Section 6

Claims Release 3.0 Standards
Data Dictionary

CLAIMS RELEASE 3.0 JANUARY 1, 2010 PUBLICATION © 2010 IAIABC

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CLAIMS RELEASE 3.0 JANUARY 1, 2010 PUBLICATION © 2010 IAIABC

SECTION 6:
RELEASE 3 COMBINED BUSINESS & TECHNICAL DATA DICTIONARY
INTRODUCTION
Code Values: Unused data element code values for any IAIABC standards product (Claims, Proof of Coverage, Medical) are reserved for future IAIABC use and may not be assigned and used for any proprietary purpose. Proposals to add new codes should be submitted through the IRR process
This dictionary contains some or all of the following information for every Claims Release 3 business and technical data element:
Definition:    The meaning or purpose of the data element
Orig/Rev.:    The date that the data element was originally created, followed by any revision dates, if
applicable. 
Record:      An indication of which flat file the ta element resides:
148 = First Report
R21 = First Report Companion Record
A49 = Subsequent Report
R22 = Subsequent Report Companion Record
AKC = Claims Acknowledgment Detail Record
ARC = Claims Re-Acknowledgment Detail Record
HD1 = Transmission Header Record
TR2 = Transmission Trailer Record Format:      The field length and type of the data element Values:      When applicable, a list of valid codes and their meaning. Refer to the Jurisdiction Value
Table in their Edit Matrix for the codes that are excluded by each jurisdiction. DP Rule:     The data population (DP) rule for the data element. Implementation notes and other
process rules for the data element are located in this section as well.

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ACCIDENT/INJURY DESCRIPTION NARRATIVE – DN0038
Definition:     A free form description of how the accident occurred and the resulting injuries.
Orig/Rev.:     08/09/95, 07/01/97
Record:       R21
Format:       500 A/N (up to 10 occurrences of 50)
ACCIDENT PREMISES CODE – DN0249
Definition:     A code to indicate the premises where the accident occurred. Orig/Rev:     07/01/97, 04/24/03, 03/31/07 Record:       R21 Format:       1 A/N Values:       E = Employer
Accident occurred on employer’s/lessor’s premises.
	L = Lessee
Accident occurred on the premises of the lessee for which the employee was hired to work.
X = Other
Accident occurred at a location other than the employer or for which the employee was hired to work.
ACCIDENT SITE CITY – DN0121
Definition:     The city where the accident or injury occurred. Orig/Rev:     07/01/97 Record:       R21 Format:       15 A/N
DP Rule: Accident Site City cannot be required when Accident Site Location Narrative is used.
ACCIDENT SITE COUNTRY CODE – DN0280
Definition:     A code to indicate the country where the accident or injury occurred
Orig/Rev:     03/01/03, 04/24/03
Record:       R21
Format:       3 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org
DP Rule:      Accident Site Country Code cannot be required when Accident Site Location
Narrative is used. Not required unless other than US.
Values are 2 digit left-justified
ACCIDENT SITE COUNTY/PARISH – DN0118
Definition:     The county or parish where the accident or injury occurred. Orig/Rev:     07/01/97 Record:       R21 Format:       20 A/N
ACCIDENT SITE LOCATION NARRATIVE – DN0119
Definition: A free form text field describing the address of the accident when the location is not post office identifiable.
Orig/Rev:     07/01/97, 04/24/03
Record:       R21
Format:       50 A/N
DP Rule: Either an Accident Site Organization Name and physical address or an Accident Site Location Narrative can be required, but not both. Enough information must be sent to sufficiently identify the site. Accident Site Location Narrative cannot be required when Accident Site Street/City/State/Postal Code/Country is used.

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ACCIDENT SITE ORGANIZATION NAME – DN0120
Definition:     The name of the entity corresponding to the Accident Site Street/City/State/Country.
Orig/Rev:     07/01/97, 04/24/03
Record:       R21
Format:       50 A/N
DP Rule: Accident Site Organization Name cannot be required unless the Accident Premises Code is equal to “L”. If Accident Premises Code is equal to “E” or “X”, Accident Site Organization Name cannot be required when Accident Site Location Narrative is used in lieu of Accident Site Address/City/State/Country.
ACCIDENT SITE POSTAL CODE – DN0033
Definition:     The postal code for the location where the accident or injury occurred. Orig/Rev:     03/11/94, 07/01/97, 04/24/03 Record:       148 Format:       9 A/N
DP Rule: For the United States and its territories, this will be the USPS zip code. For non-U.S. and its territories, refer to each country’s postal code list.
Accident Site Postal Code cannot be required when Accident Site Location Narrative is used.
ACCIDENT SITE STATE CODE – DN0123
Definition:     A code to indicate the state where the accident or injury occurred. Orig/Rev:     07/01/97, 04/24/03 Record:       R21 Format:       2 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org DP Rule:      Accident Site State Code cannot be required when Accident Site Location Narrative is used.
ACCIDENT SITE STREET – DN0122
Definition:     The street address where the accident or injury occurred. Orig/Rev:     07/01/97 Record:       R21 Format:       40 A/N
DP Rule: Accident Site Street cannot be required when Accident Site Location Narrative is used.
ACKNOWLEDGMENT TRANSACTION SET ID – DN0110
Definition:     Identifies the type of transaction being acknowledged.
Orig/Rev:     09/26/98, 07/12/02, 05/27/03
Record:       AKC, ARC
Format:       3 A/N
Values:       148 – First Report
A49 – Subsequent Report
ACTUAL REDUCED EARNINGS – DN0124
Definition:     The weekly wages of an employee who has returned to work with physical
restrictions or reduced earnings. Orig/Rev:     07/01/97 Record:       R22 Format:       $9.2

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AGREEMENT TO COMPENSATE CODE – DN0075
Definition:     A code identifying the condition under which compensation benefits are being
paid. Orig/Rev:     08/09/95, 07/01/97 Record:      A49 Format:       1 A/N Values:       W = Without Liability
L = With Liability

ANTICIPATED WAGE LOSS INDICATOR – DN0201
Definition:
An indicator that Temporary Partial Disability benefits are anticipated to be owed,
but the claim administrator has not yet received the required wage
documentation in order to make payment(s).
Orig/Rev: Record: Format: Values:
11/30/06
R22
1 A/N
Y = Yes
N = No
APPLICATION ACKNOWLEDGMENT CODE – DN0111
Definition:     A code used to identify the accepted/rejected status of the transaction being acknowledged.
Orig/Rev:     08/09/95, 07/01/97, 07/12/02
Record:       AKC, ARC
Format:       2 A/N
Values:       HD = Batch Rejected: Batch rejected in its entirety.
TA = Transaction Accepted: The transaction was accepted by the jurisdiction.
No errors were found on the transaction.
TE = Transaction Accepted with Error: An error was found on an expected
data element. A CO (Correction) should be submitted to resolve the error(s).
TN = Transaction Rejected by Service Provider: Fails Jurisdiction Mandatory
Requirements
TR = Transaction Rejected: An error was found on a mandatory or mandatory
conditional data element. The transaction was not accepted by the jurisdiction. A
review of the error should take place to determine if the transaction should be
resubmitted with the same MTC – correcting the error. If an error of duplicate
AVERAGE WAGE – DN0286
transaction, invalid event sequence, etc. then resubmission may not be required.
Definition:
The employee’s pre-injury wage for the wage period as statutorily defined by the
jurisdiction, including discontinued fringes and concurrent employer wages,  
if any.
Orig/Rev: Record: Format: DP Rule:
03/11/94, 07/01/97, 04/24/03, 04/28/04
R22
$9.2
This amount may include commissions, piecework earnings, and other forms of
income converted to a normal scheduled workweek, plus the estimated value of
lodging, food, laundry and other payments in kind, as per jurisdictional
requirements.

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AWARD/ORDER DATE
Definition:
Orig.Rev: Record: Format: DP Rule:

DN0299
The date associated with an award, order, settlement or agreement as defined by
the jurisdiction.
04/30/04, 02/24/05
R22
8 DATE
If required on a transaction, the most recent Award/Order Date should always be
reported.   If a jurisdiction does not accept all MTC’s, it is possible that they will
not receive all Award/Order Dates.
Jurisdictions requiring this data element should include in their Trading Partner
Tables (all that apply):
•	description of the type of award, order, settlement or agreement and the resulting filing requirements on their Event Table.
•	description of the conditions that cause the element to be required on their Element Requirement Table.
•	description of the data expected in the field on their Edit Matrix.
•	
BENEFIT ADJUSTMENT CODE – DN0092
Definition:
Orig/Rev:
Record:
Format:
A code identifying reductions or increases applied to the Gross Weekly Amount
resulting in a new Net Weekly Amount for a specific benefit type.
06/07/95, 07/01/97, 04/24/03
R22
4 A/N (BNNN)
B = Benefit Adjustment Code (See values below)
NNN = Benefit Type Codes (DN0085)
Values:
A = Apportionment/Contribution
Weekly payment amount reduced for shared or partial liability(s).
B = Subrogation (Third Party Offset)
Weekly payment amount reduced for recovery from third party tort-feasor.
E = Employer Provided Pension
Weekly payment amount reduced for eligibility or payments under an employer provided pension program.
G = Age 65 Reduction
Weekly payment amount reduced after employee reaches age 65.
I = Intoxication
Weekly payment amount reduced due to employee’s intoxication at the time of the injury.
J = Appeal Adjustment
Weekly payment amount reduced while case is on appeal.
L = Disability Insurance/Income
Weekly payment amount reduced for disability insurance/income eligibility or payment other than social security.
N = Non-cooperation: Rehabilitation, Training, Education, and Medical
Weekly payment amount reduced for non-cooperation/failure to comply with jurisdictional requirements.
Q = Illegally Employed Minor
Weekly payment amount increased for any minor less than 18 years of age whose employment has been shown to be illegal.

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R = Social Security Retirement
Weekly payment amount reduced for eligibility for, or payments under, the Federal Old Age Survivors Act, 42 USC 402.
S = Social Security Disability
Weekly payment amount reduced for eligibility for, or payments under, the Federal Disability Act, 42 USC 423.
T = Acceleration of Benefits
Weekly payment amount increased over and above the compensation rate.
U = Unemployment Compensation
Weekly payment amount reduced for eligibility for, or payments under, unemployment compensation.
V	= Safety Violation
Weekly payment amount reduced for safety violation(s).
W = Partial Wage Continuation
Weekly payment amount reduced for continuation of fringe benefits by the employer. (For example: room, board, health insurance, etc).
X = Death Benefit Reduction
Weekly payment amount reduced for eligibility for, or payment to survivors.
Y	= Partial Reimbursement of Claimant Attorney Fees
Weekly payment amount increased to the employee for partial reimbursement of claimant attorney fees.
Z = 2 Years Continuous Disability
Weekly payment amount increased for employees who have been disabled for two continuous years and who are receiving a gross weekly amount, which is less than 50% of the jurisdiction average weekly wage for the year of injury.
1	= Cost of Living Adjustment
Weekly payment amount increased for cost of living adjustment.
2	= Fraud/Misrepresentation
Weekly payment amount reduced due to fraud/misrepresentation as defined by the jurisdiction.
BENEFIT ADJUSTMENT END DATE – DN0125
Definition:     The last date through which the benefit adjustment was applied to the Benefit
Type Code. Orig/Rev:     07/01/97 Record:       R22 Format:       8 DATE

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BENEFIT ADJUSTMENT START DATE – DN0094
Definition: The first date of the uninterrupted period in which the current Benefit Adjustment Weekly Amount was applied to the Benefit Type Code. For acquired claims, the Benefit Adjustment Start Date will be the first date of the uninterrupted period in which the current Benefit Adjustment Weekly Amount was applied to the Benefit Type Code by the acquiring claim administrator. This may be prior to the acquisition date if the acquiring claim administrator issued an adjustment for a period of time in which the file was handled by the previous claim administrator.
Orig/Rev:     03/11/94, 07/01/97, 03/15/05, 06/28/05, 11/22/05, 01/01/08
Record:       R22
Format:       8 DATE
BENEFIT ADJUSTMENT WEEKLY AMOUNT – DN0093
Definition:     The weekly amount of benefit adjustment corresponding to the Benefit
Adjustment Code. Orig/Rev:     07/24/95, 07/01/97, 01/01/09 Record:       R22 Format:       $9.2 DP Rule:      If the period represented by the Benefit Adjustment Start Date and Benefit
Adjustment End Date are less than 7 days, the Benefit Adjustment Weekly
Amount may represent the actual amount of the adjustment rather than being a
weekly amount.

BENEFIT CREDIT CODE – DN0126
Definition:
Orig/Rev:
Record:
Format:
A code identifying a reduction that is applied to the Gross Weekly Amount to
yield a new Net Weekly Amount to recoup monies previously paid.
07/01/97, 04/24/03
R22
4 A/N (BNNN)
B = Benefit Credit Code (see values below)
NNN = Benefit Type Code (DN0085)
Values:
C = Overpayment
Recoupment of benefits paid, but not due.
M = Credit for Employer Provided Benefits in Excess of Covered Weekly Benefit
Claim administrator’s liability for payment of certain benefits is reduced or fully offset because the employer provided excess payments to the worker (in excess of the weekly benefit amount) by agreement, as provided by jurisdiction.
P = Advance
Reimbursement of pre-paid benefit/advance.
BENEFIT CREDIT END DATE – DN0128
Definition:     The last date through which the benefit credit was applied to the Benefit Type
Code. Orig/Rev:     07/01/97 Record:       R22 Format:       8 DATE

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BENEFIT CREDIT START DATE – DN0127
Definition: The first date of the uninterrupted period in which the current Benefit Credit Weekly Amount was applied to the Benefit Type Code. For acquired claims, the Benefit Credit Start Date will be the first date of the uninterrupted period in which the current Benefit Credit Weekly Amount was applied to the Benefit Type Code by the acquiring claim administrator. This may be prior to the acquisition date if the acquiring claim administrator issued a credit for a period of time in which the file was handled by the previous claim administrator.
Orig/Rev:     07/01/97, 03/15/05, 06/28/05, 11/22/05, 01/01/08
Record:       R22
Format:       8 DATE
BENEFIT CREDIT WEEKLY AMOUNT – DN0129
Definition: The weekly amount of benefit credit corresponding to the Benefit Credit Code (DN0126).
Orig/Rev:     07/01/97, 01/01/09
Record:       R22
Format:       $9.2
DP Rule: If the period represented by the Benefit Credit Start Date and Benefit Credit End Date are less than 7 days, the Benefit Credit Weekly Amount may represent the actual amount of the credit rather than being a weekly amount.
BENEFIT PAYMENT ISSUE DATE - DN0192
Definition: For IP, AP, PY, RB: The date that the check that initiated the MTC is officially surrendered during business hours to a letter delivery organization; or available for pickup per agreement with the employee. For Sx MTC's, the Benefit Payment Issue Date is the date the last indemnity check was issued prior to the suspension. For CO transactions that have an MTCC of IP, AP, PY, or RB: the date of the check that initiated the IP, AP, PY, or RB that received a TE acknowledgment code.
Orig/Rev:     03/01/06
Record:       R22
Format:       8 DATE
DP Rule: The Benefit Payment Issue Date is in the Benefits Segment. The equivalent of this data element in the Payments Segment is Payment Issue Date (DN0195). Refer to Variable Segment Population Rules (Benefits Segment and Payments Segment) in Section 4. The Steering Committee/EDI Council directed that Payment Issue Date (DN0195) (and the corresponding Benefit Payment Issue Date DN0192) was established for specified transactions only (IP, AP, PY, RB, Sx or any corresponding 02 or CO for those specified Maintenance Type Codes) and that individual weekly check information would not be reported.
For IP, AP, RB MTC's when No Payment Due - No Payment Issued - When no payment is due the claimant because Actual Reduced Earnings (DN0124), Deemed Reduced Earnings (DN0147) and/or Benefit Adjustment Weekly Amount(s) (DN0093) have resulted in a Net Weekly Amount (DN0087) of zero, the MTC Date should be used as the Benefit Payment Issue Date.

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BENEFIT PERIOD START DATE – DN0088
Definition: For all MTC’s that are initiating or reinstating a Benefit Type Code (AB, IP, RB, EP, ER, CB): The Benefit Period Start Date is the first date of the uninterrupted period of benefit payments that corresponds to the Benefit Type Code. For MTC AP and all subsequent MTC’s filed on acquired claims, the Benefit Period Start Date is the first date of the uninterrupted period of benefit payments made by the acquiring claim administrator that corresponds to the Benefit Type Code. This may be prior to the acquisition date if the acquiring claim administrator issued payment(s) for a period of time in which the file was handled by the previous claim administrator.
For MTC’s (on non-acquired claims) that are not initiating or reinstating a Benefit Type Code (Sx, Px, PY, CA, RE, PD, CO, FN, AN, BM, BW, MN, QT, SA, UR, and 04 if preceded by payment): The Benefit Period Start Date is the earliest date for that Benefit Type Code regardless of whether multiple benefit periods have been paid for that Benefit Type Code.
Orig/Rev:     03/11/94, 07/1/97, 04/26/03, 03/15/05, 11/22/05, 01/01/08
Record:       R22
Format:       8 DATE
DP Rule: One per Benefit Type Code used. Benefit Period Start Date should not be edited on full or partial settlements as they may vary considerably from one claim administrator to the other.
BENEFIT PERIOD THROUGH DATE – DN0089
Definition: For all MTC’s that are initiating or reinstating a Benefit Type Code (AB, AP, IP, RB, EP, ER, CB): The Benefit Period Through Date is the latest date of the uninterrupted period of benefit payments that corresponds to the Benefit Type Code.
For MTC’s that are not initiating or reinstating a Benefit Type Code (Sx, Px, PY, CA, RE, PD, CO, FN, AN, BM, BW, MN, QT, SA, and UR): The Benefit Period Through Date is the latest date for that Benefit Type Code regardless of whether multiple benefit periods have been paid for that Benefit Type Code.
Orig/Rev:     03/28/94, 07/1/97, 04/26/03
Record:       R22
Format:       8 DATE
DP Rule: One per Benefit Type Code used. Benefit Period Through Date should not be edited on full or partial settlements as they may vary considerably from one claim administrator to the other. Benefit Period Through Date may be a future date if Permanent Partial Scheduled Benefits (030 or 530) are paid in a lump sum.
BENEFIT REDISTRIBUTION CODE – DN0130
Definition: A code identifying that a portion of the Net Weekly Amount is directed to another party on behalf of the employee or beneficiary, but which does not reduce the Gross Weekly Amount or affect the Net Weekly Amount.
Orig/Rev:     07/01/97, 04/24/03
Record:       R22
Format:       4 A/N (BNNN)
B = Benefit Redistribution Code (see values below) NNN = Benefit Type Code (DN0085)
Values:       H = Court Ordered Lien
A portion of the Net Weekly Amount which is being sent to another party on behalf of the employee as a result of a court order (i.e. Child Support)
K = Claimant Attorney Fees
A portion of the Net Weekly Amount which is being sent to another party on behalf of the employee in order to pay attorney fees.

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BENEFIT REDISTRIBUTION END DATE – DN0132
Definition:     The last date through which the benefit redistribution was applied to the Benefit
Type Code. Orig/Rev:     07/01/97 Record:       R22 Format:       8 DATE
BENEFIT REDISTRIBUTION START DATE – DN0131
Definition: The first date of the uninterrupted period in which the current Benefit Redistribution Weekly Amount was applied to the Benefit Type Code. For acquired claims, the Benefit Redistribution Start Date will be the first date of the uninterrupted period in which the current Benefit Redistribution Weekly Amount was applied to the Benefit Type Code by the acquiring claim administrator, This may be prior to the acquisition date if the acquiring claim administrator issued a redistribution for a period of time in which the file was handled by the previous claim administrator.
Orig/Rev:     07/01/97, 03/15/05, 06/28/05, 11/22/05, 01/01/08
Record:       R22
Format:       8 DATE
BENEFIT REDISTRIBUTION WEEKLY AMOUNT – DN0133
Definition:     The weekly amount of benefit redistribution corresponding to the Benefit
Redistribution Code (DN0130). Orig/Rev:     07/01/97, 01/01/09 Record:       R22 Format:       $9.2 DP Rule:      If the period represented by the Benefit Redistribution Start Date and Benefit
Redistribution End Date are less than 7 days, the Benefit Redistribution Weekly
Amount may represent the actual amount of the redistribution rather than being a
weekly amount.
BENEFIT TYPE AMOUNT PAID – DN0086
Definition:     The cumulative paid to date amount for the Benefit Type Code(s) being reported.
For acquired claims, the Benefit Type Amount Paid will be the cumulative paid to
date amount by the acquiring claim administrator. Orig/Rev:     03/11/94, 07/01/97, 04/24/03, 02/24/05, 03/15/05 Record:       R22 Format:       $9.2 DP Rule:      One per Benefit Type (DN0085) Code used. Not required for Benefit Type Code
240.
BENEFIT TYPE CLAIM DAYS – DN0091
Definition:     The residual number of days after determining the Benefit Type Claim Weeks
(DN0090).
For acquired claims, the Benefit Type Claim Days will be the residual number of
days after determining the Benefit Type Claim Weeks paid by the acquiring claim
administrator. Orig/Rev:     03/11/94, 07/01/97, 04/24/03, 02/8/05, 02/24/05, 03/15/05, 11/22/05 Record:       R22 Format:       1 N Values:       0 through 6 DP Rule:      One per Benefit Type Code used. Benefit Type Claim Days may not be required
for Benefit Type Code 240, full or partial settlements, or lump sum payments with
a Benefit Type Code of 5XX.

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BENEFIT TYPE CLAIM WEEKS – DN0090
Definition:     The cumulative number of whole weeks paid for a Benefit Type Code (DN0085)
for all benefit periods.
For acquired claims, the Benefit Type Claim Weeks will be the cumulative
number of whole weeks paid for a Benefit Type Code, by the acquiring claim
administrator. Orig/Rev:     03/11/94, 07/01/97, 04/24/03, 02/8/05, 02/24/05, 03/14/05, 11/22/05 Record:       R22 Format:       4 N DP Rule:      One per Benefit Type Code used. Benefit Type Claim Weeks may not be
required for Benefit Type Code 240, full or partial settlements, or lump sum
payments with a Benefit Type Code of 5XX.
BENEFIT TYPE CODE – DN0085
Definition:     A code identifying the payment being made.
Orig/Rev:     09/16/94, 07/01/97, 04/26/03, 02/8/05
Record:       R22
Format:       3 A/N
Values:       010 = Fatal
Benefits paid or payable for the death of the claimant resulting from a work-related accident or occupational injury or disease.
020	= Permanent Total
Benefits paid or payable for the loss of or the permanent loss of use of any body part or function, which renders the claimant unable to engage in any employment or occupation.
021	= Permanent Total Supplemental
Benefits paid to supplement permanent total benefits.
030 = Permanent Partial Scheduled
Benefits paid or payable as established by a statutory list (schedule) of payments for certain injuries. The benefit amount is determined by the part of body that was injured subject to limitations set forth in the statute. This includes:
Wage loss without impairment – (Florida - accident dates of 08/01/79 through 12/31/93) Benefits paid or payable for injuries not resulting in permanent disability, but with an impairment rating of at least 1% and post-injury wages of less than 80% of the pre-injury wage.
Impairment income benefits – (Florida - accident dates 01/01/94 and subsequent) Paid scheduled Impairment Benefits on permanent partial claims.
Supplemental earnings without permanent partial – (Louisiana - accident dates of 07/01/83 and subsequent) Benefits paid or payable for injuries, which are not covered by permanent partial schedule that cause wage loss of at least 10%.
Scheduled Disabilities – Benefits paid or payable for injuries that specifically appear on the schedule.
Economic Recovery – (Minnesota - Accident dates of 01/01/84 and subsequent) Benefits paid or payable for permanent partial injuries not covered in the schedule.

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040 = Permanent Partial Unscheduled
Benefits paid or payable for injuries to parts of the body not covered by a schedule. These benefits are payable for the claimant’s actual wage loss or reduction in wage earning ability, subject to limitations set forth in the statute. This includes:
Supplemental Income Benefits - (Florida - accident dates of 01/01/94 and subsequent) Paid supplemental benefits after the expiration of Scheduled Impairment benefits on Permanent Partial claims.
Supplemental Earnings and Permanent Partial – (Louisiana - accident dates of 07/01/83 and subsequent) Benefits paid or payable for the anatomical loss of use of 25% loss of physical function of a member, in addition to permanent partial benefits.
Other Partial Disability – Benefits paid or payable for injuries not appearing on the schedule.
050	= Temporary Total
Benefits paid or payable for the period during which the claimant is unable to perform any work for pay as a result of disability from which that individual can be expected to fully recover, and which period precedes the date of maximum medical improvement.
051	= Temporary Total Catastrophic
Temporary Total Benefits (defined in 050 above) paid for catastrophic injuries.
070 = Temporary Partial
Benefits paid or payable for the period during which the claimant, as a result of disability from which he/she is expected to fully recover, is unable to perform work for his/her regular pay, but is receiving or is entitled to receive a reduced rate of pay, and which period precedes the date of maximum medical improvement.
080 = Employers Liability
Reports the indemnity loss portion of Employer’s Liability.
090 = Permanent Partial Disfigurement
Benefits paid or payable for any scarring or cosmetic defect.
Includes:
Impairment Without Wage Loss - (Florida - accident dates of 08/01/79 through 12/31/93) Benefits paid or payable for amputation, loss of 80% or more of vision of either eye after correction, or serious facial or head disfigurement resulting from an injury, not resulting in a Permanent Total award without any wage loss benefits.
Permanent Partial Without Supplemental Earnings – (Louisiana -accident dates of 07/01/83 and subsequent) Benefits paid or payable for permanent partial injuries without supplemental earnings.
Impairment Compensation – (Minnesota - accident dates of 01/01/84 and subsequent) Benefits paid pr payable for scheduled permanent partial injuries.
210 = Employer Paid Fatal Benefits
Wages paid by the employer in lieu of Fatal/Death compensation due.

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230 = Employer Paid Permanent Partial Scheduled
Wages paid by the employer in lieu of Permanent Partial Scheduled compensation due.
240 = Employer Paid Unspecified
Wages paid by the employer in lieu of compensation of an unspecified benefit type due.
242 = Employer Paid Vocational Rehabilitation Maintenance
Wages paid by the employer in lieu of Vocational Rehabilitation Maintenance compensation due.
250	= Employer Paid Temporary Total
Wages paid by the employer in lieu of Temporary Total compensation due.
251	= Employer Paid Temporary Total Catastrophic
Wages paid by the employer in lieu of Temporary Total Catastrophic compensation due.
270 = Employer Paid Temporary Partial
Wages paid by the employer in lieu of Temporary Partial compensation due.
410 = Vocational Rehabilitation Maintenance
Weekly maintenance benefits paid while the claimant is participating in vocational rehabilitation program.
500	Unspecified Lump Sum Payment/Settlement
Lump sum payment/ settlement amount that cannot be assigned to a specific benefit type.
501	Medical Lump Sum Payment/Settlement
Lump Sum Payment/Settlement amount to end past, present, and/or future
medical exposure.
510 Fatal Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for benefits paid or payable for the death of the claimant resulting from a work-related accident or occupational injury or disease.
520	Permanent Total Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for benefits paid or payable for the loss of or the permanent loss of use of any body part or function which renders the claimant unable to engage in any employment or occupation.
521	Permanent Total Supplemental Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for permanent total supplemental benefits.
524 Employer Paid Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for wages paid by the employer in lieu of compensation of an unspecified benefit type due.

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530 Permanent Partial Scheduled Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for benefits paid or payable as established by a statutory list (schedule) of payments for certain injuries. The benefit amount is determined by the part of the body that was injured subject to limitations set forth in the statute. Includes, as described above in Benefit Type Code 030 Permanent Partial Scheduled: -- Wage Loss Without Impairment - - Impairment Income Benefits – Supplemental Earnings Without Permanent Partial – Scheduled Disabilities-Economic Recovery
540	Permanent Partial Unscheduled Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present or future liability for benefits paid or payable for injuries to parts of the body not covered by a schedule. These benefits are payable for the claimant's actual wage loss or reduction in wage earning ability, subject to limitations set forth in the statute. Includes, as described above in Benefit Type Code 040 Permanent Partial Unscheduled:- Supplemental Income Benefits - Supplemental Earnings and Permanent Partial - Other Partial Disability
541	Vocational Rehabilitation Maintenance Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for weekly maintenance benefits paid while the claimant is participating in a vocational rehabilitation program.

550	Temporary Total Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for benefits paid or payable for the period during which the claimant is unable to perform any work for pay as a result of disability from which that individual can be expected to fully recover and which period precedes the date of maximum medical improvement.
551	Temporary Total Catastrophic Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for benefits paid for catastrophic injuries.
570 Temporary Partial Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability benefits paid or payable for the period during which the claimant, as a result of a disability from which he/she is expected to fully recover, is unable to perform work for his/her regular pay, but is receiving a reduced rate of pay and which period precedes the date of maximum medical improvement.
580 Employers Liability Lump Sum Payment/Settlement
Lump Sum Payment/Settlement amount to end past, present, or future liability for
the indemnity loss portion of employer’s liability.
590 Permanent Partial Disfigurement Lump Sum Payment/Settlement Lump Sum Payment/Settlement amount to end past, present, or future liability for benefits paid or payable for any scarring or cosmetic defect. Includes, as described above in Benefit Type Code 090 Permanent Partial Disfigurement: --Impairment Without Wage Loss –Permanent Partial Without Supplemental Earnings - Impairment Compensation.

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CALCULATED WEEKLY COMPENSATION AMOUNT – DN0134
Definition: The result of multiplying the employee’s Average Wage (DN0286) by the statutory percentage and applying the minimum and maximum compensation amounts.
Orig/Rev:     07/01/97
Record:       R22
Format:       $9.2
CAUSE OF INJURY CODE – DN0037
Definition: The code corresponding to the cause of the injury based on the information available to the claim administrator.
Orig/Rev:     03/11/94, 07/01/97, 04/26/03
Record:       148
Format:       2 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org
DP Rule: This code is subjective in nature and is assigned based on employer supplied text and other information available to the claim administrator. Minor differences between the code supplied and the text that supports the code should be expected based on the fact that the claim administrator is using additional information to meet their reporting needs.
CLAIM ADMINISTRATOR ALTERNATE POSTAL CODE – DN0200
Definition:     The alternate postal code of the claim adjusting office handling the claim as
defined by the jurisdiction. Orig/Rev.:     03/09/06 Record:       R21; R22; AKC; ARD Format:       9 A/N DP Rule:      The 9-digit code associated with the Claim Administrator FEIN (DN00187). For
the United States and its territories, this will be the USPS zip code.
CLAIM ADMINISTRATOR CITY – DN0012
Definition:     The city of the claim adjusting office handling the claim. This will be the carrier’s
claim adjusting office if there is no TPA. Orig/Rev.:     06/07/95, 07/01/97, 04/30/04, 03/09/06 Record:       148 Format:       15 A/N
CLAIM ADMINISTRATOR CLAIM NUMBER – DN0015
Definition:     An identifier for a specific claim within a claim administrator’s claims processing
system. Orig/Rev:     06/07/95, 07/01/97 Record:       148; A49; R22; R21; AKC; ARC Format:       25 A/N DP Rule:      This data element shall not contain leading spaces or leading special characters.
The number may contain embedded spaces and special characters.
CLAIM ADMINISTRATOR CLAIM REPRESENTATIVE BUSINESS PHONE NUMBER – DN0137
Definition:     The telephone number of the individual responsible for handling the claim.
Orig/Rev:     07/01/97, 04/26/03
Record:       R22
Format:       15 A/N
DP Rule:      Standard telephone numbers are 10 numeric positions (area code and number).
The additional 5 bytes should be used for a numeric extension, when applicable.
The numeric extension immediately follows the 10 digit phone number and can
be 0 to 5 positions in length.

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CLAIM ADMINISTRATOR CLAIM REPRESENTATIVE E-MAIL ADDRESS - DN0138
Definition:	The Internet E-mail address of the individual responsible for handling the claim.
Orig/Rev:	07/01/97, 04/26/03
Record:	R22
Format:	80 A/N
CLAIM ADMINISTRATOR CLAIM REPRESENTATIVE FAX NUMBER - DN0139
Definition:	The fax number of the individual responsible for handling the claim.
Orig/Rev:	07/01/97, 04/26/03
Record:	R22
Format:	10 A/N
CLAIM ADMINISTRATOR CLAIM REPRESENTATIVE NAME - DN0140
Definition:	The name of the individual working for the claim administrator that is responsible
for handling the claim.
Orig/Rev:	07/01/97, 04/26/03
Record:	R22
Format:	40 A/N
DP Rule:	This field may be invalid or not available on a periodic or final if the claim
administrator is not currently paying indemnity benefits. Jurisdictions recommend that this data element be updated upon the triggering of a new event. A claim representative name change does not require the triggering of a change transaction.
This field should be populated as follows:
•	First name, middle initial, last name (no prefix or suffix) with commas as the delimiters (e.g., John,J,Smith)
•	If there is no middle initial, a comma must be inserted in its place (leaving two commas between the first and last name) (e.g., John,,Smith)
•	Only hyphens and apostrophes may be sent as special characters
•	Multiple word first and last names must be separated by a space (e.g., Mary Jane,L,Smith or Mary,L,Smith Baker)
•	Do not abbreviate words or use acronyms if there is enough room in the field to enter the entire name.
CLAIM ADMINISTRATOR COUNTRY CODE - DN0136
Definition:	The country code of the claim adjusting office handling the claim. This will be the
carrier’s claim adjusting office if there is no TPA.
Orig/Rev:	07/01/97, 04/26/03, 04/30/04, 03/09/06
Record:	R21
Format:	3 A/N
Values:	See IAIABC Website: www.iaiabc.org
DP Rule:	Not required unless other than US.
Values are 2 digit left-justified
CLAIM ADMINISTRATOR FEIN - DN0187
Definition:	The Federal Employer Identification Number of the entity licensed or allowed by
a jurisdiction to adjust a claim.
Orig/Rev:	07/01/97, 04/26/03
Record:	R21; R22; AKC; ARC
Format:	9 A/N
DP Rule:	Always required. Claim Administrator FEIN may match Insurer FEIN.

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CLAIM ADMINISTRATOR INFORMATION/ATTENTION LINE – DN0135
Definition:     The name of the person, department or other information to facilitate delivery
within the claim administrator’s organization. Orig/Rev:     07/01/97, 03/09/06 Record:       R21 Format:       50 A/N DP Rule:      This is a free form text field that cannot be edited by the jurisdiction.
CLAIM ADMINISTRATOR NAME – DN0188
Definition:     The legal name of the entity adjusting the claim.
Orig/Rev:     07/01/97, 05/13/03
Record:       R21; R22
Format:       40 A/N
DP Rule: Always required. Name may match Insurer Name if the insurance carrier or self-insured employer is administering the claim. Otherwise, it is the entity contracted to adjust the claim on behalf of the insurance carrier or self-insured employer.
CLAIM ADMINISTRATOR POSTAL CODE – DN0014
Definition: The postal code of the claim adjusting office handling the claim. This will be the carrier’s claim adjusting office if there is no TPA.
Orig/Rev.:     08/09/95, 07/01/97, 04/30/04, 12/19/05, 03/09/06
Record:       148; A49; AKC; ARC
Format:       9 A/N
DP Rule: For the United States and its territories, this will be the USPS zip code. For non-U.S. and its territories, refer to each country’s postal code list.
CLAIM ADMINISTRATOR PRIMARY ADDRESS – DN0010
Definition:     The address of the claim adjusting office handling the claim. This will be the
carrier’s claim adjusting office if there is no TPA. Orig/Rev.:     06/07/95, 07/01/97, 04/30/04, 03/09/06 Record:       R21 Format:       40 A/N
CLAIM ADMINISTRATOR SECONDARY ADDRESS – DN0011
Definition:     The address of the claim adjusting office handling the claim. This will be the
carrier’s claim adjusting office if there is no TPA. Orig/Rev.:     06/07/95, 07/01/97, 04/30/04, 03/09/06 Record:       R21 Format:       40 A/N DP Rule:      The Secondary Address field is for overflow text, characters that exceed the field
length. It is not for formatting, such as a second address line, mailstop or PO
Box. If the entire street address fits in the Primary Address field, the Secondary
Address field is not used. Do not use two lines.
CLAIM ADMINISTRATOR STATE CODE – DN0013
Definition:     The state code of the claim adjusting office handling the claim. This will be the
carrier’s claim adjusting office if there is no TPA. Orig/Rev.:     03/11/94, 07/01/97, 04/26/03, 04/30/04, 03/09/06 Record:       148 Format:       2 A/N Values:       See link to code list at IAIABC Website: www.iaiabc.org

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CLAIM STATUS CODE – DN0073
Definition:     A code representing the claim administrator’s current status. Orig/Rev:     06/07/95, 07/01/97, 04/26/03 Record:      A49; R21 Format:       1 A/N Values:       O = Open
C = Closed
R = Re-open
X = Re-open/Closed
CLAIM TYPE CODE – DN0074
Definition:     A code representing the current classification of the claim as interpreted by the
jurisdiction. Orig/Rev:     08/09/95, 07/01/97, 05/27/03, 02/08/05, 05/05/06 Record:      A49; R21 Format:       1 A/N Values:       M = Medical Only
I = Lost Time/Indemnity
N = Notification Only
B = Became Medical Only
L = Became Lost Time/Indemnity
CONCURRENT EMPLOYER CONTACT BUSINESS PHONE NUMBER – DN0142
Definition:     The phone number associated with the Concurrent Employer Name.
Orig/Rev:     07/01/97
Record:       R22
Format:       15 A/N
DP Rule:      Standard telephone numbers are 10 numeric positions (area code and number).
The additional 5 bytes should be used for a numeric extension, when applicable.
The numeric extension immediately follows the 10 digit phone number and can
be 0 to 5 positions in length.
CONCURRENT EMPLOYER NAME – DN0141
Definition:
The legal name of an additional employer who employed the employee,
independently of the employer associated with the injury, during the period when
the injury occurred.
Orig/Rev: Record: Format: DP Rule:
07/01/97
R22
40 A/N
This is the employee’s additional employer at the time of injury which is not
otherwise reported, e.g. regular, lessee, lessor, or joint liability employer.
CONCURRENT EMPLOYER WAGE – DN0143
Definition:
The average wage the employee was earning at a concurrent employer at the
time of the injury as calculated by the Claim Administrator or jurisdictional
authority for the wage period.
Orig/Rev: Record: Format: DP Rule:
07/01/97, 04/26/03
R22
$9.2
The wage period for the concurrent employer is always equivalent to the Wage
Period Code (DN0063) for the primary employer.

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CURRENT DATE DISABILITY BEGAN - DN0144
Definition:	The first qualifying day of disability in the current period of disability being
reported.
Orig/Rev:	07/01/97, 05/27/03
Record:	R22
Format:	8 DATE
DP Rule:	This date is used on subsequent periods of disability.   An Initial Date Disability
Began (DN0056) should have already been sent, or the Current Date Disability Began should represent a subsequent period of disability in the same transaction, i.e., waiting period (see non-consecutive period code).
CURRENT DATE LAST DAY WORKED - DN0145
Definition:	The last day worked prior to the first day of disability for a period subsequent to
the first period of disability.
Orig/Rev:	07/01/97, 05/27/03, 01/01/09
Record:	R22
Format:	8 DATE
DP Rule:	This date is used on subsequent periods of disability.
•	An Initial Date Last Day Worked (DN0065) should have already been sent, or the Current Date Last Day Worked should represent a subsequent period of disability in the same transaction, i.e., waiting period (see non-consecutive period code).
•	Is after the Initial Date Last Day Worked
•	Is on or before the Current Date Disability Began
•	
CURRENT RETURN TO WORK DATE – DN0072
Definition:
The date, following the most recent disability period, on which the employee
actually returned to work, or was released to return to work, as identified by the
Return to Work Type Code (DN0189).
Orig/Rev: Record: Format: DP Rule:
06/07/95, 07/01/97, 05/27/03
A49
8 DATE
This date is used on subsequent periods of disability. An Initial Return to Work
Date (DN0068) should have already been sent, or the Current Return to Work
Date should represent a subsequent period of disability in the same transaction,
i.e., waiting period (see non-consecutive period code).
DATE CLAIM ADMINISTRATOR HAD KNOWLEDGE OF LOST TIME – DN0298
Definition:
The date the claim administrator was notified or became aware that the
employee was disabled beyond the waiting period and/or was entitled to
Orig.Rev.:
Record:
Format:
indemnity benefits.
04/27/04
R22
8 DATE
DATE CLAIM ADMINISTRATOR HAD KNOWLEDGE OF THE INJURY – DN0041
Definition:     The earlier of the date(s) the claim administrator or the insurer first received
notice of the accident or injury from any source. Orig/Rev:     03/11/94, 07/01/97 Record:       148 Format:       8 DATE DP Rule:      If the notice of loss or occurrence is passed from one entity to another; i.e.
Insurer to TPA, then the date reported will be the date that the first entity had
knowledge of the occurrence, whether notification was by phone, fax, mail, or
any other means.

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DATE CLAIM ADMINISTRATOR NOTIFIED OF EMPLOYEE REPRESENTATION – DN0076
Definition:     The date the claim administrator was notified that the employee or beneficiary
has secured legal representation. Orig/Rev:     06/07/95, 07/01/97 Record:      A49 Format:       8 DATE DP Rule:      In California, this is the date the attorney lien was filed.
DATE EMPLOYER HAD KNOWLEDGE OF DATE OF DISABILITY – DN0281
Definition: The date the employer was notified or became aware of the initial or subsequent period of the employee’s work-related disability/incapacity.
Orig/Rev:     12/01/02
Record:       R21; R22
Format:       8 DATE
DP Rule: This date may be equal to or different than Date Employer Had Knowledge of the Injury (DN0040). This date is used to reflect when the employer was aware of the Initial Date Disability Began (DN0056) or Current Date Disability Began (DN0144), as applicable.
DATE EMPLOYER HAD KNOWLEDGE OF THE INJURY – DN0040
Definition:     The earlier of the date that the accident was reported to the employer or the date
that the employer had actual knowledge of an accident or injury. Orig/Rev:     06/07/95, 07/01/97 Record:       148 Format:       8 DATE

DATE OF INJURY – DN0031
Definition:
Orig/Rev:
Record:
Format:
For traumatic injury, the date on which the accident occurred. For occupational disease or cumulative injury, the date of injury is the date of last injurious exposure to the cause or substance creating the condition; unless otherwise defined by statute. 03/11/94, 07/01/97 148; A49 8 DATE

DATE OF MAXIMUM MEDICAL IMPROVEMENT – DN0070
Definition:
The date after which further recovery from or lasting improvement to an injury or
disease can no longer be anticipated, based upon reasonable medical
probability.
Orig/Rev:
Record:
Format:
03/11/94, 07/01/97
A49
8 DATE
DATE PROCESSED – DN0108
Definition:
The date that the receiver processed the detail transaction. Together with the
time processed and a record sequence number, it will uniquely identify a specific
acknowledgment detail record.
Orig/Rev:
Record:
Format:
08/09/95
AKC; ARC
8 DATE

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DATE TRANSMISSION SENT – DN0100
Definition:     Actual date the batch of data was sent to the receiver. Orig/Rev:     06/07/95, 07/01/97, 05/25/04 Record:       HD1 Format:       8 DATE
DEATH RESULT OF INJURY CODE – DN0146
Definition:     A code that indicates whether the worker’s death was a result of the injury. Orig/Rev:     07/01/97 Record:       R21; R22 Format:       1 A/N Values:       Y = Yes
N = No
U = Unknown
DEEMED REDUCED EARNINGS – DN0147
Definition:     The estimated weekly wages an employee would have earned had they actually
returned to work. Orig/Rev:     07/01/97 Record:       R22 Format:       $9.2
DENIAL REASON NARRATIVE – DN0197
Definition: A description identifying reasons for denying a claim in its entirety or defending the assertion. The narrative may be used to present denial reasons not identified by code(s) or to provide a factual basis supporting and information for the denial reason(s) identified by codes(s). If both code and text are required, the narrative will contain only reasons in excess of the five codes, as text, and/or supporting information for any reasons submitted. Narrative reason will not include code values. The narrative will not be required to be a text equivalent of the denial reason codes. The narrative description will not invalidate a denial reason code.
Orig/Rev:     07/01/97, 11/30/98, 05/08/02, 03/1/05, 11/04/05, 9/9/09
Record:      R21; R22
Format:       150 A/N (up to 3 occurrences of 50)
DP Rule: This is only applicable on MTC 04, PD (or its corresponding CO), 02 or UR. A FROI or SROI MTC 02 changing the denial reason narrative will only update the denial reason narrative on the most recently accepted denial transaction, regardless of whether the most recent denial reported was a FROI or a SROI transaction. See Variable Segment Population Rules for Denial Reason Narratives Segment in Section 4 for further explanation.
DENIAL RESCISSION DATE – DN0196
Definition:     The date a previous denial was revoked.
Orig/Rev:     07/01/97, 11/30/98, 05/08/02, 03/1/05, 02/08/06, 9/21/06
Record:       R22
Format:       8 DATE
DP Rule: This is only applicable on MTC IP, AP, PD, PY, RB, EP, ER, CD, VE, (or their corresponding CO), 02 or UR. This may also be applicable on MTC FN, AN, BM, BW, MN, QT, or SA if the claim administrator is rescinding a “Medical Only” denial.

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DEPENDENT/PAYEE RELATIONSHIP CODE – DN0097
Definition:     The code identifying the relationship of the qualified dependent(s)/payee(s) to the
deceased employee. Orig/Rev:     09/16/94, 07/01/97, 09/21/06 Record:      A49
Format:       2 A/N (first position is relationship and second position is birth order) Values:       R = Relationship
2	= Widow
3	= Widower
4	= Son or Daughter
5	= Brother or Sister
6	= Mother or Father
7	= Disabled Child
8	= Jurisdiction Fund/Estate (e.g., Death Without Dependents Fund – CA; Subsequent Injury Fund – TX; Employee’s Estate – MN)
9	= Other
N = Numerical Birth Order
0 – 9 Birth order for each Relationship classification (Use 0 when paying Jurisdiction Fund/Estate) DP Rule:      Both positions must be populated with values before being sent to the jurisdiction
DETAIL RECORD COUNT – DN0106
Definition:     Total number of records sent as part of this batch. This count represents the number of records where the Record Type Qualifier is not equal to HD1 or TR2. Orig/Rev:     08/18/94, 07/01/97 Record:       TR2 Format:       9 N
DISCONTINUED FRINGE BENEFITS – DN0149
Definition:     The amount of non-salary remuneration which the employer has discontinued as
applicable to the calculation of benefits per the jurisdiction. Orig/Rev:     07/01/97 Record:       R22 Format:       $9.2
ELEMENT ERROR NUMBER – DN0116
Definition:     A number to uniquely identify the edit performed on an element and is part of the
error report. Orig/Rev:     07/21/93, 07/01/97, 07/17/02 Record:       AKC; ARC Format:       3 A/N DP Rule:      Refer to Error Message Dictionary and Edit Matrix
ELEMENT ERROR TEXT – DN0291
Definition:     A free form text conveying additional information regarding the error detected on
the data element. It is part of the error segment. Orig/Rev:     06/01/02 Record:       AKC; ARC Format:       50 A/N

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ELEMENT NUMBER
Definition:
Orig/Rev:
Record:
Format:

DN0115
A unique number assigned to each data element and is part of the error segment. Abbreviation used “DN”. 08/18/94, 07/12/02 AKC; ARC 4 A/N

EMPLOYEE AUTHORIZATION TO RELEASE MEDICAL RECORDS INDICATOR – DN0150
Definition:     An indicator that the employee’s written authorization to release medical records
related to the injury is on file. Orig/Rev:     07/01/97, 11/30/98 Record:       R21 Format:       1 A/N Values:       Y = Yes
N = No
EMPLOYEE DATE OF BIRTH – DN0052
Definition:     The date the employee was born. Orig/Rev:     06/07/95, 07/01/97, 05/27/03 Record:       148; R22 Format:       8 DATE
EMPLOYEE DATE OF DEATH – DN0057
Definition:     The date the employee died. Orig/Rev:     06/07/95, 07/01/97 Record:       148; A49 Format:       8 DATE

EMPLOYEE DATE OF HIRE – DN0061
Definition:
The date the employee began his/her employment with the employer under
whose coverage the claim is being filed. If there have been multiple periods of
employment with the same employer, this would be the beginning date of the
Orig/Rev: Record: Format: DP Rule:
current employment period.
03/11/92, 07/01/97, 05/22/03
148
8 DATE
If only employee’s number of years employed is known, an appropriate date
should be calculated using the Date of Injury month and 01 for the day.
EMPLOYEE EDUCATION LEVEL – DN0151
Definition:     The highest number of years or equivalency level of formal education completed.
Orig/Rev:     07/01/97
Record:       R22
Format:       2 N
Values:       12 = High School Grad/GED
NN = Actual grade of completion (e.g. 06, 15)
EMPLOYEE EMPLOYMENT VISA – DN0152
Definition:     The number assigned to an endorsement to a passport, by the proper authority, to note examination of the passport, and authorization of the bearer to proceed. Orig/Rev:     07/01/97 Record:       R21; R22 Format:       15 A/N

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EMPLOYEE FIRST NAME – DN0044
Definition:     The employee’s legally recognized first name. Orig/Rev:     06/07/95, 07/01/97 Record:       148; R22 Format:       15 A/N
DP Rule:      This field may only include a hyphen, apostrophe or multiple words if contained in the person’s legally recognized last name.
EMPLOYEE GENDER CODE – DN0053
Definition:     The code indicating the sex of the employee. Orig/Rev:     03/11/94, 07/01/97, 05/28/03 Record:       148 Format:       1 A/N Values:       M = Male
F = Female
U = Unknown

EMPLOYEE GREEN CARD – DN0153
Definition:
The number assigned by the United States Government and issued on an Official
Document to foreign nationals permitting them to work in the United States.
Orig/Rev:
Record:
Format:
(Alien identification number.)
07/01/97
R21; R22
15 A/N
EMPLOYEE ID ASSIGNED BY JURISDICTION – DN0154
Definition:     A number assigned to the employee by the jurisdiction in the absence of the
preferred identifier. Orig/Rev:     07/01/97 Record:       R21; R22 Format:       15 A/N
EMPLOYEE ID TYPE QUALIFIER – DN0270
Definition:     Identifies the employee ID being transmitted.
Orig/Rev:     07/01/97
Record:       R21; R22
Format:       1 A/N
Values:       A = Employee ID Assigned by Jurisdiction (DN0154)
E = Employee Employment Visa (DN0152)
G = Employee Green Card (DN0153)
P = Employee Passport Number (DN0156)
S = Employee Social Security Number (DN0042) DP Rule:      There are five types of Employee ID numbers: Only one type can be sent. If SSN
is known, it is preferred.
EMPLOYEE LAST NAME – DN0043
Definition:     The employee’s legally recognized last name. Orig/Rev:     06/07/95, 07/01/97 Record:       R21; R22 Format:       40 A/N
DP Rule:      This field may only include a hyphen, apostrophe or multiple words if contained in the person’s legally recognized last name.

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EMPLOYEE LAST NAME SUFFIX – DN0255
Definition:     The legally recognized last name suffix, which is used on legal documents (Jr.,
Sr., II, III etc.) Orig/Rev:     07/01/97 Record:       R21; R22 Format:       4 A/N
EMPLOYEE MAILING CITY – DN0048
Description:   The city of the employee’s mailing address. Orig/Rev:     06/07/95, 07/01/97 Record:       148 Format:       15 A/N
EMPLOYEE MAILING COUNTRY CODE – DN0155
Description:   The country of the employee’s mailing address. Orig/Rev:     07/01/97 Record:       R21 Format:       3 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org DP Rule:      This code is required only if the employee country address is not in the US. Values are 2 digit left-justified
EMPLOYEE MAILING POSTAL CODE – DN0050
Description:   The postal code of the employee’s mailing address. Orig/Rev:     06/07/95, 07/01/97, 12/19/05 Record:       148 Format:       9 A/N
DP Rule: For the United States and its territories, this will be the USPS zip code. For non-U.S. and its territories, refer to each country’s postal code list.
EMPLOYEE MAILING PRIMARY ADDRESS – DN0046
Definition:     The mailing address for the employee. Orig/Rev:     06/07/95, 07/01/97 Record:       R21 Format:       40 A/N
EMPLOYEE MAILING SECONDARY ADDRESS – DN0047
Definition:     The mailing address for the employee.
Orig/Rev:     06/07/95, 07/01/97
Record:       R21
Format:       40 A/N
DP Rule: The Secondary Address field is for overflow text, characters that exceed the field length. It is not for formatting, such as a second address line, mailstop or PO Box. If the entire street address fits in the Primary Address field, the Secondary Address field is not used. Do not use two lines.
EMPLOYEE MAILING STATE CODE – DN0049
Definition:     The state of the employee’s mailing address.
Orig/Rev:     06/07/95, 07/01/97
Record:       148
Format:       2 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org

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EMPLOYEE MARITAL STATUS CODE – DN0054
Definition:     A code indicating the employee’s marital status as of the date of injury.
Orig/Rev:     03/11/94, 07/01/97, 05/28/03
Record:       148; R22
Format:       1 A/N
Values:       U = Unmarried, Widowed, Divorced, Single
M = Married
S = Separated
K = Unknown
EMPLOYEE MIDDLE NAME/INITIAL – DN0045
Definition:     The employee’s legally recognized middle name or initial. Orig/Rev:     06/07/95, 07/01/97 Record:       R21; R22 Format:       15 A/N
EMPLOYEE NUMBER OF DEPENDENTS – DN0055
Definition:     The number of individuals relying on the employee for economic support as
defined by the jurisdiction’s statute. Orig/Rev:     03/11/95, 07/01/97 Record:       148; A49 Format:       2 N
EMPLOYEE NUMBER OF ENTITLED EXEMPTIONS – DN0213
Definition:     The maximum number of exemptions that the employee is entitled to claim on
their annual Federal Income Tax. Orig/Rev:     07/01/97 Record:       R22 Format:       2 N

EMPLOYEE PASSPORT NUMBER – DN0156
Definition:
The number assigned to an officially recognized passport by a country’s
government to one of its citizens that authenticates the bearer’s identity,
citizenship, right to protection while abroad, and right to re-enter his or her native
Orig/Rev:
Record:
Format:
country.
07/01/97
R21; R22
15 A/N
EMPLOYEE PHONE NUMBER – DN0051
Definition:     The phone number where the employee can be reached.
Orig/Rev:     06/07/95, 07/01/97
Release:      R21
Format:       15 A/N
DP Rule:      Standard telephone numbers are 10 numeric positions (area code and number).
The additional 5 bytes should be used for a numeric extension, when applicable.
The numeric extension immediately follows the 10 digit phone number and can
be 0 to 5 positions in length.

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EMPLOYEE SOCIAL SECURITY NUMBER RELEASE INDICATOR – DN0157
Definition:
An indicator acknowledging Claim Administrator’s receipt of the employee’s
written authorization to release the employee’s Social Security Number. It is used
Orig/Rev: Record: Format: Values:
when required by the trading partner (e.g. by statute).
07/01/97
R21
1 A/N
Y = Yes
N = No
EMPLOYEE SSN – DN0042
Definition:     An identification number, issued by the Social Security Administration, used to
record an individual’s reported wages or self-employment income. Orig/Rev:     06/07/95, 07/01/97 Record:       R21; R22 Format:       9 A/N
EMPLOYEE TAX FILING STATUS CODE – DN0158
Definition:     The employee’s federal tax filing status as of the date of injury used on the
Internal Revenue Service tax forms. Orig/Rev:     07/01/97 Record:       R22 Format:       1 A/N Values:       A = Single
B = Single/Head of Household
C = Married/Filing Joint
D = Married/Filing Separate
EMPLOYER CONTACT BUSINESS PHONE NUMBER – DN0159
Definition:     The business phone number of the intended contact, organization or individual.
Orig/Rev:     07/01/97
Record:       R21
Format:       15 A/N
DP Rule:      Standard telephone numbers are 10 numeric positions (area code and number).
The additional 5 bytes should be used for a numeric extension, when applicable.
The numeric extension immediately follows the 10 digit phone number and can
be 0 to 5 positions in length.
EMPLOYER CONTACT NAME – DN0160
Definition:     The name of the intended contact organization, or individual.
Orig/Rev:     07/01/97
Record:       R21
Format:       40 A/N
DP Rule:      This is a free form text field that cannot be edited by the jurisdiction.
EMPLOYER FEIN – DN0016
Definition:     The Federal Employer Identification Number (FEIN) of the employer where the
employee was employed at the time of the injury. Orig/Rev:     08/09/95, 07/01/97, 11/22/05 Record:       148; R22 Format:       9 A/N DP Rule:      This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident) or 3D (No Coverage - No jurisdiction)

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EMPLOYER MAILING CITY – DN0165
Definition:     The city of the employer’s mailing address as provided by the employer to the
claim administrator. Orig/Rev:     07/01/97 Record:       R21 Format:       15 A/N DP Rule:      This may or may not be the official address at the employer’s organization to
receive legal documents, notices, or inquiries from the jurisdiction.
EMPLOYER MAILING COUNTRY CODE – DN0166
Definition:     The country of the employer’s mailing address as provided by the employer to
the claim administrator. Orig/Rev:     07/01/97 Record:       R21 Format:       3 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org DP Rule:      This may or may not be the official address of the employer‘s organization to
receive legal documents, notices, or inquiries from the jurisdiction.
This code is only required if the employer address is not in the US.
Values are 2 digit left-justified
EMPLOYER MAILING INFORMATION/ATTENTION LINE – DN0163
Definition:     The name of the person, department, or other information, as provided by the
employer to the claim administrator that facilitates delivery within the employer’s
organization. Orig/Rev:     07/01/97 Record:       R21 Format:       50 A/N DP Rule:      This may or may not be the official contact at the employer’s organization to
receive legal documents, notices, or inquiries from the jurisdiction.
This is a free form text field that cannot be edited by the jurisdiction.
EMPLOYER MAILING POSTAL CODE – DN0167
Definition:     The postal code of the employer’s mailing address as provided by the employer o the claim administrator.
Orig/Rev:     07/01/97, 12/19/05
Record:       R21
Format:       9 A/N
DP Rule:      This may or may not be the official address of the employer’s organization to receive legal documents, notices, or inquiries from the jurisdiction. For the United States and its territories, this will be the USPS zip code. For non-U.S. and its territories, refer to each country’s postal code list.
EMPLOYER MAILING PRIMARY ADDRESS – DN0168
Definition:     The primary address of the employer’s mailing address as provided by the
employer to the claim administrator. Orig/Rev:     07/01/97 Record:       R21 Format:       40 A/N DP Rule:      This may or may not be the official address of the employer’s organization to
receive legal documents, notices, or inquiries from the jurisdiction.

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EMPLOYER MAILING SECONDARY ADDRESS – DN0169
Definition:     The secondary address of the employer’s mailing address as provided by the employer to the claim administrator.
Orig/Rev:     07/01/97
Record:       R21
Format:       40 A/N
DP Rule: This may or may not be the official address of the employer’s organization to receive legal documents, notices, or inquiries from the jurisdiction. The Secondary Address field is for overflow text, characters that exceed the field length. It is not for formatting, such as a second address line, mailstop or PO Box. If the entire street address fits in the Primary Address field, the Secondary Address field is not used. Do not use two lines.
EMPLOYER MAILING STATE CODE – DN0170
Definition:     The state of the employer’s mailing address as provided by the employer to the
claim administrator. Orig/Rev:     07/01/97 Record:       R21 Format:       2 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org DP Rule:      This may or may not be the official address of the employer’s organization to
receive legal documents, notices, or inquiries from the jurisdiction.

EMPLOYER NAME – DN0018
Definition:
The legal name of the business entity that is filing the claim, hired the employee
and provided direction and remuneration to the employee at the time of injury; or
as jurisdictionally defined for volunteers and other non-paid classes of
Orig/Rev:
Record:
Format:
employees. In a leasing situation, this would be the lessor.
08/09/95, 07/01/97
R21
40 A/N
EMPLOYER PAID SALARY IN LIEU OF COMPENSATION INDICATOR – DN0273
Definition:     The status of whether the employer is currently paying the employee’s salary in
lieu of compensation caused by a work-related injury. Orig/Rev:     06/07/94, 07/01/97, 11/30/98, 04/28/04 Record:       R21; R22 Format:       1 A/N Values:       Y = Yes
N = No DP Rule:      If the employer is reimbursed the full statutory amount for the benefit period paid
by the employer, then the indicator should be re-set to “N”.
EMPLOYER PHYSICAL CITY – DN0021
Definition:     The city of the employer’s facility where the employee was employed at the time
of injury. Orig/Rev:     06/07/95, 07/01/97 Record:       148 Format:       15 A/N

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EMPLOYER PHYSICAL COUNTRY CODE – DN0164
Definition:     The country of the employer’s facility where the employee was employed at the
time of injury. Orig/Rev:     07/01/97 Record:       R21 Format:       3 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org DP Rules:     This code is required only if the employer country address is not in the US.
Values are 2 digit left-justified
EMPLOYER PHYSICAL POSTAL CODE – DN0023
Definition: The postal code of the employer’s facility where the employee was employed at the time of the injury.
Orig/Rev:     06/07/95, 07/01/97, 12/19/05
Record:       148; R22
Format:       9 A/N
DP Rule: For the United States and its territories, this will be the USPS zip code. For non-U.S. and its territories, refer to each country’s postal code list.
EMPLOYER PHYSICAL PRIMARY ADDRESS – DN0019
Definition:     The address of the employer’s facility where the employee was employed at the
time of the injury. Orig/Rev:     06/07/9, 07/01/97 Record:       R21 Format:       40 A/N
EMPLOYER PHYSICAL SECONDARY ADDRESS – DN0020
Definition:     The address of the employer’s facility where the employee was employed at the
time of the injury. Orig/Rev:     06/07/95, 07/01/97 Record:       R21 Format:       40 A/N DP Rule:      The Secondary Address field is for overflow text, characters that exceed the field
length. It is not for formatting, such as a second address line, mailstop or PO
Box. If the entire street address fits in the Primary Address field, the Secondary
Address field is not used. Do not use two lines.
EMPLOYER PHYSICAL STATE CODE – DN0022
Definition:     The state of the employer’s facility where the employee was employed at the
time of the injury. Orig/Rev:     06/07/95, 07/01/97 Record:       148 Format:       2 A/N Values:       See link to code list at IAIABC Website: www.iaiabc.org
EMPLOYER UI NUMBER – DN0329
Definition:     The unemployment insurance number assigned by the jurisdiction unemployment
agency to each employer. Orig/Rev:     07/01/97 Record:       R21 Format:       15 A/N DP Rule:      Depending on the jurisdiction, this information may be difficult for claim
administrators to report.

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EMPLOYMENT STATUS CODE – DN0058
Definition: A code indicating the employee’s primary work status at the time of the injury with the covered employer.
Orig/Rev:     03/28/94, 07/01/97, 05/27/03, 01/20/06
Record:       148; R22
Format:       2 A/N
Values: Hierarchy – In the event that two Employment Status Codes apply to an employee the topmost code in the following hierarchy will be reported, i.e., if employee is a part time seasonal worker, report as a seasonal worker.
C = Piece Worker indicates that the claimant was paid for employment according to the number of products/services completed or number of trips completed.
9 = Volunteer indicates that the injured worker is a volunteer for the covered employer and sustained a compensable injury, but the claim administrator will make no indemnity payments unless indemnity benefits are required based on concurrent employment. .
8 = Seasonal Worker indicates that the claimant was employed in a position dependent on or controlled by the season of the year.
A = Apprenticeship Full-time indicates that the claimant was bound by a legal agreement to work full-time for another in return for instruction in a trade or occupation.
B = Apprenticeship Part-time indicates that the claimant was bound by a legal agreement to work part-time for another in return for instruction in a trade or occupation.
1	= Regular/Full-time Employee indicates that the injured worker was employed on a full-time basis. (Schedule is comparable to other employees of the company and/or other employees in the same business or vicinity that are considered fulltime). This status is NOT used when reporting experience for full-time seasonal, volunteer, apprenticeship or piece workers.
2	= Part-time Employee indicates that the injured worker was employed on a part-time basis and whose work history in the preceding months shows that the person worked on less than a full-time basis. This status is NOT used when reporting experience for part-time seasonal, volunteer, apprenticeship or piece workers.
3	= Unemployed/Not Employed indicates that the injured worker was not employed by the employer against whom the claim is submitted after the date of injury for reasons other than disability, strike, or retirement.
6 = Retired indicates that the claimant was in retirement after the time of injury (i.e. a claimant with black lung). This status is also used when reporting experience for retired season, volunteer, apprenticeship or piece worker.
4	= On Strike indicates that the injured worker was on strike after the time of injury. This status is also used when reporting experience for on strike seasonal, volunteer, apprenticeship, or piece workers.
5	= Disabled indicates that the injured worker (who is still working) had a disability unrelated to the new injury in this report. This status is also used when
4	
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reporting experience for disabled seasonal, volunteer, apprenticeship, or piece workers.
7 = Other indicates that the claimant had an employment status other than those previously listed at the time of the injury.

Hierarchy	Name	Value	
1	Piece Worker	C	
2	Volunteer	9	
3	Seasonal	8	
4	Apprenticeship Full-Time	A	
5	Apprenticeship Part-Time	B	
6	Regular/Full-Time	1	
7	Part-Time Employee	2	
8	Unemployed/Not Employed	3	
9	Retired	6	
10	On Strike	4	
11	Disabled	5	
12	Other	7	
ENTIRE BATCH/TRANSACTION - DN0000
Definition:     DN0000 was created to express rejection of the entire batch or transaction and is communicated in the acknowledgment.
Batch: A batch is a set of records containing one header record, one or more detail transactions and one trailer record. Trading partner tables (Transmission Profile, Element Requirement Table, System Rules, Edit Matrix, etc.) should be used to determine batch edit rules. Any batch edit failure will cause the entire batch to be rejected. If a batch is rejected, the individual transactions within the rejected batch are not processed. If a batch is accepted, the process continues to validate detail transactions within the batch.
Transaction: A POC transaction consists of 1 or more 'Records' to communicate a policy event. Failure of edits on the "primary" record will cause "all" "related" records to be rejected. DN0000 is used to express the rejection of the "related" records.
Claims uses DN0000 to communicate rejections at the “batch” level only; DN0000 is not used for transaction level rejections.

Orig/Rev: Record:
Format: Values: DP Rule:

POC:
•	Failure of edits on the PC1 (primary) record will cause the PC2 (related) record(s) to be rejected. DN0000 is used to communicate the rejection of the related record.
•	Failure of edits on the PC2 (related) record(s) may cause PC1 (primary) record to be rejected. DN0000 is used to communicate the rejection of the primary record.
07/01/97, 05/07/04
Not a DN located on a specific file layout. Used to communicate a batch or
transaction error on AK1, AKC, AKP
A/N 4
0000 = Entire Batch/Transaction
See Acknowledgment Scenarios in Section 3 for batch error examples.

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ESTIMATED GROSS WEEKLY AMOUNT INDICATOR – DN0172
Definition:     An indicator that the Gross Weekly Amount is based on an estimated wage. Orig/Rev:     07/01/97, 11/30/98 Record:       R22 Format:       1 A/N Values:       Y = Yes N = No
FREE FORM TEXT – DN0113
Definition:     An unstructured field conveying a trading partner’s transaction review comments. Orig/Rev:     08/18/94, 07/01/97 Record:       AKC; ARC Format:       60 A/N
FULL DENIAL EFFECTIVE DATE – DN0199
Definition:     The date from which the claim administrator is denying all benefits for the claim.
Orig/Rev:     07/01/97, 11/30/98, 05/08/02, 03/1/05, 02/08/06
Record:       R21; R22
Format:       8 DATE
DP Rule:      This is only applicable on MTC 04 (or its corresponding CO), 02 or UR.
FULL DENIAL REASON CODE – DN0198
Definition:     A code used to identify reasons for denying a claim in its entirety or defending
that assertion. Orig/Rev:     07/01/97, 11/30/98, 05/08/02, 03/1/05, 02/08/06, 11/07/06 Record:       R21; R22 Format:       2 A/N Values:       1 = No Compensable Accident
A = Coming and going
B = Horseplay
C = Willful intent to injure oneself
D = Does not meet statutory definition of accident
E = Deviation from employment
F = Recreational/social activity
G = Traveling employee
H = Subsequent intervening accident
2	= No Causal Relationship A = Idiopathic condition B = Pre-existing condition C = Stress non-work related D = No medical evidence of injury E = No injury per statutory definition F = Accident Not Major Contributing Cause of Injury
3	= No Coverage A = No employer/employee relationship B = Independent contractor C = Does not meet statutory definition of employee D = No jurisdiction
E = No policy in effect on the date of accident F = Statute of limitation expired
G = Statutory exemptions (sole proprietor, corporate officer etc) H = Elected other coverage (24 hour, collective bargaining, opted out) I = Employee Not Reported to PEO

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4	= Substance Use/Abuse
A = Injury primarily occasioned by intoxication or use of any drug B = Substance use/abuse, violation of drug-free work place policy in effect
5	= Other (Not Elsewhere Classified)
A = Failure to report accident timely
B = Right to reserve
C = Misrepresentation DP Rule: If above code(s) and Denial Reason Narrative are approved for jurisdiction use, narrative will provide denial reasons for which there is no Full Denial Reason Code and/or supportive comments. Code fields will not be edited against the narrative. The Full Denial Reason Code may occur up to five times. This is only applicable on MTC 04 (or its corresponding CO), 02 or UR.
FULL WAGES PAID FOR DATE OF INJURY INDICATOR – DN0066
Definition:     Indicates whether the employer paid full wages for the date of the accident/injury
or illness. Orig/Rev:     03/11/94, 07/01/97, 11/30/98 Release:      148; R22 Format:       1 A/N Values:       Y = Yes
N = No
GROSS WEEKLY AMOUNT – DN0174
Definition: For MTC’s IP, CA, CB, AP, AB, 02, CO, RB, RE, PY, Px, Sx (Benefit Type Code 0XX series only): The weekly benefit amount due for a benefit type which is based on criteria such as pre-injury wages, statutory percentage, maximum and minimum limits, number of dependents, temporary partial earnings, etc (as determined by jurisdiction rule). Gross Weekly Amount always excludes the application of any adjustments, credits or redistributions.
For MTC’s EP and ER only (other than Benefit Type Code 240): The gross weekly amount of the workers’ compensation benefit the employee would be receiving instead of salary paid in lieu of compensation benefits by the employer as continued wages.
Orig/Rev:     07/01/97, 05/27/03, 02/8/05, 02/24/05, 03/31/07
Record:       R22
Format:       $9.2
DP Rule:      Refer to Variable Segment Population Rules (Benefit Segment) in Section 4
In the event of an acquired claim, the current claim administrator would report the gross weekly amount as it applies to their own payments rather than the previous claim administrator’s payments. This is a benefit level amount and may be different than the Calculated Weekly Compensation Amount (DN134).
Temporary Partial (or other benefit types where the claimant’s current weekly earnings reduce the Gross Weekly Amount) – The Gross Weekly Amount will represent the most current Temporary Partial rate for which benefits were paid.

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GROSS WEEKLY AMOUNT EFFECTIVE DATE – DN0175
Definition: For MTC’s IP, CA, CB, AB, 02, CO, RB, RE, PY, Px, Sx (Benefit Type Code 0XX series only): The date the gross weekly amount became effective as applied by the current Claim Administrator. For MTC AP and all subsequent MTC’s filed on acquired claims, this may be prior to the acquisition date if the acquiring claim administrator issued payment(s) for a period of time in which the file was handled by the previous claim administrator. For MTC’s EP and ER only (other than Benefit Type Code 240): The date the Gross Weekly Amount became effective if the employee is receiving salary paid in lieu of compensation benefits by the employer as continued wages.
For Gross Weekly Amount Effective Dates for different types of temporary benefits, see the DP Rules below.
Orig/Rev:     07/01/97, 05/28/03, 02/8/05, 02/24/05, 03/31/07, 01/01/08 Record:       R22 Format:       8 DATE
DP Rule:      Refer to Variable Segment Population Rules (Benefit Segment) in Section 4 This date should never be prior to the date of accident

Temporary Total (Standard Claim)
Date will be the Date of Injury.

The initial Gross Weekly Amount Effective

Subsequent Temporary Total effective dates – If the Gross Weekly Amount changes, its effective date will reflect the first date that payments could have been paid at that amount, regardless of that date being a scheduled work day.
Temporary Partial (or other benefit types where the claimant’s current weekly earnings reduce the Gross Weekly Amount) – The Gross Weekly Amount Effective Date will represent the most current Temporary Partial rate and date reported for which benefits were paid, and should be the first date that payments were made at this amount. (e.g. the first day of a benefit week).
Acquired Claims – The initial Gross Weekly Amount Effective Date will be the first date the Gross Weekly Amount became effective for the acquiring claim administrator

INDUSTRY CODE – DN0025
Definition:
The NAICS (North American Industry Classification System) code representing
the nature of the employer’s business which is contained in the industrial
classification manual published by the Federal Office of Management and
Budget.
Orig/Rev: Record: Format: Values:
DP Rule:
03/11/94, 07/01/97, 12/01/99, 05/28/03, 04/08/05, 04/09/08
148
6 A/N
The code list is maintained by the Federal Office of Management & Budget and
has been updated every 5 years since 1997.
It is recommended that the Industry Code (NAICS) be required as an element on
Proof of Coverage reporting PRIOR to being required as a mandatory data
element on Claims transactions. It is advised that claim administrators receive
this data element from their policy reporting areas.
The Federal Register always comes out about 6 months before the effective date for NAICS codes. The IAIABC will monitor the Federal Register and give the jurisdictions and industry 6 months notice that new NAICS codes are available.

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Jurisdictions should be prepared to accept and not reject the most recent version of NAICS codes 90 days prior to the effective date of that version.
The IAIABC recommends that jurisdictions could accept 6 digits but require no more than 5 digits.
INITIAL DATE DISABILITY BEGAN - DN0056
Definition:	The first day qualifying as a day of disability in the first period of disability. This
will be the first day of the waiting period.
Orig/Rev:	08/09/95, 07/01/97
Record:	148; A49
Format:	8 DATE
INITIAL DATE LAST DAY WORKED - DN0065
Definition:	The last day worked prior to initial disability entitlement.
Initial Date Last Day Worked must meet all of the following conditions:
•	Must be in the course of employment
•	Is not contingent on payment of wages
•	Is on or after the Date of Injury
•	Is on or before the Initial Date Disability Began
•	Be the first such event in this claim
Orig/Rev:           08/09/95, 07/01/97
Record:	148; R22
Format:	8 DATE
INITIAL DATE OF LOST TIME - DN0297
Definition:	The first day qualifying as a day of disability in the first period of disability after
the waiting period requirements have been met.
Orig.Rev:	04/27/04
Record:	R22
Format:	8 DATE
INITIAL RETURN TO WORK DATE – DN0068
Definition:     The first date on which the employee was released to or actually returned to work
at full or reduced wages. Orig/Rev:     10/04/00, 04/11/08 Record:       148; R22 Format:       8 DATE DP Rule:      This date could be equal to the Date of Injury if temporary partial benefits were
initially paid.
If an MTC 02 is sent with a change to the RTW Type Code and/or Physical Restrictions Indicator and there is no second period of disability, a subsequent Initial Return to Work Date may be sent to correspond with the revised RTW Type Code and/or Physical Restrictions Indicator. If a subsequent Initial Return to Work Date is not sent on an MTC 02, the jurisdiction could use the MTC Date as an estimate of when the subsequent RTW Type Code and/or Physical Restrictions Indicator took effect.

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INITIAL TREATMENT CODE – DN0039
Definition:     A code identifying the extent of medical treatment received by the employee
immediately following the accident. Orig/Rev:     03/11/94, 07/01/97 Record:       148 Format:       2 A/N Values:       0 = No medical treatment
1	= Minor on-site remedies by employer medical staff
2	= Minor clinic/hospital medical remedies and diagnostic testing
3	= Emergency evaluation, diagnostic testing, and medical procedures
4	= Hospitalization greater than 24 hours
5	= Future major medical/Lost time anticipated (i.e. hernia case)
INSOLVENT INSURER FEIN – DN0292
Definition:     The Federal Employer Identification Number (FEIN) of the insolvent insurance
company who no longer has financial responsibility for this claim. Orig/Rev:     05/14/03 Record:       R21; R22 Format:       9 A/N DP Rule:      This data element can only be required if the insurer is a Guarantee Fund.
INSURED FEIN – DN0314
Definition:     The Federal Employer Identification Number (FEIN) corresponding to and
uniquely identifying the insured. Orig/Rev:     07/01/97 Record:       R21; R22 Format:       9 A/N DP Rule:      This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident)
INSURED LOCATION IDENTIFIER – DN0027
Definition:     A code defined by the insured identifying the employer’s location of the accident.
Orig/Rev:     06/07/95, 07/01/97, 05/16/03
Record:       148
Format:       15 A/N
DP Rule:      This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident)
INSURED NAME – DN0017
Definition:     The named entity of the policy. Typically, the insured name is the parent
company in a hierarchically structured organization. Orig/Rev:     06/07/95, 07/01/97 Record:       R21 Format:       40 A/N DP Rule:      This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident)

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INSURED REPORT NUMBER – DN0026
Definition:     A number assigned by the insured to identify a specific claim.
Orig/Rev:     03/11/94, 07/01/97, 12/19/05
Record:       R21; A49; AKC; ARC
Format:       25 A/N
DP Rule:      This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident)
If this data element is included on any FROI/SROI transaction, it should be
returned on the transaction’s acknowledgment regardless of whether it is a data
element collected by the jurisdiction.
INSURED TYPE CODE – DN0184
Definition:     A code representing the kind of insurance arrangement held by the financially
responsible party associated with the claim. Orig/Rev:     07/01/97 Record:       R21 Format:       1 A/N Values:       I = Insured
S = Self-Insured
U = Uninsured DP Rule:      This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident)
INSURER FEIN – DN0006
Definition: The Federal Employer Identification Number (FEIN) of the insurance company, self-insured, or guarantee fund assuming the employer’s financial responsibility for this claim.
Orig/Rev:     08/09/95, 07/01/97
Record:       148; A49; AKC; ARC
Format:       9 A/N
DP Rule: In the instance where the Insurer is denying the entire claim (MTC 04) because they are not the Insurer, no financial responsibility is inferred.
INSURER NAME – DN0007
Definition: The legal name of the insurance company self-insured, or guarantee fund assuming the employer’s financial responsibility for this claim.
Orig/Rev:     06/07/95, 07/01/97
Record:       R21
Format:       40 A/N
DP Rule: In the instance where the Insurer is denying the entire claim (MTC 04) because they are not the Insurer, no financial responsibility is inferred.
INSURER TYPE CODE – DN0185
Definition:     A code representing the type of entity providing financial responsibility for the
claim. Orig/Rev:     07/01/97, 05/22/03 Record:       R21 Format:       1 A/N Values:       I = Insurer
S = Self-Insurer
G = Guarantee Fund

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INTERCHANGE VERSION ID – DN0105
A composite field comprised of a batch type (positions 1-3), release number
(position 4) and version number (position 5). Interchange Version ID is a data
element located in the header record (HD1). It is used to identify the batch type,
release and version of the transactions contained within the batch following the
HD1 header through the trailer record (TR2). Batch type designates the type of
transactions within a batch. Release number identifies the release level of the
data of the record layout contained in the detail record that follow. Version
number identifies the version level of the release.
07/01/97, 12/31/02, 05/27/03
HD1
Batch Type 3 A/N
Release Number 1 A/N
Version Number 1 A/N
14830 = First Report of Injury; Release 3, Version 0
A4930 = Subsequent Report of Injury; Release 3, Version 0
AKC30 = Claims Acknowledgment Detail Record; Release 3, Version 0
ARC30 = Claims Re-Acknowledgment Detail Record, Release 3, Version 0
Definition:
Orig/Rev:
Record:
Format:
Values:
JURISDICTION BRANCH OFFICE CODE – DN0186
Definition:     A number assigned by the jurisdiction identifying the branch/field office
overseeing the handling of the claim. Orig/Rev:     07/01/97 Record:       R21; R22; AKC; ARC Format:       2 A/N
JURISDICTION CLAIM NUMBER – DN0005
Definition:     The number assigned by the jurisdiction to identify a specific claim. Orig/Rev:     03/11/94, 07/01/97 Record:       148; A49; AKC; ARC Format:       25 A/N

JURISDICTION CODE
Definition:
Orig/Rev: Record: Format: Values:

– DN0004
The code uniquely identifying the governing body or territory whose statutes
apply.
06/07/95, 07/01/97
148; A49
2 A/N
See link to code list at IAIABC Website: www.iaiabc.org
plus list of non-state jurisdictions as follows:
UL = Long Shore & Harbor Workers’ Compensation Act
U1 = Defense Base Act
U2 = Non-Appropriated Fund Instrumentalities Act
U3 = Outer Continental Shelf Act
U4 = War Hazards Compensation Act
FC = Federal Coal Mine Health & Safety Act
FE = Federal Employers Liability Act
M1 = Admiralty I & II

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LATE REASON CODE – DN0077
Definition:     A code, identifying the reason a payment/report was not made within a
jurisdiction’s time requirements. Orig/Rev:     06/07/95, 07/01/97, 02/8/05, 05/05/06 Record:      A49; R21 Format:       2 A/N Values:       Delays
L1 = No excuse
L2 = Late notification, employer
L3 = Late notification, employee
L4 = Late notification, jurisdiction transfer
L5 = Late notification, health care provider
L6 = Late notification, assigned risk
L7 = Late investigation
L8 = Technical processing delay, computer failure
L9 = Manual processing delay
LA = Intermittent lost time prior to first payment
LB - Late notification/payment due to a Natural Disaster
LC - Late notification/payment due to an act of Terrorism
Coverage
C1 = Coverage lack of information
Errors
E1 = Wrongful determination of no coverage
E2 = Errors from employer
E3 = Errors from employee
E4 = Errors from jurisdiction
E5 = Errors from health care provider
E6 = Errors from other claim administrator/IA/TPA
Disputes
D1 = Dispute concerning coverage
D2 = Dispute concerning compensability in whole
D3 = Dispute concerning compensability in part
D4 = Dispute concerning disability in whole
D5 = Dispute concerning disability in part
D6 = Dispute concerning impairment
LUMP SUM PAYMENT/SETTLEMENT CODE – DN0293
Definition:     A code describing the type of lump sum payment/settlement made.
Orig/Rev:     04/22/03, 02/8/05, 04/6/05, 02/08/06, 11/30/09
Record:       R22
Format:       2 A/N
DP Rule: This can only be required on MTC “PY” (or its corresponding CO), 02 or UR. Refer to the Lump Sum Payment/Settlement rules in section 4.
Values: SF - Settlement Full - A settlement agreed upon by all parties to end past, present and future liability of all benefits. No future indemnity or medical benefits are due. The “SF” Lump Sum Payment/Settlement Code should also be used if all indemnity was previously settled and medical is now being settled, or if all medical was previously settled and indemnity is now being settled.
DP Rule: Refer to the Lump Sum Payment/Settlement Rules in Section 4 for processing rules. The Payment Reason Code equating to the Benefit Type Code 5XX would be used to report the benefits settled. The jurisdiction will determine which 5xx Payment Reason Code(s)/Benefit Type Code(s) is to be used to report

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a full settlement, and would not be able to calculate the accuracy of the payment. A claim administrator is not expected to pay any future benefits on this case.
SP – Settlement Partial - A settlement agreed upon by all parties to: o Settle all indemnity benefit type codes, but not medical (reported as BTC
5xx as defined by jurisdiction) –OR-o Settle a specific indemnity benefit type code(s) (reported as a specific
5xx BTC other than 500 or 501) –OR-o Settle all medical, but not indemnity (reported as BTC 501).
DP Rule: Refer to the Lump Sum Payment/Settlement Rules in Section 4 for processing rules The Payment Reason Code equating to the Benefit Type Code 5XX as defined above would be used to report the benefits settled. The jurisdiction would not be able to calculate the accuracy of the payment.
If all indemnity was previously settled and medical is now being settled, this should be reported with a Lump Sum Payment/Settlement Code of “SF” rather than “SP”.
If all medical was previously settled and indemnity is now being settled, this should be reported with a Lump Sum Payment/Settlement Code of “SF” rather than “SP”.
AS – Agreement Stipulated - A lump sum payment, agreed upon by the parties, of one or more benefit types for one or more disputed periods of disability, which does not limit future liability. Future indemnity and medical benefits may be due. DP Rule: The Benefit Type Code 0XX series would be used to report an agreement that specified a rate and time period (the jurisdiction should be able to calculate the accuracy of the payment). The Benefit Type Code 5XX series would be used to report an agreement that did not specify a rate and/or time period.
AW - Award – An adjudicated lump sum payment of one or more benefit types for a disputed period of disability, which does not limit future liability. DP Rule: The Benefit Type Code 0XX series would be used to report an award that specified a rate and time period (the jurisdiction should be able to calculate the accuracy of the payment). The Benefit Type Code 5XX series would be used to report an award that did not specify a rate and time period, or if more than one rate was ordered.
AD - Advance - A lump sum payment of benefits in advance of when it is due. This may be recouped as a weekly credit against future benefits; or by resuming benefit payments at the end of the advanced period; or by discontinuing benefits prior to the statutory limit.
DP Rule: The Benefit Type Code 0XX series would be used to report an advance that specified a rate and time period. The Benefit Type Code 5XX series would be used to report an advance that did not specify a rate and time period. An Advance on a pending settlement must be coded to the same Payment Reason Code and Benefit Type Code as the settlement.

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MAINTENANCE TYPE
Definition:
Orig/Rev:
Record: Format: DP Rule:
Values:

CODE - DN0002
A code defining the specific purpose of individual records within the transaction
being transmitted.
08/09/95, 07/01/97,  11/30/98, 05/27/03, 02/8/05, 03/1/05, 04/08/05, 02/08/06,
04/06/09, 08/21/09
148; A49; AKC; ARC; R22 - refer to specific MTC
2 A/N
Refer to Variable Segment Population Rules and MTC Simplification Guide in
Section 4 for valid MTC values within a batch and population Rules.
00	Original - The original/initial first report (FROI) transmitted between partners,
including the re-transmission of a first report that was rejected due to a critical
error or a claim that was previously cancelled (01), or a subsequent first report
(FROI) for a claim that was previously denied in its entirety (04), was under
investigation (UI) or was sent upon request (UR).
Record: 148
DP Rule: A jurisdiction may or may not allow a 00 Original after a 04, UI or UR. For example, in a case where a jurisdiction does not allow a 00 after a 04, the 04 is accepted as the originating document and a 00 may be rejected as a duplicate claim based on their match data rules. A different jurisdiction may choose to accept both the 04 and the 00.
01	Cancel - The original first report was sent in error.
Record: 148
DP Rule: A previous first report must have been filed before the 01 is sent and may be sent even after subsequent report(s) have been filed. Refer to 01 Cancel Processing Rules and Jurisdiction Change in Section 4.
02	Change - The claim administrator initiates a Change (02) MTC when it
identifies a change in a data element designated on the Element Requirement
Table. Refer to 02 Change Processing Rules in Section 4.
Record: 148; A49; R22 DP Rule:
■	Subsequent Report: The “02” Maintenance Type Code should be used if the Average Wage (DN0286), Concurrent Employer Wage (DN0143), Calculated Weekly Compensation Amount (DN0134), Benefit Redistribution Weekly Amount (DN0133), or Gross Weekly Amount (DN0174) changes but the Net Weekly Amount (DN0087) does not change, unless it is in response to a “TE” (in which case a “CO” is used).If the Net Weekly Amount (DN0087) or Benefit Type Code (DN0085) changes, use the CA or CB Maintenance Type Code respectively, unless it is in response to a “TE” (in which case a “CO” is used).
■	First or Subsequent Report - A transaction may not include changes to more than one "Match" Data element at a time in order to allow a match of the remaining values to the trading partner's records. Refer to the Match Data Rules in Section 4 and the Jurisdiction's Match Data Table.
04 Denial -
■	First Report (FROI): The FROI 04 Denial serves the dual purpose of
concurrently reporting a new claim to the jurisdiction while denying it
in its entirety; or denying a previously reported claim in its entirety.
The Event Table will indicate whether a jurisdiction will accept a
FROI 04 to deny a claim after a previously reported FROI was
accepted.

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■	Subsequent Report (SROI): The entire claim is being denied after
any FROI or any SROI has been filed. The Event Table will indicate
whether a jurisdiction will require a SROI 04 to deny a claim after a
previously reported FROI was accepted.
■
Record: 148; A49; R22 DP Rule:
■	Depending upon the jurisdiction’s Event Table, a FROI 04 may be sent (whether or not payments have been made) after an establishing FROI.
■	The FROI 04 is intended to function as a first report. If it is intended to also replace a jurisdiction’s “denial” form, it should be indicated on the jurisdiction’s Event Table
■	Depending upon the jurisdiction’s requirements, the SROI 04 may act like a suspension when benefit(s) are being terminated at the time of the denial. However, since a SROI 04 only contains Sweep Benefits segment data, if the jurisdiction needs Gross and/or Net Weekly Amounts and/or Effective Dates, or Benefit Payment Issue Date, they must also require an MTC Sx.
AB Add Concurrent Benefit Type - Indemnity benefits are currently being paid and a concurrent benefit type is being added or reinstated. Record: A49; R22 - Refer to Variable Segment Rules
AP Acquired/Payment - The claim administrator who acquired the claim has
processed their first payment of indemnity benefits.
Record: A49; R22
DP Rule: A previous AQ or AU must have been filed.  If a jurisdiction requires a
Payments segment on an IP and more than one check is issued for the same
indemnity Benefit Type/Payment Reason Code, all indemnity checks issued
should be populated in the Payments segment.
AQ Acquired Claim - Minimal data sent to report that a new claim administrator
has acquired the claim.
Record: 148
DP Rule: AQ or AU must always be the first filing on an acquired claim.     If
neither the claim administrator nor insurer has changed, but some match data
has  changed,  a  change  MTC  02  is transmitted   instead  of an  MTC  AQ
transaction.
AU Acquired/Unallocated - The equivalent of an initial first report (MTC 00) filed by new claim administrator in response to an AQ transaction that has been rejected because of no claim match on database or when an AU is sent in lieu of an AQ based on the Jurisdiction’s Event Table, or when the acquiring claim administrator is reopening a claim that was previously cancelled. Record: 148
DP Rule: If neither the claim administrator nor insurer has changed, but some match data has changed, a change MTC 02 is transmitted instead of an MTC AU transaction.

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CA Change in Benefit Amount - The Claim Administrator has identified that the Net Weekly Amount (DN0087) for this benefit type has changed from the previously reported Net Weekly Amount, and the Benefit Type Code has not changed, and benefits are not currently being reinstated. If the Net Weekly Amount is being changed in response to a TE, the CO MTC is used. Record: A49; R22 DP Rule:
•	The CA Maintenance Type Code should only be used if a previous IP,
AP or SROI UR has been filed, benefits are not currently being
reinstated, and any of the following apply:
>	The Net Weekly Amount is changed after a Suspension and a check for the rate adjustment is being issued for the same Benefit Period Start and/or Through Dates that were reported on the previous Suspension (unless in response to a TE, in which case a CO MTC is used). No additional Sx MTC is due.
>	The Net Weekly Amount changes due to recalculation of the Gross Weekly Amount, or there are adjustments and/or credits that affect the Net Weekly Amount but not the Gross Weekly Amount.
•	The RB Maintenance Type Code should be used if either of the following
conditions apply:
>	Ongoing benefits are being reinstated (regardless of the Net Weekly Amount)
>	The Net Weekly Amount changes after a Suspension, and a check for the rate adjustment is being issued for a different Benefit Period Start Date and/or Benefit Period Through Date than was reported on the previous Suspension.

•	The RE Maintenance Type Code should be used if the Gross Weekly Amount changes because of application of the employee’s current weekly wages while receiving Temporary Partial benefits (Benefit Type Code 070).
•	The 02 Maintenance Type Code should be used if the Average Wage, or Concurrent Employer Wage changes but the Net Weekly Amount does not change.
CB Change in Benefit Type - The Claim Administrator has identified that the
Benefit Type Code (DN0085) has changed from the previously reported Benefit
Type Code without a break in continuity of benefits. A CB would also be filed if an
employer previously paid salary in lieu of compensation (EP with Benefit Type
Code 2xx) and is now paying salary in lieu of compensation again after the claim
administrator either began paying (IP with Benefit Type Code 0xx) or reinstated
benefits (RB with Benefit Type Code 0xx), without a break in continuity of
benefits (Sx).
If the Benefit Type Code is being corrected in response to a TE, the CO MTC is
used.
Record: A49; R22
DP Rule: A previous IP, AP or Subsequent Report UR has been filed.
CD Compensable Death - No Known Dependents/Payees - The injured employee has died as a result of a covered injury and no payment(s) of indemnity benefits have been made pending further beneficiary investigation. Record: A49
DP Rule: Filed to meet jurisdiction timeliness requirement as replacement for Initial Payment report.

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If accepting compensability after full denial for a CD claim, the MTC CD would be used.
CO Correction - Corrected data element values are transmitted in response to a “TE” Application Acknowledgment Code. Record: 148; A49; R22
DP Rule: “CO” (Correction) Maintenance Type Code is only sent in response to transaction “Accepted with Errors” (TE). Maintenance Type Code “02” is used when there is a change of an element designated on the trading partner tables. Transactions reported on an Acknowledgment Report as “Transaction Rejected” (TR) are corrected and re-sent as the original Maintenance Type Code in their entirety.
EP Employer Paid - The first report of payment of an indemnity benefit other
than a lump sum payment/settlement that has been paid by the employer in lieu
of compensation,  and the claim administrator is not paying any indemnity
benefits at this time.
Record: A49; R22
DP Rule: A previous subsequent report may or may not have been filed.
ER Employer Reinstatement - The employer has resumed paying the injured employee’s salary in lieu of compensation, after a suspension of benefits, and the claim administrator is not paying any indemnity benefits at this time. Record: A49; R22
DP Rule: A previous subsequent report has been filed with a Maintenance Type Code of EP.
FN Final - Closed claim, no further payments of any kind anticipated. Record: A49
IP Initial Payment - A claim administrator has issued the first payment of an indemnity benefit other than a lump sum payment/settlement. Record: A49; R22 DP Rule:
■	The Initial Payment transaction implies that indemnity benefit payments are ongoing.
■	The IP may follow an EP or the suspension (Sx) of Employer Paid benefits if the claim administrator is making the initial payment of indemnity benefits other than a lump sum payment/settlement after the employer has been paying salary in lieu of compensation.
■	The IP may follow a PY if the claim administrator is making the initial payment of indemnity benefits after the payment of a lump sum/settlement. If the claim administrator’s initial payment of ongoing indemnity is issued as part of the lump sum payment, the IP should be triggered when the next indemnity check is issued.
■	First indemnity payments by the acquiring claim administrator on acquired claims are reported on the AP transaction.
■	If a jurisdiction requires a Payments segment on an IP and more than one check is issued for the same indemnity Benefit Type/Payment Reason Code, all indemnity checks issued should be populated in the Payments segment.
■	
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P1 Partial Suspension, Returned to Work or Medically Determined/Qualified to Return to Work - Payment(s) of one concurrent indemnity benefit have stopped because the injured employee has returned to work, and payment(s) of other indemnity benefits continues. Record: A49; R22
P2  Partial  Suspension,   Medical   Non-Compliance  -  Payment(s)  of one concurrent indemnity benefit have stopped because of medical non-compliance, and payment(s) of other indemnity benefits continues. Record: A49; R22
P3 Partial Suspension, Administrative Non-Compliance - Payment(s) of one concurrent indemnity benefit have stopped  because  of administrative  non-compliance, and payment(s) of other indemnity benefits continues. Record: A49; R22
P4 Partial Suspension, Employee Death - Payment(s) of one concurrent indemnity benefit have stopped because of employee death, and payment(s) of other indemnity benefits continues. Record: A49; R22
P5   Partial   Suspension,   Incarceration  -   Payment(s)   of  one   concurrent indemnity benefit have stopped because the employee has been incarcerated, and payment(s) of other indemnity benefits continues. Record: A49; R22
P7 Partial Suspension, Benefits Exhausted - Payment(s) of one concurrent indemnity benefit have stopped because limits of benefit or entitlement have been reached, and payment(s) of other indemnity benefits continues. Record: A49; R22
P9 Partially Suspended Pending Settlement Approval - Payment(s) of one concurrent indemnity benefit have stopped pending settlement approval, and payment(s) of other indemnity benefits continues. Record: A49; R22
PJ Partially Suspended Pending Appeal or Judicial Review - Payment(s) of one concurrent indemnity benefit have stopped pending appeal or judicial review and payment(s) of other indemnity benefits continues. Record: A49; R22
PD Partial Denial - A specific benefit(s) is currently being denied. Record: A49 DP Rule:
■	A previous subsequent report may or may not have been filed. A previous First Report must have been filed
■	MTC PD (Partial Denial) is not to be used in conjunction with the Full Denial data elements: Full Denial Reason Code and Full Denial Effective Date. Denial Reason Narrative can be used to further explain benefits being denied.
■	Depending upon the jurisdiction’s requirements, for sequencing purposes, an RB may follow a PD without a previous Sx
■	
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PY Payment Report - Identifies lump sum payment/settlement reports OR jurisdiction required reporting of the first payment of Other Benefit Type Codes for medical, funeral, penalty and attorney fees. This is not to be used for monitoring ongoing payments.
DP Rule:
If more than one check is issued for the same indemnity Benefit Type/Payment Reason Code, all indemnity checks issued should be populated in the Payments segment. Refer to Variable Segment Population Rules (Payments Segment) in Section 4. The Steering Committee directed that Payee (DN0217) was established for specified transactions only (IP, AP, PY, RB or any corresponding 02 or CO for those specified Maintenance Type Codes) and that individual weekly check information would not be reported in Release 3. This is a free form text field that cannot be edited by the jurisdiction. Record: A49; R22
RB Reinstatement of Benefits - Indemnity payments previously paid by the claim administrator have been resumed by the claim administrator, but the reinstated benefit type may or may not have been paid previously. Record: A49; R22 DP Rule:
•	A previous subsequent report must have been filed terminating all indemnity
payments. Depending upon the jurisdiction's termination requirements, this
could include an MTC Sx (Full Suspension), MTC 04 (SROI Full Denial) that
is acting like a suspension when benefit(s) are being terminated at the time
of the denial, or MTC FN (Final).
>	The Benefit Type Code being resumed may or may not have been previously paid.
>	The RB Maintenance Type Code should be used if either of the following conditions apply
>	A previous subsequent report must have been filed terminating all indemnity payments. Depending upon the jurisdiction's termination requirements, this could include an MTC Sx (Full Suspension), MTC 04 (SROI Full Denial) that is acting like a suspension when benefit(s) are being terminated at the time of the denial, or MTC FN (Final).
•	The Benefit Type Code being resumed may or may not have been previously
paid.
RE Reduced Earnings - The injured employee has returned/been released to return to work and actual or deemed earnings for each reduced earnings week is reported.
Record: A49; R22 DP Rules:
•	An IP or AP report has already been filed. The user must reference the trading partner agreement to determine when a submission is required.
•	Reduced Earnings are transmitted upon payment of Temporary Partial Disability.
•	When a Temporary Partial Disability payment is made at the time of a claim event, such as Initial Payment, Change of Benefit, or Suspension, etc. the corresponding MTC (IP, CB, Sx, etc) is used.
•	The RE Maintenance Type Code should be used if the Gross Weekly Amount changes because of application of the employee’s current weekly wages while receiving Temporary Partial benefits (Benefit Type Code 070).
•	Whenever there is a change to the Actual or Deemed Reduced Earnings which  result in  a  change to the Gross Weekly Amount,  a  new “RE”
•	
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transaction that includes the Reduced Earnings segment is sent to the jurisdiction. The only exception is when the Gross Weekly Amount changes to zero as a result of the injured worker’s earnings meeting or exceeding the Average Wage. In that situation, an “RE” filing is not necessary until Temporary Partial benefits are actually paid (at that time, however, a Reduced Earnings segment must be sent covering all weeks from the Benefit Period Through Date on the previous transaction) or some other event occurs in the claim (i.e., suspension due to lifting of restrictions, etc.). (see Variable Segment Population Rules in Section 4)
51	Suspension, Returned to Work, or Medically Determined/Qualified to Return to Work - All payments of indemnity benefits have stopped because the employee has returned to work or has been medically determined qualified to return to work. Record: A49; R22
52	Suspension, Medical Non-Compliance – All payments of indemnity benefits have stopped because of medical non-compliance. Record: A49; R22
DP Rule: Non-compliance of any party, relating to a medical issue. For example: employer, doctor, and employee. This includes vocational rehabilitation for those jurisdictions that consider vocational rehabilitation a medical benefit.
53	Suspension, Administrative Non-Compliance – All payments of indemnity
benefits have stopped because of administrative non-compliance.
Record: A49; R22
DP Rule: Non-compliance of any party, relating to a non-medical issue. For example: employer, doctor, and employee. This includes vocational rehabilitation for those jurisdictions that do not consider vocational rehabilitation a medical benefit.
54	Suspension, Claimant Death – All payments of indemnity benefits have
stopped because the employee has died.
Record: A49; R22
DP Rule: The Death Result of Injury Code (DN0146) will provide a determination as to whether the employee died as a result of a work-related injury.
55	Suspension, Incarceration – All payments of indemnity benefits have stopped because the employee has been incarcerated. Record: A49; R22
56	Suspension, Claimant’s Whereabouts Unknown – All payments of indemnity benefits have stopped because the employee’s whereabouts are unknown. Record: A49; R22
57	Suspension, Benefits Exhausted – All payments of indemnity benefits have stopped because limits of benefit or entitlement have been reached. Record: A49; R22
58	Suspension, Jurisdiction Change – All payments of benefits for the jurisdiction receiving the S8 have stopped because the jurisdiction has been changed. The jurisdiction receiving the S8 should mark their claim as closed. Record: A49; R22
DP Rule: When a claim is transferred to another jurisdiction after a payment(s) has been made, a Maintenance Type Code S8, Jurisdiction Change is used to

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submit a Subsequent Report to the original jurisdiction. Maintenance Type Code 00 is used to submit a First Report to the new jurisdiction. Maintenance Type Code “IP” with Late Reason Code “L4” (Late notification, jurisdiction transfer) is used to submit a Subsequent Report to the new jurisdiction. Refer to 01 Cancel Processing Rules and Jurisdiction Changes in Section 4.
S9 Suspended Pending Settlement Approval – All payments of indemnity benefits have stopped pending settlement approval. Record: A49; R22
SD Suspension, Directed by Jurisdiction – All payments of indemnity benefits have stopped per jurisdiction order. Record: A49; R22
SJ Suspended Pending Appeal or Judicial Review – All payments of indemnity benefits have stopped pending appeal or judicial review. Record: A49; R22
UI Under Investigation – A determination has not yet been made as to whether this is a compensable claim. This MTC may be sent as the First Report. Record: 148; A49
UR Upon Request – Submitted in response to a specific request from the
Jurisdiction, and manually triggered by the Claim Administrator.
Record: 148; A49
DP Rule:   A separate Element Requirement Table “Upon Request
Requirements” has been developed to assist jurisdictions in defining their
requirements when a data call is necessary. The Requirement Table can be
downloaded from the IAIABC Release 3 EDI Implementation Guide page. .
VE Volunteer – The employee is a volunteer for the covered employer, and the
claim administrator will make no indemnity payments.
Record: A49
DP Rule: Filed to meet jurisdiction timeliness requirement as replacement for
Initial Payment report.
If accepting compensability after full denial for a VE claim, the MTC VE would be
used.
Periodic Report Values – Periodic Reports are subsequent Reports that commence and terminate according to Trading Partner Table options, and repeat at specified intervals during the period.
AN Annual – Submitted at yearly intervals based on the report trigger criteria column located on the jurisdiction’s Event Table. Record: A49
BM Bi-Monthly – Submitted at two-month intervals based on the report trigger criteria column located on the jurisdiction’s Event Table. Record: A49
BW Bi-Weekly – Submitted at two-week intervals based on the report trigger criteria column located on the jurisdiction’s Event Table. Record: A49

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MN Monthly – Submitted at one-month intervals based on the report trigger criteria column located on the jurisdiction’s Event Table. Record: A49
QT Quarterly – Submitted at three-month intervals based on the report trigger criteria column located on the jurisdiction’s Event Table. Record: A49
SA Sub-Annual – Submitted at timeframe(s) as defined on the jurisdiction’s Event Table. Record: A49
MAINTENANCE TYPE CODE DATE – DN0003
Definition:     The date the Maintenance Type Code was moved to the transmission queue or
flagged for transmission. Orig/Rev:     03/11/94, 07/01/97, 09/26/98, 11/30/98, 09/03/03 Record:       148; A49; AKC; ARC Format:       8 DATE
MAINTENANCE TYPE CORRECTION CODE – DN0295
Definition: The Maintenance Type Code from the transaction that is being corrected in response to an acknowledgment containing non-critical errors (TE).
Orig/Rev:     06/15/03
Record:       R21; R22; AKC; ARC
Format:       2 A/N
Values:       Maintenance Type Codes (DN0002) except “CO”
DP Rule: Refer to Error Correction Technical Rules in Section 4 for usage and processing of this data element. The Maintenance Type Correction Code must be populated with the Maintenance Type Code from the erroneous transaction. This field is only populated on a Correction (CO) transaction.
MAINTENANCE TYPE CORRECTION CODE DATE – DN0296
Definition: The Maintenance Type Code Date from the transaction that is being corrected in response to an acknowledgment containing non-critical errors (TE).
Orig/Rev:     06/15/03
Record:       R21; R22; AKC; ARC
Format:       8 DATE
DP Rule: The Maintenance Type Correction Code Date must be populated with the date from the erroneous transaction. This field is only populated on a Correction (CO) transaction.
MANAGED CARE ORGANIZATION CODE – DN0207
Definition:     A code indicating the existence and type of managed care organization involved
in the claim. Orig/Rev:     07/01/97 Record:       R21 Format:       2 A/N
Values:       See link found on IAIABC Website: www.iaiabc.org page DP Rule:      The MCO code term “approved” was defined as “meeting jurisdiction
requirements”.

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MANAGED CARE ORGANIZATION IDENTIFICATION NUMBER – DN0208
Definition: The jurisdiction assigned number corresponding to and uniquely identifying the managed care organization involved in the claim.
Orig/Rev:     07/01/97
Record:       R21
Format:       9 A/N
DP Rule: Send either the Managed Care Organization Name (DN0209) or the Managed Care Organization Identification Number (DN0208) at the time of the initial reporting of the claim. Refer to the Trading Partner Agreement for Jurisdictional requirements. Resend if any of the information changes.
If the Managed Care Organization Code (DN0207) shows that a managed care organization is involved, then either Managed Care Organization Name (DN0209) or Managed Care Organization Identification Number (DN0208) should be sent depending upon jurisdictional requirements.
MANAGED CARE ORGANIZATION NAME – DN0209
Definition:     The legal name of the managed care organization involved in the claim. Orig/Rev:     07/01/97 Record:       R21 Format:       40 A/N
DP Rule: Used when Managed Care Organization Identification Number (DN0208) is unassigned or unknown.
MANUAL CLASSIFICATION CODE – DN0059
Definition: A code that corresponds to the primary occupation in which the employee was engaged at the time of accident/injury, or injurious exposure.
Orig/Rev:     06/07/95, 07/01/97
Record:       148
Format:       4 A/N
Values: Contact the jurisdiction for the source of Manual Classification Codes. Generally, these codes are generated, maintained, and available through the Data Collection Organization (DCO) authorized in a jurisdiction. The DCO's authorized to publish manual classification codes are NCCI and the Independent Rating Organizations, although there may be some exceptions for monopolistic states.
DP Rule: If a jurisdiction requires both the Occupation Description (DN0060) and Manual Classification (DN0059), the two elements cannot be edited against each other.
NATURE OF INJURY CODE – DN0035
Definition:     A code corresponding to the nature of the injury sustained by the employee.
Orig/Rev:     03/11/94, 07/01/97
Record:       148
Format:       2 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org

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NET WEEKLY AMOUNT – DN0087
Definition: For MTC’s IP, CA, CB, AP, AB, 02, CO, RB, RE, PY, Px, Sx (Benefit Type Code 0XX series only): The weekly amount which is due by the current claim administrator for that benefit type, after applying adjustments and credits to the Gross Weekly Amount.
For MTC’s EP and ER only (other than Benefit Type Code 240): The weekly amount of the workers’ compensation benefit the employee would be receiving instead of salary paid in lieu of compensation benefits by the employer as continued wages.
Orig/Rev:     02/03/95, 07/01/97, 10/09/03, 02/8/05, 02/24/05, 03/31/07
Record:       R22
Format:       $9.2
DP Rule:      Refer to Variable Segment Population Rules (Benefits Segment) in Section 4
The amount will equal the weekly rate as determined by jurisdiction statute (i.e.
comp rate) plus or minus any applicable adjustments or credits for the
corresponding benefit type. This is equal to the Gross Weekly Amount (DN0174)
when there are no adjustments or credits.
In the event of an acquired claim, the current claim administrator would report the Net Weekly Amount as it applies to their payments rather than to the previous claim administrator’s payments.
NET WEEKLY AMOUNT EFFECTIVE DATE – DN0211
Definition: For MTC’s IP, CA, CB, AB, 02, CO, RB, RE, PY, Px, Sx (Benefit Type Code 0XX series only): The date the Net Weekly Amount became effective as applied by the current Claim Administrator. For MTC AP and all subsequent MTC’s filed on acquired claims, this may be prior to the acquisition date if the acquiring claim administrator issued payment(s) for a period of time in which the file was handled by the previous claim administrator.
For MTC’s EP and ER only (other than Benefit Type Code 240): The date the Net Weekly Amount became effective is the date the employee is receiving salary paid in lieu of compensation benefits by the employer as continued wages.
Orig/Rev:     07/01/97, 10/09/03, 02/8/05, 02/24/05, 03/31/07, 01/01/08 Record:       R22 Format:       8 DATE
DP Rule: Refer to Variable Segment Population Rules (Benefits Segment) in Section 4. This date should never be prior to the date of accident
NON-CONSECUTIVE PERIOD CODE – DN0212
Definition: Reflects whether the waiting period or benefit period being reported was comprised of non-consecutive days of disability.
Orig/Rev:     07/01/97
Record:       R22
Format:       1 A/N
Values: W = Waiting Period: The actual dates of the waiting period cannot be captured if they are non-consecutive. If the employee is off work more than once during the waiting period, the Non-Consecutive Period Code "W" is used to report that the waiting period is composed of intermittent dates. The data elements: Initial Date Last Day Worked; Initial Date Disability Began; Initial Return to Work Date; Current Date Last Day Worked; Current Date Disability Began and Current Return to Work Date will give you the first and most recent of those dates. Any

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dates in between are not transmitted/provided. If applicable, this code is transmitted with MTC – IP, or AP (if this is the first payment on the case) B = Benefit Period: The Benefit Type Amount Paid, Benefit Type Claim Weeks and Benefit Type Claim Days do not represent a continuous period of time from the Benefit Period Start Date through the Benefit Period Through Date. This code is not transmitted with Final or Periodic MTC's. If sent with MTC IP, use “B” only if Code “W” doesn’t apply.
A = Adjustment/Credit/Redistribution: The A/C/R Start and End Dates do not represent a continuous period of time in relation to the adjusted Benefits. This code is not transmitted with Final or Periodic MTC's. If sent with MTC IP, use “A” only if neither Code “B” or “W” applies. DP Rule: The Non-Consecutive Period Code should be transmitted if the employee returns to work at least once during the waiting period, the benefit period being reported contains payment information for non-consecutive days or applied adjustment, credit or redistribution dates are non-consecutive. Hierarchy – In the event that two Non-Consecutive Period Codes apply to the reported benefit period the topmost code in the following hierarchy will be reported, i.e., if both the Benefit Period and an Adjustment period apply, report as a Benefit period:
W – Waiting Period
B – Benefit Period
A – Adjustment/Credit/Redistribution
NUMBER OF ACCIDENT/INJURY DESCRIPTION NARRATIVES – DN0274
Definition:	The number of Accident/Injury Description Narrative segment occurrences.
Orig/Rev:	04/22/02
Record:	R21
Format:	2 N
Max Occ:	10
Values:	00 through 10
NUMBER OF BENEFIT ACR – DN0289
Definition:	The number of Benefit ACR segment occurrences.
Orig/Rev:	04/22/02, 09/01/07
Record:	R22
Format:	3 N
Max Occ.	090
Values:	00 – 090
NUMBER OF BENEFITS – DN0288
Definition:	The number of Benefit segment occurrences.
Orig/Rev:	04/22/02
Record:	R22
Format:	2 N
Max. Occ.	10
Values:	00 through 10
NUMBER OF CONCURRENT EMPLOYERS – DN0275
Definition:	The number of Concurrent Employers segments occurrences.
Orig/Rev:	04/22/02
Record:	R22
Format:	2 N
Max Occ:	2
Values:	00 through 02

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NUMBER OF DAYS WORKED PER WEEK – DN0064
Definition:     The employee’s number of regularly scheduled workdays per week.
Orig/Rev:     03/11/94, 07/01/97, 06/01/06
Record:       148; A49
Format:       1 N
DP Rule:      Since this is the number of days worked with the covered employer at the time of
injury, it should not change, unless reported incorrectly. This data element has
no relationship to concurrent employment.
NUMBER OF DEATH DEPENDENT/PAYEE RELATIONSHIPS – DN0082
Definition:     The number of Death/Dependent Payee segment occurrences. Orig/Rev:     06/07/95 Record:      A49 Format:       2 N Values:       00 through 12
NUMBER OF DENIAL REASON NARRATIVES – DN0276
Definition:	The number of Denial Reason Narrative segment occurrences.
Orig/Rev:	04/22/02
Record:	R21; R22
Format:	2 N
Max Occ:	3
Values:	00 through 03
NUMBER OF ERRORS – DN0114
Definition:     The number of error code segment occurrences. Orig/Rev:     08/18/94, 07/01/97 Record:       AKC; ARC Format:       2 N
NUMBER OF FULL DENIAL REASON CODES – DN0277
Definition:	The number of Full Denial Reason Codes segment occurrences.
Orig/Rev:	04/22/02
Record:	R21; R22
Format:	2 N
Max Occ:	5
Values:	00 through 05
NUMBER OF MANAGED CARE ORGANIZATIONS – DN0278
Definition:	The number of Managed Care Organization segment occurrences.
Orig/Rev:	04/22/02
Record:	R21
Format:	2 N
Max Occ:	2
Values:	00 through 02
NUMBER OF OTHER BENEFITS – DN0282
Definition:	The number of Other Benefits segment occurrences.
Orig/Rev:	04/22/02
Record:	R22
Format:	2 N
Max Occ:	25
Values:	00 through 25

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NUMBER OF PAYMENTS – DN0283
Definition:
Orig/Rev:
Record:
Format:
Max Occ:
Values:
The number of Payment segment occurrences.
04/22/02
R22
2 N
5
00 through 05
NUMBER OF PERMANENT IMPAIRMENTS – DN0078
Definition:
Orig/Rev:
Record:
Format:
Max Occ:
Values:
The number of Permanent Impairment segment occurrences.
06/07/95
A49
2 N
6
00 – 06
NUMBER OF RECOVERIES – DN0284
Definition:	The number of Recoveries segments occurrences.
Orig/Rev:	04/22/02
Record:	R22
Format:	2 N
Max Occ:	10
Values:	00 through 10
NUMBER OF REDUCED EARNINGS – DN0285
Definition:	The number of Reduced Earnings segment occurrences.
Orig/Rev:	04/22/02
Record:	R22
Format:	2 N
Max Occ:	52
Values:	00 through 52
NUMBER OF SUSPENSION NARRATIVES – DN0287
Definition:	The number of suspension narrative segment occurrences.
Orig/Rev:	04/22/02
Record:	R22
Format:	2 N
Max Occ:	3
Values:	00 through 03
NUMBER OF WITNESSES – DN0279
Definition:
Orig/Rev:
Record:
Format:
Max Occ:
Values:
The number of Witness segment occurrences.
04/22/02
R21
2 N
5
00 through 05

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OCCUPATION DESCRIPTION – DN0060
Definition: Identifies the employee’s primary occupation at the time of the accident or injurious exposure.
Orig/Rev:     06/07/95, 07/01/97
Record:       R21
Format:       50 A/N
DP Rule:      The data that is passed should be sufficient to assign an occupation code. This text can be, but cannot be required to be, the Occupation Code source description. This is not the NCCI class code text description. If a jurisdiction requires both the Occupation Description (DN0060) and Manual Classification (DN0059), the two elements cannot be edited against each other.
ORIGINAL TRANSMISSION DATE – DN0102
Definition: The value obtained from the Date Transmission Sent (DN0100), from the originating batch header record. To allow a receiving party the ability to match back to the original batch file for reconciliation purposes. This field should only be populated on the acknowledgement (AKC or ARC) batch header to allow a receiving party the ability to match back to the original batch file for reconciliation purposes. It is used in conjunction with the Original Transmission Time field in the acknowledgment process.
Orig/Rev:     08/19/94, 07/01/97, 07/12/02, 05/12/06
Record:       HD1 (of AKC or ARC only)
Format:       8 DATE
ORIGINAL TRANSMISSION TIME – DN0103
Definition: The value obtained from the Time Transmission Sent (DN0101), from the originating batch header record. This field should only be populated on the acknowledgement (AKC or ARC) batch header to allow the receiving party the ability to match back to the original batch file for reconciliation purposes. It is used in conjunction with the Original Transmission Date field in the acknowledgment process.
Revised      08/19/94, 07/01/97, 07/12/02, 05/12/06
Record:       HD1 (of AKC or ARC only)
Format:       6 TIME
OTHER BENEFIT TYPE AMOUNT – DN0215
Definition:     The cumulative amount paid to date associated with an Other Benefit Type Code
(DN0216).
For acquired claims, the Other Benefit Type Amount will be the cumulative
amount to date associated with an Other Benefit Type Code paid by the
acquiring claim administrator. Orig/Rev:     07/01/97, 03/15/05, 11/22/05 Record:       R22 Format:       $9.2
OTHER BENEFIT TYPE CODE – DN0216
Definition:     A code identifying miscellaneous benefits not otherwise specifically defined with
a Benefit Type Code (DN0085). Orig/Rev:     07/01/97, 12/01/99, 05/13/03, 03/14/2005, 11/22/05, 05/05/06, 04/11/08 Reference:    See each code below for specifics. Record:       R22 Format:       3 A/N DP Rule:      If a medical bill covers charges that fall under more than one OBT code, the code
that is tied to the type of provider being paid should be used. Values:       300 Total Funeral Expense – Sum of the funeral expenses paid for this claim.

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310	Total Penalties – Sum of the penalties paid for this claim, including the
penalty amount(s) paid to the employee/dependents (code 311).
311	Total Employee Penalties - Sum of penalties paid to the
employee/dependents for this claim.
320	Total Interest – Sum of the interest paid for this claim, including the interest
paid to the employee/dependents (code 321).
321	Total Employee Interest – Sum of interest paid to the
employee/dependents for this claim.
330 Total Employer’s Legal Expenses – Sum of the employer’s legal expenses paid for this claim.
340 Total Claimant’s Legal Expenses – Sum of the claimant’s legal expenses paid for this claim. Note: This excludes employee attorney fees that are determined to be the responsibility of the employee but are deducted from any lump sum payments/settlements. Those attorney fees should be coded as the same indemnity type as the lump sum payment/settlement. If part of a weekly indemnity check is redistributed to a claimant’s attorney, it should be sent as a weekly Benefit Redistribution Code “K” (Claimant Attorney Fees) rather than OBT Code 340.
350 Total Payments to Physicians – Sum of services paid to physicians for this claim.
360 Total Hospital Costs – Sum of services paid to hospitals for this claim.
370 Total Other Medical – Sum of medical services not otherwise reported for this claim.
380 Total Vocational Rehabilitation Evaluation – Sum of vocational rehabilitation evaluation services for this claim.
390 Total Vocational Rehabilitation Education – Sum of vocational rehabilitation education payments to this claim.
400 Total Other Vocational Rehabilitation – Sum of vocational rehabilitation services not otherwise reported for this claim.
420	Total Expert Witness Fees – Sum of fees paid to expert witnesses for this claim.
421	Total Court Reporter Fees – Sum of fees paid to court reporters taking transcription at court hearings and depositions on this claim
422	Total Private Investigator Fees – Sum of fees paid to private investigators monitoring and documenting activities of the claimant for this claim
430 Total Unallocated Prior Indemnity Benefits – Sum of prior indemnity benefits paid to date by the previous Claim Administrator(s).
440 Total Unallocated Prior Medical – Sum of prior medical paid to date by the previous Claim Administrator(s).

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450 Total Pharmaceutical Costs – Sum of the prescribed pharmacy costs paid for this claim.
455 Total Dental Expenses – Sum of dental expenses paid for this claim.
460 Total Physical Therapy Costs – Sum of physical therapy expenses paid for this claim.
465 Total Chiropractic Expenses – Sum of relevant chiropractic expenses paid for this claim.
470 Total Durable Medical Costs – Sum of costs for durable medical goods paid for this claim.
475 Total Medical Travel Expenses – Sum of relevant medical travel expenses paid for this claim. Examples are: mileage, room & board, childcare expenses etc.
480 Total Employee Medical-Legal Costs – The cost for ordered evaluations, medical exams, and related non-treatment medical opinions selected by the employee and paid by the claim administrator for the purpose of adjudication or dispute resolution.
485 Total Employer/Claim Administrator Medical-Legal Costs – The cost for ordered evaluations, medical exams, and related non-treatment medical opinions selected and paid by the employer/claim administrator for the purpose of adjudication or dispute resolution.
490 Total Agreed Upon/Directed Medical-Legal Costs – The cost for ordered evaluations, medical exams, and related non-treatment medical opinions selected by both parties or the jurisdiction and paid by the employer/claim administrator for the purpose of adjudication or dispute resolution.
PART OF BODY INJURED CODE – DN0036
Definition:     The code corresponding to the part(s) of the body injured.
Orig/Rev:     06/07/95, 07/01/97
Record:       148
Format:       2 A/N
Values:       See link to code list at IAIABC Website: www.iaiabc.org

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PARTIAL DENIAL CODE – DN0294
Definition:     A code identifying which portion of the claim is currently being denied.
Orig/Rev:     05/08/02, 09/10/03, 01/20/06, 02/8/06, 09/21/06, 08/21/09
Record:       R22
Format:       1 A/N
Values:       A = Denying Indemnity in whole, but not Medical
B = Denying Indemnity in part, but not Medical
C = Denying Medical in whole, but not Indemnity
D = Denying Medical in part, but not Indemnity
E = Denying Indemnity in whole and Medical in part
F = Denying Medical in whole and Indemnity in part
G = Denying both Indemnity and Medical in part DP Rule:      *Applicable to MTC PD (Partial Denial) (or its corresponding CO, 02 or UR) only.
*Partial Denial Codes are used when only a portion of the claim is being denied.
These codes are always sent with MTC PD (Partial Denial or its corresponding
CO, 02 or UR), and are not to be used in conjunction with the Full Denial data
elements: Full Denial Reason Code and Full Denial Effective Date.
*If the Initial Payment (IP or AP) on the claim involves partial denial of indemnity
PAYEE – DN0217
Definition:
For PY (or any corresponding 02 or CO), or when the jurisdiction requires the
reporting of Payee on an IP, AP or RB: The name of the individual, organization,
or court assignment to whom the check is being issued.
07/01/97, 12/01/99, 05/27/03, 02/8/05
R22
40 A/N
Refer to Variable Segment Population Rules (Payments Segment) in Section 4.
The Steering Committee directed that Payee (DN0217) was established for
specified transactions only (IP, AP, PY, RB or any corresponding 02 or CO for
those specified Maintenance Type Codes) and that individual weekly check
information would not be reported in Release 3.
This is a free form text field that cannot be edited by the jurisdiction.
benefits, the MTC IP should be preceded by MTC PD.
Orig/Rev: Record: Format: DP Rule:
PAYMENT AMOUNT – DN0218
Definition:     The net amount of the check.
Orig/Rev:     07/01/97
Record:       R22
Format:       $9.2
DP Rule: Refer to Variable Segment Population Rules (Payments Segment) in Section 4. Used for reporting one-time payments. Not to be used for on-going indemnity benefit payments. If a Payment Amount is present, Payment Reason Code (DN222) should also be sent.
PAYMENT COVERS PERIOD START DATE – DN0219
Definition:     The beginning date of the period covered by a payment.
Orig/Rev:     07/01/97
Release:      R22
Format:       8 DATE
DP Rule:      Refer to Variable Segment Population Rules (Payments Segment) in Section 4.
PAYMENT COVERS PERIOD THROUGH DATE – DN0220
Definition:     The last date of the period covered by a payment. Orig/Rev:     07/01/97 Record:       R22 Format:       8 DATE

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DP Rule:	Refer to Variable Segment Population Rules (Payments Segment) in Section 4.
PAYMENT ISSUE DATE - DN0195
Definition:	For IP, AP, PY, RB: The date that the check that initiated the MTC is officially
surrendered during business hours to a letter delivery organization; or available for pickup per agreement with the employee. For CO transactions that have an MTCC of IP, AP, PY, or RB: the date of the check that initiated the IP, AP, PY, or RB that received a TE acknowledgment code.
Orig/Rev:	07/01/97, 11/30/98, 12/01/99, 05/27/03, 09/6/03, 02/8/05, 02/25/05, 3/1/06
Record:	R22
Format:	8 DATE
DP Rule:	The Payment Issue Date is in the Payments Segment. The equivalent of this
data element in the Benefits Segment is Benefit Payment Issue Date (DN0192). Refer to Variable Segment Population Rules (Benefits Segment and Payments Segment) in Section 4. The Steering Committee/EDI Council directed that Payment Issue Date (DN0195) was established for specified transactions only (IP, AP, PY, RB, or any corresponding 02 or CO for those specified Maintenance Type Codes) and that individual weekly check information would not be reported.
PAYMENT REASON CODE - DN0222
Definition:	A code, equating to a Benefit Type Code (DN0085) or an Other Benefit Type
Code (DN0216), used when:
•	The jurisdiction requires the reporting of lump sum payments/settlements (PY MTC)
•	The jurisdiction requires the reporting of the first payment of funeral, penalty, attorney fees, or a minimum threshold amount of medical.
•	The jurisdiction requires the reporting of Payee on an IP, AP, or RB (which requires the Payments segment to be sent).
Orig/Rev:	07/01/97, 04/08/03, 02/08/05, 05/05/06
Record:	R22
Format:	3 A/N
Values:	See Benefit Type Code and Other Benefit Type Code values for medical (350,
360, 370, 450, 455, 460, 465, 470), funeral (300), penalty (310, 311), and
attorney fees (330 & 340)
DP Rule:	Refer to Variable Segment Population Rules (Payments Segment) in Section 4
PERMANENT IMPAIRMENT BODY PART CODE - DN0083
Definition:	A code referencing the anatomic classification of the injury.
Orig/Rev:	03/11/94, 07/01/97
Record:	A49
Format:	3 A/N
Values:	See link to code list at IAIABC Website: www.iaiabc.org and whole body “99”.
PERMANENT IMPAIRMENT MINIMUM PAYMENT INDICATOR - DN0223
Definition:	An indicator that the payment is being made for a minimum amount when a final
rating is not yet available.
Orig/Rev:	07/01/97, 11/30/98
Record:	R22
Format:	1 A/N
Values:	Y = Yes
N = No
DP Rule:	If this data element is required by the jurisdiction, the code should be set to “Y” if
the amount was based on a minimum and “N” if not.   If the code was originally
sent as “Y” and a minimum rate is no longer being paid, the code should be reset
to “N”.

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PERMANENT IMPAIRMENT PERCENTAGE – DN0084
Definition:     The amount of anatomic or functional abnormality or loss which results from the
injury and exists after the date of maximum medical improvement. Orig/Rev:     03/11/94, 07/01/97, 09/15/05 Record:      A49 Format:       3.2 Values:       00000 (0%) to 10000 (100%)
PHYSICAL RESTRICTIONS INDICATOR – DN0224
Definition:     An indicator that identifies the presence of physical restrictions upon the
employee’s release and/or return to work. Orig/Rev:     07/01/97, 11/30/98, 10/04/00, 04/11/08 Record:       R21; R22 Format:       1 A/N Values:       N = Without Physical Restrictions
Y = With Physical Restrictions DP Rule:      This is required whenever an Initial Return to Work Date or Current Return to
Work Date is sent on the transaction.
If an MTC 02 is sent with a change to the RTW Type Code and/or Physical Restrictions Indicator and there is no second period of disability, a subsequent Initial Return to Work Date may be sent to correspond with the revised RTW Type Code and/or Physical Restrictions Indicator. If a subsequent Initial Return to Work Date is not sent on an MTC 02, the jurisdiction could use the MTC Date as an estimate of when the subsequent RTW Type Code and/or Physical Restrictions Indicator took effect.
POLICY EFFECTIVE DATE – DN0029
Definition:     The date the employer’s insurance policy or self-insurance license/certificate
became effective. Orig/Rev:     06/06/95, 07/01/97, 11/22/05 Record:       148 Format:       8 DATE DP Rule:      “Coverage” is usually equivalent to POC “Policy”, except when the employer is
self-insured where a policy does not exist but coverage does.
This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident) or 3D (No Coverage - No jurisdiction)
POLICY EXPIRATION DATE – DN0030
Definition:     The date that the employer’s insurance policy or self-insurance license/certificate
expired. Orig/Rev:     06/06/95, 07/01/97, 11/22/05 Record:       148 Format:       8 DATE DP Rule:      “Coverage” is usually equivalent to POC “Policy” except when the employer is
self-insured where a policy does not exist but coverage does.
This data element cannot be required on initiating 04 FROI Denial if DN0198 -
Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of
accident) or 3D (No Coverage - No jurisdiction)

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POLICY NUMBER IDENTIFIER – DN0028
Definition:     The number identifying the coverage policy in effect for the claim. Orig/Rev:     03/11/94, 07/01/97, 11/22/05 Record:       148 Format:       18 A/N
DP Rule:      “Coverage” is usually equivalent to POC “Policy”, except when self-insured status where policy does not exist but coverage does.
Report the alphanumeric characters used for uniquely identifying the policy. Do NOT report any embedded blanks, marks of punctuation, or special characters.
This data element cannot be required on initiating 04 FROI Denial if DN0198 -Full Denial Reason Code is 3E (No Coverage -No policy in effect on the date of accident) or 3D (No Coverage - No jurisdiction)
PRE-EXISTING DISABILITY CODE – DN0069
Definition:     An indicator identifying the existence of a disability that existed prior to the injury. Orig/Rev:     03/11/94, 07/01/97 Record:      A49 Format:       1 A/N Values:       Y = Yes
N = No
U = Unknown
RECEIVER ID – DN0099
Definition:     A composite or group level comprised of Receiver FEIN (Primary FEIN of the
receiving party), Filler, and Receiver Postal Code (Primary Postal Code of the
receiving party). Orig/Rev:     08/18/94, 07/01/97 Record:       HD1 Format:       Receiver FEIN 9 A/N
Filler 7 A/N
Receiver Postal Code 9 A/N
RECORD SEQUENCE NUMBER – DN0107
Definition:     Identifying control number that must be unique within a batch. The originator of a
transaction assigns the number. Orig/Rev:     08/18/94, 07/01/97, 01/20/06 Record:       AKC; ARC Format:       9 N Values:       000000000 = Header or batch structure Error
000000001 thru 999999998 = Detail Record Identifier
999999999 = Trailer Error DP Rule:      The Record Sequence Number is assigned by the receiver based on the order of
the records in the original batch. The Record Sequence Number returned in the
acknowledgement corresponds to the Record Sequence Number of the primary
record of the transaction unless it is a Header, Batch Structure or Trailer Record
error.

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RECOVERY AMOUNT – DN0225
Definition:     The sum of monies received by the insurer to date for the corresponding
recovery code. Orig/Rev:     07/01/97, 01/26/06, 01/19/07 Record:       R22 Format:       $9.2 DP Rule:      If there is a Recovery Amount present, a Recovery Code (DN0226) must also be
sent.
To ensure that a claim reflects costs actually incurred, the Claim Administrator will back out the recoveries made under Code 830, 880 and/or 890 from the appropriate Benefit Type Amount Paid or Other Benefit Type amount before it transmits the report. Any recoveries the claims administrator receives under any other Recovery codes must not be backed out of their respective Benefit Type Amount Paid or Other Benefit Type Amounts.
RECOVERY CODE – DN0226
Definition:     A code that identifies the type of recovery being made. Orig/Rev:     07/01/97, 12/19/05, 01/19/07 Record:       R22 Format:       3 A/N
Values:       800 Special Fund Recovery – Sum of monies recovered from special funds for this claim.
810 Deductible Recovery – Sum of monies recovered through insured reimbursement deductible amounts.
820 Subrogation Recovery – Sum of monies recovered through subrogation for this claim.
830 Overpayment Recovery – Sum of monies recovered due to overpayment of indemnity, medical or expenses for this claim.
840 Unspecified Recovery – Sum of monies recovered through salvage and all others not defined for this claim.
845 Apportionment/Contribution Recovery - Sum of monies recovered due to apportionment/contribution as a result of shared or partial liability(s) for this claim.
850 Second Injury Fund – Monies reimbursed from a jurisdictional second injury fund.
860 Future Credit Amount – The residual amount of monies available from a third party settlement after the insurer has recovered pre-paid benefits. Credit to be applied to future benefits.
865	Vocational Rehabilitation - Monies reimbursed from a jurisdictional vocational rehabilitation fund.
866	Uninsured Employer – Monies reimbursed from a jurisdictional uninsured employer fund.
867	Silicosis, Dust and Logging Industry Fund – Monies reimbursed from a jurisdictional dust/logging industry fund.
865	
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868 Vocationally Handicapped Fund – Monies reimbursed from a jurisdictional vocationally handicapped fund.
870 Other Funds – A code to identify the monies reimbursed from a jurisdictional special fund other than those listed above.
880 – Voided Indemnity Benefit Check Recovery - The cumulative sum of monies for all indemnity checks returned/cancelled/voided in the Benefits segment(s).
DP Rule: The Claim Administrator will back out the returned/cancelled/voided indemnity check amounts from the Benefit Type Amount Paid in the Benefits segment(s) and any corresponding Benefit Adjustment, Credit, or Redistribution Amount in the Benefit A/C/R Segment(s). If all indemnity checks have been returned/cancelled/voided, a Benefit segment will not be present. If some, but not all indemnity checks have been returned/cancelled/voided, at least 1 Benefit segment will be present, but will be less the amount of the indemnity checks that were returned/cancelled/voided. The Benefit Type Amount Paid (if present) will reflect the amount that was actually paid out, but the other DN’s in the Benefits or A/C/R segment may or may not be retroactively adjusted. This value will always remain on the transaction and if additional checks are returned/cancelled/voided, this value will increase. If the jurisdiction compares the transaction to its database and everything calculates accurately, it should ignore the code/amount because the returned/cancelled/voided check may have occurred between the last transaction sent to the jurisdiction and the current transaction.
890 – Voided Other Benefit Check Recovery – The cumulative sum of monies for all Other Benefit Type check(s) returned/cancelled/voided included the Other Benefit Type segment(s).
DP Rule: The Claim Administrator will back out the returned/cancelled/voided check amounts from the Other Benefit Type Amount in the Other Benefits segment(s). If all “other benefit” checks have been returned/cancelled/voided, an Other Benefit segment will not be present. If some, but not all “other benefits” checks have been returned/cancelled/voided, at least 1 Other Benefit segment will be present, but will be less the amount of the other benefits checks that were returned/cancelled/voided. The Other Benefit Type Amount (if present) will reflect the amount that was actually paid out. This value will always remain on the transaction and if additional checks are returned/cancelled/voided, this value will increase. If the jurisdiction compares the transaction to its database and everything appears to be accurate, it should ignore the code/amount because the returned/cancelled/voided check may have occurred between the last transaction sent to the jurisdiction and the current transaction.
DP Rule: If there is a Recovery Amount (DN0225) present, a Recovery Code must also be sent.
REDUCED BENEFIT AMOUNT CODE – DN0202
Definition: A code that identifies the reason a Benefits segment may be missing from a transaction or may contain values less than reported in a previous transaction due to a benefit amount being reclassified or a claim being reported that was settled under another Date of Injury.
Orig/Rev:     01/19/07, 09/21/09
Record:       R22
Format:       1 A/N

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Values:       R = Reclassification of Benefit
Indemnity benefits paid on this claim have been fully or partially reclassified to a different Benefit Type Code than was previously reported. DP Rule: The presence of code “R” means that a Benefits segment is always present but the Benefit Type Amount Paid for one or more Benefit Type Codes (and any corresponding ACR Amount(s)) that were previously reported may be either reduced or removed. This value will always remain on the transaction.
S = Claim Settled Under Another DOI
A lump sum settlement covered multiple dates of injury, including this case, and the settlement amount was reported on a different date of injury. DP Rule: The presence of code “S” means that a “Payments” segment will not be present on the transaction and a “Benefits” segment will only be present on the transaction if indemnity benefits had been paid for this date of injury prior to the settlement. If required by the jurisdiction, the Award/Order Dates and Lump Sum Payment/Settlement Codes would be the same for all files settled under one amount/date of injury. This value will always remain on the transaction.
N = No Money Settlement
A settlement has been agreed upon/approved for a single date of injury and the Claim Administrator is not paying any money as part of the workers’ compensation settlement.
DP Rule: The presence of code “N” means that a “Payments” segment will not be present on the transaction and a “Benefits” segment will only be present on the transaction if indemnity benefits had been paid for this date of injury prior to the settlement. If required by the jurisdiction, the Award/Order Date and Lump Sum Payment/Settlement Code would be sent.
Examples include a settlement with no dollars being paid due to waiver of a lien or forgiveness of overpayment.
REDUCED EARNINGS WEEK NUMBER – DN0242
Definition:     A sequential value that indicates the week(s) for which reduced earning amounts
are being reported on this transaction. Orig/Rev:     07/01/97 Record:       R22 Format:       2 N DP Rule:      The Reduced Earnings Week Number is reset for each transaction.
REQUEST CODE – DN0112
Definition:     A code conveying additional information such as the need to follow up or respond
manually to the transaction. Orig/Rev:     08/18/94, 07/01/97, 05/16/03 Record:       AKC; ARC Format:       3 A/N Values:       001 = Contact Sender

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RETURN TO WORK TYPE CODE – DN0189
Definition: A code identifying the type of Initial Return to Work Date (DN0068) or Current Return to Work Date (DN0072).
Orig/Rev:     07/01/97, 10/04/00, 05/14/03, 04/11/08
Record:       R21; R22
Format:       1 A/N
Values:       A = Actual R = Released
DP Rule: The Return to Work Type Code will be required and used in conjunction with Initial Return to Work Date and Current Return to Work Date. If both Initial and Current Return to Work Dates are sent in one transaction, the Return to Work Type Code will refer to the Current Return to Work Date.
If an MTC 02 is sent with a change to the RTW Type Code and/or Physical Restrictions Indicator and there is no second period of disability, a subsequent Initial Return to Work Date may be sent to correspond with the revised RTW Type Code and/or Physical Restrictions Indicator. If a subsequent Initial Return to Work Date is not sent on an MTC 02, the jurisdiction could use the MTC Date as an estimate of when the subsequent RTW Type Code and/or Physical Restrictions Indicator took effect.
RETURN TO WORK WITH SAME EMPLOYER INDICATOR – DN0228
Definition:     An indicator identifying whether or not the employee returned to work with the
same employer at which the injury occurred. Orig/Rev:     07/01/97, 10/04/00, 05/14/03, 06/15/04 Record:       R21; R22 Format:       1 A/N Values:       Y = Yes
N = No DP Rule:      This value applies only when the Return to Work Type Code = “A” (Actual).
SENDER ID – DN0098
Definition:     Composition or group level comprised of Sender FEIN (Primary FEIN of the
sending party), Filler, and Sender Postal Code (Primary Postal Code of the
sending party). Orig/Rev:     08/18/94 Record:       HD1 Format:       Sender FEIN 9 A/N
Filler 7 A/N
Sender Postal Code 9 A/N
SUSPENSION EFFECTIVE DATE – DN0193
Definition: The last date through which the concurrent indemnity benefit being partially suspended are due or the last date through which all indemnity benefits are due.
Orig/Rev:     07/01/97, 03/01/05, 02/08/06
Record:       R22
Format:       8 DATE
DP Rule: This is only applicable on MTC Px and Sx (or its corresponding CO), 02 or UR. Suspension Effective Date may be a future date if Permanent Partial Scheduled Benefits (030 or 530) are paid in a lump sum and benefits are subsequently suspended.

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SUSPENSION NARRATIVE – DN0233
Definition:     A factual basis for suspending all indemnity benefits or for partially suspending a
concurrent indemnity benefit. Orig/Rev: 07/01/97, 03/01/05, 02/08/06 Record:       R22
Format:       150 A/N (up to 3 occurrences of 50) DP Rule:      This is only applicable on MTC Px and Sx (or its corresponding CO), 02 or UR.

TEST/PRODUCTION CODE – DN0104
Definition:
Reflects an EDI participation status for specific transaction. It indicates whether
the transaction being sent is being targeted to a receiver’s “production” or “test”
system. Transactions performed while under “parallel” status should have the
Orig/Rev: Record: Format: Values:
Tech Note:
“test” indicator set.
08/18/94, 07/01/97, 5/16/03
HD1
1 A/N
P = Production
T = Test (Pilot parallel or Test)
This flag is set at the batch header level in the HD1. Therefore, all transactions
within a batch must be at the same test/production level.
TIME OF INJURY – DN0032
Definition:     The time of the accident/injury.
Orig/Rev:     03/11/94, 07/01/97, 11/30/98
Record:       148
Format:       4 TIME
DP Rule: Only a valid time in military format, zeroes, or spaces are allowed in time fields. Use 24-hour military time. All zeroes in a time field is valid and equivalent to 240000 or 2400. Spaces indicate absence of data. May be left blank for occupational disease or cumulative injury.

TIME PROCESSED – DN0109
Definition:
Orig/Rev:
Record:
Format:
The time the receiver processed the detail transaction. Together with date processed and a record sequence number it will uniquely identify a specific acknowledgment detail record. 08/09/95, 07/01/97 AKC; ARC 6 TIME
TIME TRANSMISSION SENT – DN0101
Definition:     The time the sender prepared the batch file for transmission. Together with the
Date Transmission Sent will uniquely identify a specific transmission batch. Orig/Rev:     08/09/95, 07/01/97 Record:       HD1 Format:       6 TIME
TRANSACTION COUNT – DN0191
Definition:     Total number of transaction sent as part of the batch. Orig/Rev:     07/01/97, 07/12/02 Record:       TR2 Format:       9 N

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TRANSACTION SET ID – DN0001
Definition:     A code that identifies the transaction being sent/received.
Orig/Rev:     08/18/94
Record:       HD1; A49; 148; R21; R22; TR2; AKC; ARC
Format:       3 A/N
Values:       148 = First Report
R21 = First Report Companion Record
A49 = Subsequent Report
R22 = Subsequent Report Companion Record
AKC = Claims Acknowledgment Detail Record
ARC = Claims Re-Acknowledgment Detail Record
HD1 = Transmission Header Record
TR2 = Transmission Trailer Record
TYPE OF LOSS CODE – DN0290
Definition:     A code indicating the type of loss being reported. Orig/Rev:     12/31/02, 05/16/03 Record:       R21; R22 Format:       2 A/N
Values:       01 = Traumatic Injury – An injury that is traceable to a definite accident during the workers’ present employment.
2	= Occupational Disease – An injury caused by exposure to a disease-producing agent in the workers’ occupational environment. Injuries of this type are not traceable to a definite accident during the workers’ past or present employment.
3	= Cumulative Injury (Other than Disease) – An injury having occurred from, or aggravated by, a repetitive employment activity. Injuries of this type are not traceable to a definite accident during the workers’ past or present employment.
VARIABLE SEGMENT NUMBER – DN0117
Definition:     A number to identify the occurrences of the variable segment in error and is part of the error code.
Orig/Rev:	08/18/94	
Record:	AKC; ARC	
Format:	2 N	
WAGE EFFECTIVE DATE – DN0256	
Definition:	The date the average wage became effective.	
Orig/Rev:	07/01/97	
Record:	R22	
Format:	8 DATE	
DP Rule:	This date should never be prior to the date of accident	
WAGE – DN0062		
Definition:	The employee's pre-injury wage for the Wage Period a	
	employer.	
Orig./Rev.:	03/11/94, 07/01/97, 04/24/03, 04/28/04	
Record:	148	
Format:	$9.2	

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WAGE PERIOD CODE
Definition:
Orig/Rev: Record: Format: Values:
DP Rule:

– DN0063
A code to designate the time period upon which the reported Wage (DN0062) or Average Wage (DN0286) was based. 03/11/94, 07/01/97, 12/01/99, 05/27/03, 04/28/04 148; A49 2 A/N
148 (FROI)	A49 (SROI)
1	= Weekly	01 = Weekly
2	= Bi-Weekly	04 = Monthly 04 = Monthly

6	= Daily
7	= Hourly
Always required when Wage, Average Wage, or Concurrent Employer Wage (DN0143) is reported. The Wage Period Code for the concurrent employer is always equivalent to the Wage Period Code for the primary employer.

WITNESS BUSINESS PHONE NUMBER – DN0237
Definition:     The business phone number of the witness to the incident/accident.
Orig/Rev:     07/01/97
Record:       R21
Format:       15 A/N
DP Rule:      Standard telephone numbers are 10 numeric positions (area code and number).
The additional 5 bytes should be used for a numeric extension, when applicable.
The numeric extension immediately follows the 10-digit phone number and can
be 0 to 5 positions in length.
WITNESS NAME – DN0238
Definition:     The legal name of the person who observed the incident/accident.
Orig/Rev:     07/01/97
Record:       R21
Format:       40 A/N
DP Rule:      This is a free form text field that cannot be edited by the jurisdiction.

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