claimant 2 Entity/Organization.

Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 2 Relationship is ‘X’, ‘Y’ or ‘Z’. If Claimant 2 Relationship is equal to a space or blank, leave blank.

118 Claimant 2 Mailing Address1 AlphaNumeric 50 2383 2432 Optional First line of the mailing address for the claimant named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party is deceased and claimant is not the Injured Party. If Claimant 2 Relationship is equal to a space or blank, leave blank.

119 Claimant 2 Mailing Address2 AlphaNumeric 50 2433 2482 Optional Second line of the mailing address of the claimant named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. If Claimant 2 Relationship is equal to a space or blank, leave blank.

120 Claimant 2 City AlphaNumeric 30 2483 2512 Optional Mailing address city for the claimant named above.

Field may contain only alphabetic, space, comma, & - ' . @ # / ; : characters. No numeric characters allowed. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code.

Required if Injured Party is deceased and claimant is not the Injured Party. If Claimant 2 Relationship is equal to a space or blank, leave blank.

121 Claimant 2 State Alphabetic 2 2513 2514 Optional US Postal abbreviation State Code for the claimant named above.

See http://www.usps.com. If no US address is available, supply ‘FC’. Guam, Puerto Rico, and the US Virgin Islands are considered to have US addresses. Required if injured party is deceased and claimant is not the Injured Party. If Claimant 2 Relationship is equal to a space or blank, leave blank.

122 Claimant 2 Zip AlphaNumeric 5 2515 2519 Optional 5-digit Zip Code for the claimant named above.

If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party is deceased claimant is not the Injured Party. If Claimant 2 Relationship is equal to a space or blank, leave blank.

123 Claimant 2 Zip+4 AlphaNumeric 4 2520 2523 Optional 4-digit Zip Code Extension for the claimant named above.

If not applicable or unknown, leave blank. If Claimant 2 Relationship is equal to a space or blank, leave blank.

124 Claimant 2 Phone AlphaNumeric 10 2524 2533 Optional Telephone number of the claimant named above.

Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation. If no US phone number is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party is deceased and claimant is not the injured party. If Claimant 2 Relationship is equal to a space or blank, leave blank.

125 Claimant 2 Phone Extension AlphaNumeric 5 2534 2538 Optional Telephone extension number of the claimant named above.

Leave blank if unknown or not applicable. If Claimant 2 Relationship is equal to a space or blank, leave blank.

126 Claimant 2 Representative Indicator

Alphabetic 1 2539 2539 Optional Code indicating the type of Attorney/Other Representative information provided for Claimant 2.

Valid values:

A = Attorney G = Guardian/Conservator P = Power of Attorney O = Other Space or blank = Not applicable If Claimant 2 has more than one representative, provide information for his/her attorney if available. Required if Claimant 2 has a representative.

127 Claimant 2 Representative Last Name

Alphabetic 40 2540 2579 Optional Surname of Claimant 2 Representative.

Embedded hyphens, apostrophes and spaces accepted. Either Claimant 2 Representative Last Name and First Name OR Claimant 2 Representative Firm Name is required.

128 Claimant 2 Representative First Name

Alphabetic 30 2580 2609 Optional Given or first name of Claimant 2 Representative.

May only contain letters. Either Claimant 2 Representative Last Name and First Name OR Claimant 2 Representative Firm Name is required if Claimant 2 has a Representative. If supplied, must contain at least 2 characters. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

129 Claimant 2 Representative Firm Name

AlphaNumeric 70 2610 2679 Optional Claimant 2 Representative’s Firm Name.

Either Claimant 2 Representative Last Name and First Name OR Claimant 2 Representative Firm Name is required if Claimant 2 has a Representative. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

130 Claimant 2 Representative TIN AlphaNumeric 9 2680 2688 Optional Claimant 2 Representative’s Federal Tax Identification Number (TIN).

If Claimant 2 Representative is part of a Firm, supply the Firm’s Employer Identification Number (EIN), otherwise supply Claimant 2’s Representative’s Social Security Number (SSN). May contain only numbers. If no Claimant 2 Representative TIN is available, leave blank . If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

131 Claimant 2 Representative Mailing Address1

AlphaNumeric 50 2689 2738 Optional First line of the mailing address for the Claimant 2 Representative named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 2 has a Representative. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

132 Claimant 2 Representative Mailing Address2

AlphaNumeric 50 2739 2788 Optional Second line of the mailing address of the Claimant 2 Representative named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

133 Claimant 2 Representative City AlphaNumeric 30 2789 2818 Optional Mailing address city for the Claimant 2 Representative named above.

Field may contain only alphabetic, space, comma, & - ' . @ # / ; : characters. No numeric characters allowed. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 2 has a representative. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

134 Claimant 2 Representative State

Alphabetic 2 2819 2820 Optional US Postal abbreviation State Code for the Claimant 2 Representative named above.

See http://www.usps.com. If no US address is available, supply ‘FC’. Guam, Puerto Rico, and the US Virgin Islands are considered to have US addresses. Required if Claimant 2 has a representative. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

135 Claimant 2 Representative Zip AlphaNumeric 5 2821 2825 Optional 5-digit Zip Code for the Claimant 2 Representative named above.

If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 2 has a representative. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

136 Claimant 2 Representative Zip+4

AlphaNumeric 4 2826 2829 Optional 4-digit Zip Code Extension for the Claimant 2 Representative named above.

If not applicable or unknown, leave blank. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

137 Claimant 2 Representative Phone

AlphaNumeric 10 2830 2839 Optional Telephone number of the Claimant 2 Representative named above.

Format with 3-digit area code followed by 7-digit phone number with no dashes or other punctuation. If no US phone number is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Claimant 2 has a Representative. If Claimant 2 Representative Indicator is equal to a space or blank, leave blank.

138 Claimant 2 Representative Phone Extension

AlphaNumeric 5 2840 2844 Optional Telephone extension number of the Claimant 2 Representative named above.

Leave blank if unknown or not applicable. If Claimant 2 Representative Indicator is equal to a space, leave blank.

139 Claimant 3 Relationship Alphabetic 1 2845 2845 Optional Relationship of the claimant to the injured party/Medicare beneficiary.

This field also indicates whether the claimant’s name refers to an individual or an entity/organization.

Valid values:

E = Estate, Individual Name Provided F = Family Member, Individual Name Provided O = Other, Individual Name Provided X = Estate, Entity Name Provided Y = Family, Entity Name Provided Z = Other, Entity Name Provided Space or Blank = Not applicable Required if injured party is deceased and claimant is not the injured party.

140 Claimant 3 TIN AlphaNumeric 9 2846 2854 Optional Federal Tax Identification Number (TIN), Employer Identification Number (EIN) or Social Security Number (SSN) of Claimant 3.

May contain only numbers. Must not match other claimant(s). Required if Injured Party is deceased and claimant is not the injured party. If Claimant 3 Relationship is equal to a space or blank, leave blank.

141 Claimant 3 Last Name Alphabetic 40 2855 2894 Optional Surname of Claimant 3. Embedded hyphens (dashes), apostrophes and spaces accepted.

Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 3 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 3 Relationship is equal to a space or blank, leave blank.

142 Claimant 3 First Name Alphabetic 30 2895 2924 Optional Given/First name of Claimant 3.

May only contain letters and spaces. Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 3 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 3 Relationship is equal to a space or blank, leave blank.

143 Claimant 3 Middle Initial Alphabetic 1 2925 2925 Optional First letter of Claimant 3’s middle name.

Use only if Claimant 3 Relationship is ‘E’, ‘F’ or ‘O’. If Claimant 2 Relationship is equal to a space or blank, leave blank.

144 Claimant 3 Entity/Organization Name

AlphaNumeric 71 2926 2996 Optional Name of Claimant 3 Entity/Organization.

Required if Injured Party is deceased and claimant is not the Injured Party and Claimant 3 Relationship is ‘X’, ‘Y’ or ‘Z’. If Claimant 3 Relationship is equal to a space or blank, leave blank.

145 Claimant 3 Mailing Address1 AlphaNumeric 50 2997 3046 Optional First line of the mailing address for the claimant named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. Required if Injured Party is deceased and claimant is not the Injured Party. If Claimant 3 Relationship is equal to a space or blank, leave blank.

146 Claimant 3 Mailing Address2 AlphaNumeric 50 3047 3096 Optional Second line of the mailing address of the claimant named above.

Street number and street name should be placed on one address line field while other information such as suite number, attention to, etc. should be placed on the other. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code. If Claimant 3 Relationship is equal to a space or blank, leave blank.

147 Claimant 3 City AlphaNumeric 30 3097 3126 Optional Mailing address city for the claimant named above.

Field may contain only alphabetic, space, comma, & - ' . @ # / ; : characters. No numeric characters allowed. If no US address is available, leave blank and supply ‘FC’ in the corresponding State Code.

Required if Injured Party is deceased and claimant is not the Injured Party. If Claimant 3 Relationship is equal to a space or blank, leave blank.

148 Claimant 3 State Alphabetic 2 3127 3128 Optional…