Exhibit_4_-_Claims_Reporting_Fields.pdf

ELIGIBILITY

Member Number (SSN plus extension) Member Last Name Member First Name Member Date of Birth Member Sex Relationship Policy Code, Claim Division, Branch Benefit Option, Plan Effective date Cancellation date of coverage Coverage Tier Member Zip Code Provider ID Elligibility Date Member Street Address Member City Name Member State Alternate Member ID Member Age Age Band Medicare indicator Street Address Street Address - secondary City name State Coverage Indicator Employment Status

MEDICAL

Client ID Plan Code Group or policy number Subgroup for retiree, active, cobra Employee ID Employee Name Employee State Code Employee Zip Full time or retiree Member Number Alternate Member ID Member Name Relationship Member DOB Member Gender Claimant Age Servicing Provider Name Servicing Provider Address Servicing Provider Address Second Line Servicing Provider City Servicing Provider State Servicing Provider Zip Servicing Provider Tax ID or NPI Provider Name Provider Tax ID Provider ZIP National Provider ID Ordering Provider ID Referring provider Provider Specialty Billing Provider Name Billing Provider Address Billing Provider Address Second Line Billing Provider City Billing Provider State Billing Provider Zip Claim # Claim Line # Service Date Claim Service Date Claim Received Date Claim Paid Date Last Service Date Admit Date

Discharge Date Discharge Status Code Hospital Days Service Unit Count Type of Bill Service Type Place of Service Hospital, Ancillary, Professional In/Out Network Indicator Submitted Claim Charge Not Covered Amount Covered/Allowed Amount Discount Amount Deductible Amount Copay Amount Coinsurance Amount Paid Amount HRA Amount State Surcharge Amount Surcharge State Code Procedure Code Procedure Code Type Procedure Code Modifier CPT/HCPCS/Revenue Code ICD Diagnosis Code ICD Procedure Code ICD Version Indicator MS DRG Code Primary Dx Secondary Dx Tertiary Dx POA Indicator Savings Reason Code Remark Code Transaction Code Reason Not Covered Code

RX

Source Data Client Number Customer Number Employee ID Employee Name Member Number Member Name Patient First Name Patient Last Name Member DOB Member Age Member Gender Relationship Member Zip Code Member State Member City Name Street Address Street Address - secondary Coverage Indicator Pharmacy coverage indicator Benefit Plan (If Applicable) Plan Code Group or policy number Subgroup for retiree, active, cobra Branch Code Network Indicator (In or Out) Coverage Tier Pharmacy NABP# Pharmacy Name Pharmacy Address Pharmacy City Pharmacy State Pharmacy ZIP Rx Account Number Script # Claim Number Source of Claim Fill Date Paid Date Refill Number Days Supply Metric Quantity Dispensed Drug Name

Drug Strength Ndc Number Generic Indicator Generic/Brand/OTC Generic Therapeutic Class Code Single or Multi-Source (Must Include SSG) Formulary Indicator Specialty (Y/N) Compounding Code Tier Value Prior Auth (Yes or No) Physician ID Physician NPI Physician DEA Ordering Provider Npi Manufacturer/Distributer Name Average Wholesale Price Cost Basis (AWP, MAC, U&C,etc.)

Ingredient Cost Dispensing Fee Admin Fee Sales Tax U&C Amount Total Paid Amount Total Covered Amount Copay Amount Deductible Coinsurance Paid Amount DAW Indicator Code Retail/Mail

FIELD NBR FIELD NAME TYPE REQ/OPT DESCRIPTION FORMAT MAX LENGTH

1 CustomerCd String O UNIQUE ID FOR THE CUSTOMER, USEFUL IF COMBINING CUSTOMER DATA IN FILES 20 2 CustomerName String O NAME/DESCRIPTION OF THE CUSTOMER 50 3 SubmissionDt String R DATE OF THE FILE CREATION. REPRESENTS SUBMITTED DATA THROUGH THIS DATE YYYYMMDD 10 4 AccountId String O UNIQUE ID FOR THE CUSTOMER ACCOUNT 30 5 AccountName String O NAME/DESCRIPTION OF THE ACCOUNT 75 6 ClaimNbr String R UNIQUE CLAIM NUMBER 75 7 EmployeeId String R EMPLOYEE ID 50 8 MemberId String R MEMBER ID / PATIENT ID 50 9 MemberRelCode String R 1=SELF, 2=SPOUSE, 3=CHILD/OTHER 3

10 PharmacyNCPDP String O PHARMACY NCPDP ID 10 11 PharmacyNPI String O PHARMACY NPI ID 10 12 RxNbr String R PRESCRIPTION NUMBER 15 13 RxStatus String O P - PAID, R - REVERSED, 0 - REJECTED 1 14 FillDt String R FILL DATE OF THE SCRIPT YYYYMMDD 10 15 WrittenDt String O WRITTEN DATE OF THE SCRIPT YYYYMMDD 10 16 ClaimCount String R 1 FOR POSITIVE CLAIM, -1 FOR A REVERSAL CLAIM, 0 FOR REJECTED 2 17 NDC String R NDC 11 OF DRUG 11 18 GPI String O GPI OF THE DRUG 14 19 TheraputicClassCdQualifier String O IDENTIFIES TYPE OF DATA BEING SUBMITTED IN THE THERAPEUTIC CLASS CODE 1 20 TheraputicClassCd String O THERAPUTIC CLASS OF THE DRUG 100 21 LabelName String O DRUG NAME 100 22 NbrOfMfgs Numeric O NUMBER OF MANUFACTURERS OF THE DRUG 9 1 23 DiseaseCondition String O DRUG DISEASE CONDITION DESCRIPTION 100 24 BrandGenericDesc String R BRAND, GENERIC, OR BLANK 10 25 Channel String R MAIL, RETAIL, OR BLANK 10 26 RefillNbr String R 00 = NEW, 01-99 = REFILL 99 2 27 DaysSupplyVal Numeric R DAYS SUPPLY, USE NEGATIVE FOR REVERSALS 999 3 28 DispensedQty Numeric R DISPENSED QUANTITY, USE NEGATIVE FOR REVERSALS 99999.999 10 29 DAWCode String O DISPENSED AS WRITTEN (0-9) 1 30 DispensedProductAs String O AER, POW, TAB, CAP, SUP, ETC. 5 31 ProductType String O 0-6, OR A 1 32 CompoundIndicator String R IS THE DRUG A COMPOUND, Y OR N 1 33 SpecialtyIndicator String R IS THE DRUG A SPECIALTY DRUG, Y OR N 1 34 OTCIndicator String O WAS THE DRUG DISPENSED OVER THE COUNTER (OTC), Y OR N 1 35 UCIndicator String O WAS THE DRUG USUAL AND CUSTOMARY, Y OR N 1 36 MaintenanceIndicator String O IS THE DRUG A MAINTENANCE DRUG, Y OR N 1 37 Claim340bInd String O PART OF THE 340B DRUG DISCOUNT PROGRAM, Y OR N 1 38 MultiSourceCode String R MULTI-SOURCE CODE - N, M, O, OR Y 1 39 ClaimSourceCode String O CLAIM SOURCE CODE - 00-23 2 40 FormularyStatusCode String O 0-99, A, OR U 2 41 PriorAuthNbr String O ID OF THE AUTHORIZATION 20 42 PrescriberDEA String O PRESCRIBER DEA 10 43 PrescriberNPI String O PRESCRIBER NPI 10 44 DiscountExclusionInd String O SCRIPT IS EXCLUDED FROM DISCOUNT, Y OR N 1 45 RebateMedicationInd String O SCRIPT IS INCLUDED FOR REBATES, Y OR N 1 46 MemberOutofPocketCorrectedInd String O HAS THE MEMBER OOP BEEN CORRECTED, Y OR N 1 47 PaidTypeCd String O AWP, U&C, MAC, ETC. 5 48 AWPAmt Numeric R AWP AMOUNT 99999.999 10 49 MACAmt Numeric O MAC PRICE AMOUNT 99999.999 10 50 UCAmt Numeric O U&C AMOUNT, IF PAID TYPE WAS U&C 99999.999 10 51 DAWPenaltyAmt Numeric O DAW 1 PENALTY, USE NEGATIVE FOR REVERSALS 99999.999 10 52 DAW2PenaltyAmt Numeric O DAW 2 PENTALY, USE NEGATIVE FOR REVERSALS 99999.999 10 53 DispensingFeeAmt Numeric O DISPENSING FEE, USE NEGATIVE FOR REVERSALS 99999.999 10 54 IngredientCostAmt Numeric R INGREDIENT COST, USE NEGATIVE FOR REVERSALS 99999.999 10 55 MemberPayAmt Numeric O MEMBER PAID, USE NEGATIVE FOR REVERSALS 99999.999 10 56 SalesTaxAmt Numeric O SALES TAX, USE NEGATIVE FOR REVERSALS 99999.999 10 57 COBAmt Numeric O COORDINATION OF BENEFITS, USE NEGATIVE FOR REVERSALS 99999.999 10 58 PlanPaidAmt Numeric R PLAN PAID, USE NEGATIVE FOR REVERSALS 99999.999 10 59 CopayAssistApplyAmt Numeric O COPAY ASSIST, USE NEGATIVE FOR REVERSALS 99999.999 10 60 InvoiceAdminFeeAmt Numeric O INVOICE ADMINISTRATION FEE, USE NEGATIVE FOR REVERSALS 99999.999 10