Data Element Name | DN |
ACCIDENT DESCRIPTION /CAUSE | 38 |
CAUSE OF INJURY CODE | 37 |
CLAIM ADMINISTRATOR ADDRESS LINE 1 | 10 |
CLAIM ADMINISTRATOR ADDRESS LINE 2 | 11 |
CLAIM ADMINISTRATOR CITY | 12 |
CLAIM ADMINISTRATOR CLAIM NUMBER | 15 |
CLAIM ADMINISTRATOR FEIN | 8 |
CLAIM ADMINISTRATOR NAME | 9 |
CLAIM ADMINISTRATOR POSTAL CODE | 14 |
CLAIM ADMINISTRATOR STATE | 13 |
CLASS CODE(3) | 59 |
DATE DISABILITY BEGAN | 56 |
DATE LAST DAY WORKED | 65 |
DATE OF HIRE(1) | 61 |
DATE OF INJURY | 31 |
DATE OF RETURN TO WORK | 68 |
DATE REPORTED TO CLAIM ADMINISTRATOR | 41 |
DATE REPORTED TO EMPLOYER | 40 |
EMPLOYEE ADDRESS LINE 1(1) | 46 |
EMPLOYEE ADDRESS LINE 2(1) | 47 |
EMPLOYEE CITY(1) | 48 |
EMPLOYEE DATE OF BIRTH | 52 |
EMPLOYEE DATE OF DEATH | 57 |
EMPLOYEE FIRST NAME | 44 |
EMPLOYEE LAST NAME | 43 |
EMPLOYEE MIDDLE INITIAL(1) | 45 |
EMPLOYEE PHONE(1) | 51 |
EMPLOYEE POSTAL CODE(1) | 50 |
EMPLOYEE STATE(1) | 49 |
EMPLOYER ADDRESS LINE 1 | 19 |
EMPLOYER ADDRESS LINE 2 | 20 |
EMPLOYER CITY | 21 |
EMPLOYER FEIN | 16 |
EMPLOYER NAME | 18 |
EMPLOYER POSTAL CODE | 23 |
EMPLOYER STATE | 22 |
EMPLOYMENT STATUS CODE(1) | 58 |
GENDER CODE | 53 |
INDUSTRY CODE | 25 |
INITIAL TREATMENT CODE | 39 |
INSURED REPORT NUMBER | 26 |
INSURER FEIN | 6 |
INSURER NAME | 7 |
JURISDICTION | 4 |
MAINTENANCE TYPE CODE | 2 |
MAINTENANCE TYPE CODE DATE | 3 |
MARITAL STATUS CODE(2) | 54 |
NATURE OF INJURY CODE | 35 |
NUMBER OF DEPENDENTS(2) | 55 |
OCCUPATION DESCRIPTION | 60 |
PART OF BODY INJURED CODE | 36 |
POLICY EFFECTIVE DATE | 29 |
POLICY EXPIRATION DATE | 30 |
POLICY NUMBER | 28 |
POSTAL CODE OF INJURY SITE | 33 |
SALARY CONTINUED INDICATOR | 67 |
SELF INSURED INDICATOR | 24 |
SOCIAL SECURITY NUMBER(4) | 42 |
TIME OF INJURY | 32 |
WAGE(1) | 62 |
WAGE PERIOD(1) | 63 |
____________________ |
Data elements omitted under this subsection because they were not known by the claims administrator shall be submitted within sixty (60) days from the date of the first report under this subsection.
Data Element Name | DN |
AGENCY/JURISDICTION CLAIM NUMBER(2)(3) | 5 |
CLAIM ADMINISTRATOR CLAIM NUMBER(4) | 15 |
CLAIM ADMINISTRATOR FEIN(8) | 8 |
DATE OF INJURY(5) | 31 |
EMPLOYEE DATE OF BIRTH(6) | 52 |
EMPLOYEE FIRST NAME(7) | 44 |
EMPLOYEE FEIN(7) | 16 |
INSURER FEIN(4) | 6 |
JURISDICTION(1) | 4 |
MAINTENANCE TYPE CODE(1) | 2 |
MAINTENANCE TYPE CODE DATE(1) | 3 |
TIME OF INJURY(9) | 32 |
TRANSACTION SET ID(1) | 1 |
____________________ |
Data Element Name | DN |
BENEFIT ADJUSTMENT CODE | 92 |
BENEFIT ADJUSTMENT START DATE | 94 |
BENEFIT ADJUSTMENT WEEKLY AMOUNT | 93 |
CLAIM ADMINISTRATOR POSTAL CODE | 14 |
CLAIM STATUS | 73 |
CLAIM TYPE | 74 |
DATE DISABILITY BEGAN | 56 |
DATE OF MAXIMUM MEDICAL IMPROVEMENT | 70 |
DATE OF REPRESENTATION | 76 |
DATE OF RETURN/RELEASE TO WORK | 72 |
EMPLOYEE DATE OF DEATH | 57 |
INSURED REPORT NUMBER | 26 |
LATE REASON CODE | 77 |
NUMBER OF BENEFIT ADJUSTMENTS | 80 |
NUMBER OF DEATH DEPENDENT/PAYEE RELATIONSHIPS | 82 |
NUMBER OF DEPENDENTS | 55 |
NUMBER OF PAID TO DATE/REDUCED EARNINGS/RECOVERIES | 81 |
NUMBER OF PAYMENTS/ADJUSTMENTS | 79 |
NUMBER OF PERMANENT IMPAIRMENTS | 78 |
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES AMOUNT | 96 |
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES CODE | 95 |
PAYMENT/ADJUSTMENT CODE | 85 |
PAYMENT/ADJUSTMENT DAYS PAID | 91 |
PAYMENT/ADJUSTMENT END DATE | 89 |
PAYMENT/ADJUSTMENT PAID TO DATE | 86 |
PAYMENT/ADJUSTMENT START DATE | 88 |
PAYMENT/ADJUSTMENT WEEKLY AMOUNT | 87 |
PAYMENT/ADJUSTMENT WEEKS PAID | 90 |
PERMANENT IMPAIRMENT BODY PART CODE(1)(2) | 83 |
PERMANENT IMPAIRMENT PERCENTAGE(2) | 84 |
RETURN TO WORK QUALIFIER | 71 |
SALARY CONTINUED INDICATOR | 67 |
WAGE | 62 |
WAGE PERIOD | 63 |
____________________ | |
(1) May use Code 90 (Multiple Body Parts) to reflect combined rating for any/all impairments. | |
(2) Use actual permanent disability rating at the time of initial payment of permanent disability benefits. For compromise and release cases and stipulated settlements, use permanent disability estimate as reported to the appropriate rating organization established under Insurance Code § 11750, et seq. |
Data Element Name | DN |
ACKNOWLEDGMENT TRANSACTION SET ID | 0110 |
ADA PROCEDURE BILLED CODE | 0719 |
ADA PROCEDURE PAID CODE | 0722 |
ADMISSION DATE | 0513 |
ADMISSION HOUR | 0622 |
ADMISSION TYPE CODE | 0577 |
ADMITTING DIAGNOSIS CODE | 0535 |
APPLICATION ACKNOWLEDGMENT CODE | 0111 |
BILL ADJUSTMENT AMOUNT | 0545 |
BILL ADJUSTMENT GROUP CODE | 0543 |
BILL ADJUSTMENT REASON CODE | 0544 |
BILL ADJUSTMENT UNITS | 0546 |
BILL FREQUENCY TYPE CODE | 0505 |
BILL SUBMISSION REASON CODE | 0508 |
BILLED DRG CODE | 0548 |
BILLING FORMAT CODE | 0503 |
BILLING PROVIDER CITY | 0540 |
BILLING PROVIDER COUNTRY CODE | 0569 |
BILLING PROVIDER FEIN | 0629 |
BILLING PROVIDER FIRST NAME | 0529 |
BILLING PROVIDER LAST/GROUP NAME | 0528 |
BILLING PROVIDER NATIONAL PROVIDER ID | 0634 |
BILLING PROVIDER POSTAL CODE | 0542 |
BILLING PROVIDER PRIMARY ADDRESS | 0538 |
BILLING PROVIDER PRIMARY SPECIALTY CODE | 0537 |
BILLING PROVIDER SECONDARY ADDRESS | 0539 |
BILLING PROVIDER STATE CODE | 0541 |
BILLING PROVIDER STATE LICENSE NUMBER | 0630 |
BILLING PROVIDER UNIQUE BILL IDENTIFICATION NUMBER | 0523 |
BILLING TYPE CODE | 0502 |
CLAIM ADMINISTRATOR CLAIM NUMBER | 0015 |
CLAIM ADMINISTRATOR FEIN | 0187 |
CLAIM ADMINISTRATOR MAILING POSTAL CODE | 0014 |
CLAIM ADMINISTRATOR NAME | 0188 |
COMPOUND DRUG INDICATOR | 0762 |
CONDITION CODE | 0556 |
CONTRACT LINE TYPE CODE | 0741 |
CONTRACT TYPE CODE | 0515 |
DATE INSURER PAID BILL | 0512 |
DATE INSURER RECEIVED BILL | 0511 |
DATE OF BILL | 0510 |
DATE OF INJURY | 0031 |
DATE PROCESSED | 0108 |
DATE TRANSMISSION SENT | 0100 |
DAYS/UNITS BILLED | 0554 |
DAYS/UNITS CODE | 0553 |
DAY(S)/UNIT(S) PAID | 0580 |
DIAGNOSIS CODE | 0522 |
DIAGNOSIS POINTER | 0557 |
DISCHARGE DATE | 0514 |
DISCHARGE HOUR | 0623 |
DISPENSE AS WRITTEN CODE | 0562 |
DRUG NAME | 0563 |
DRUGS/SUPPLIES BILLED AMOUNT | 0572 |
DRUGS/SUPPLIES DISPENSING FEE | 0579 |
DRUGS/SUPPLIES NUMBER OF DAYS | 0571 |
DRUGS/SUPPLIES QUANTITY DISPENSED | 0570 |
ELEMENT ERROR NUMBER | 0116 |
ELEMENT NUMBER | 0115 |
EMPLOYEE FIRST NAME | 0044 |
EMPLOYEE LAST NAME | 0043 |
EMPLOYEE MAILING CITY | 0048 |
EMPLOYEE MAILING POSTAL CODE | 0050 |
EMPLOYEE MIDDLE NAME/INITIAL | 0045 |
EMPLOYEE SOCIAL SECURITY NUMBER | 0042 |
EMPLOYER FEIN | 0016 |
EMPLOYER NAME | 0018 |
FACILITY CITY | 0686 |
FACILITY CODE | 0504 |
FACILITY COUNTRY CODE | 0689 |
FACILITY NAME | 0678 |
FACILITY NATIONAL PROVIDER ID | 0682 |
FACILITY POSTAL CODE | 0688 |
FACILITY PRIMARY ADDRESS | 0684 |
FACILITY SECONDARY ADDRESS | 0685 |
FACILITY STATE CODE | 0687 |
FACILITY STATE LICENSE NUMBER | 0680 |
HCPCS LINE PROCEDURE BILLED CODE | 0714 |
HCPCS LINE PROCEDURE PAID CODE | 0726 |
HCPCS MODIFIER BILLED CODE | 0717 |
HCPCS MODIFIER PAID CODE | 0727 |
HIPPS RATE CODE | 0625 |
INSURER FEIN | 0006 |
INSURER NAME | 0007 |
INSURER POSTAL CODE | 0616 |
JURISDICTION CLAIM NUMBER | 0005 |
JURISDICTION MODIFIER BILLED CODE | 0718 |
JURISDICTION MODIFIER PAID CODE | 0730 |
JURISDICTION PROCEDURE BILLED CODE | 0715 |
JURISDICTION PROCEDURE PAID CODE | 0729 |
JURISDICTION TRACKING NUMBER | 0743 |
LINE ITEM PRIOR ACTUAL AMOUNT PAID | 0761 |
LINE NUMBER | 0547 |
LUMP SUM PAYMENT SETTLEMENT CODE | 0293 |
MANAGED CARE ORGANIZATION FEIN | 0704 |
MANAGED CARE ORGANIZATION IDENTIFICATION NUMBER | 0208 |
MANAGED CARE ORGANIZATION NAME | 0209 |
NDC BILLED CODE | 0721 |
NDC PAID CODE | 0728 |
ORIGINATOR TRANSACTION IDENTIFICATION BATCH CONTROL NUMBER | 0532 |
ORIGINAL TRANSMISSION DATE | 0102 |
ORIGINAL TRANSMISSION TIME | 0103 |
OTHER PROCEDURE CODE | 0736 |
OUTPATIENT REASON FOR VISIT CODE | 0520 |
PAID DRG CODE | 0549 |
PLACE OF SERVICE BILL CODE | 0555 |
PLACE OF SERVICE LINE CODE | 0600 |
PRESCRIPTION DATE(S) RANGE | 0527 |
PRESCRIPTION LINE DATE | 0604 |
PRESCRIPTION LINE NUMBER | 0561 |
PRESENT ON ADMISSION INDICATOR | 0533 |
PRINCIPAL DIAGNOSIS CODE | 0521 |
PRINCIPAL PROCEDURE CODE | 0525 |
PRINCIPLE PROCEDURE DATE | 0550 |
PRIOR ACTUAL AMOUNT PAID | 0760 |
PROCEDURE DATE | 0524 |
PROCEDURE DESCRIPTION | 0551 |
PROVIDER AGREEMENT CODE | 0507 |
PROVIDER AGREEMENT LINE CODE | 0742 |
RECEIVER ID | 0099 |
REFERRING PROVIDER FIRST NAME | 0691 |
REFERRING PROVIDER LAST/GROUP NAME | 0690 |
REFERRING PROVIDER NATIONAL PROVIDER ID | 0699 |
RENDERING BILL PROVIDER FIRST NAME | 0639 |
RENDERING BILL PROVIDER LAST/GROUP NAME | 0638 |
RENDERING BILL PROVIDER NATIONAL PROVIDER ID | 0647 |
RENDERING BILL PROVIDER PRIMARY SPECIALTY CODE | 0651 |
RENDERING BILL PROVIDER STATE LICENSE NUMBER | 0643 |
RENDERING LINE PROVIDER NATIONAL PROVIDER ID | 0592 |
RENDERING LINE PROVIDER FIRST NAME | 0587 |
RENDERING LINE PROVIDER LAST/GROUP NAME | 0589 |
RENDERING LINE PROVIDER PRIMARY SPECIALTY CODE | 0595 |
RENDERING LINE PROVIDER STATE LICENSE NUMBER | 0599 |
REPORTING PERIOD | 0615 |
REVENUE BILLED CODE | 0559 |
REVENUE PAID CODE | 0576 |
SENDER ID | 0098 |
SERVICE ADJUSTMENT AMOUNT | 0733 |
SERVICE ADJUSTMENT GROUP CODE | 0731 |
SERVICE ADJUSTMENT REASON CODE | 0732 |
SERVICE ADJUSTMENT UNITS | 0734 |
SERVICE BILL DATE(S) RANGE | 0509 |
SERVICE LINE DATE(S) RANGE | 0605 |
SUPERVISING PROVIDER FIRST NAME | 0659 |
SUPERVISING PROVIDER LAST/GROUP NAME | 0658 |
SUPERVISING PROVIDER NATIONAL PROVIDER ID | 0667 |
SUPERVISING PROVIDER PRIMARY SPECIALTY CODE | 0671 |
TEST/PRODUCTION INDICATOR | 0104 |
TIME PROCESSED | 0109 |
TIME TRANSMISSION SENT | 0101 |
TOTAL AMOUNT PAID PER BILL | 0516 |
TOTAL AMOUNT PAID PER LINE | 0574 |
TOTAL CHARGE PER BILL | 0501 |
TOTAL CHARGE PER LINE | 0552 |
TRANSACTION TRACKING NUMBER | 0266 |
UNIQUE BILL ID NUMBER | 0500 |
Data Element Name | DN |
PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT | 96 |
PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE | 95 |
PAYMENT/ADJUSTMENT CODE | 85 |
PAYMENT/ADJUSTMENT END DATE | 89 |
PAYMENT/ADJUSTMENT DAYS PAID | 91 |
PAYMENT/ADJUSTMENT PAID TO DATE | 86 |
PAYMENT/ADJUSTMENT START DATE | 88 |
PAYMENT/ADJUSTMENT WEEKLY AMOUNT | 87 |
PAYMENT/ADJUSTMENT WEEKS PAID | 90 |
Cal. Code Regs. Tit. 8, § 9702
2. Amendment filed 3-22-2006; operative 4-21-2006 (Register 2006, No. 12).
3. Amendment filed 11-15-2010; operative 11-15-2011 (Register 2010, No. 47).
4. Repealer of subsections (a)(1)-(3), amendment of subsection (e) and new subsections (e)(1)-(3) and (l)(1)-(5) filed 4-6-2015; operative 4-6-2016 (Register 2015, No. 15).
5. Amendment of subsections (b)-(e) and (e)(3), redesignation and amendment of subsection (f) as new subsection (f)(1), new subsection (f)(2) and amendment of subsections (g)-(h) filed 3-27-2017; operative 9-27-2017 (Register 2017, No. 13).
Note: Authority cited: Sections 133, 138.4, 138.6 and 138.7, Labor Code. Reference: Sections 138.4, 138.6 and 138.7, Labor Code.
2. Amendment filed 3-22-2006; operative 4-21-2006 (Register 2006, No. 12).
3. Amendment filed 11-15-2010; operative 11-15-2011 (Register 2010, No. 47).
4. Repealer of subsections (a)(1)-(3), amendment of subsection (e) and new subsections (e)(1)-(3) and (l)(1)-(5) filed 4-6-2015; operative 4/6/2016 (Register 2015, No. 15).
5. Amendment of subsections (b)-(e) and (e)(3), redesignation and amendment of subsection (f) as new subsection (f)(1), new subsection (f)(2) and amendment of subsections (g)-(h) filed 3-27-2017; operative 9/27/2017 (Register 2017, No. 13).