Work Comp Segment

Field #

Field Name

Possible Value or Explanation of Field

434-DY

Injury Date

Converts from injury date into YYYYMMDD format; located on the workman's comp tab in the Patient File (F3)

315-CF

Employer name

Patient's employer name; located on the workman's comp tab in the Patient File (F3)

321-CL

Employer Contact Name

Employer contact name for person handling this claim; located on the workman's comp tab in the Patient File (F3)

316-CG

Employer Address

Employer's address, combines address line 1 and 2; located on the workman's comp tab in the Patient File (F3)

317-CH

Employer City

Employer's city; located on the workman's comp tab in the Patient File (F3)

318-CI

Employer State

Employer's state; located on the workman's comp tab in the Patient File (F3)

319-CJ

Employer Zip Code

Employer's zip code; located on the workman's comp tab in the Patient File (F3)

320-CK

Employer Phone Number

Employer's phone number; located on the workman's comp tab in the Patient File (F3)

435-DZ

Claim Reference ID

Claim reference ID or the injury description identifying the claim; located on the workman's comp tab in the Patient File (F3)

327-CR

Carrier ID

Carrier code assigned to the claim; located on the workman's comp tab in the Patient File (F3)

117-TR

Billing Entity Type Indicator

Ø- Provider Submitted-Pay to Provider, 1- Provider Submitted-Pay to Another Party, 2- Agent Submitted-Pay to Agent, 3- Agent Submitted-Pay to Another Party; located on the workman's comp tab in the Patient File (F3)

118-TS

Pay to Qualifier

Indicate the qualifier for the below ID if the payee will be different than the person injured; located on the workman's comp tab in the Patient File (F3)

119-TT

Pay to ID

If different than patient, indicate the ID of the person who'll be getting paid for this claim that corresponds to the qualifier above; located on the workman's comp tab in the Patient File (F3)

120-TU

Pay to Name

If different than patient, indicate the name of the person who'll be getting paid for this claim; located on the workman's comp tab in the Patient File (F3)

121-TV

Pay to Street Address

Above person's address; located on the workman's comp tab in the Patient File (F3)

122-TW

Pay to City

Above person's city; located on the workman's comp tab in the Patient File (F3)

123-TX

Pay to State

Above person's state; located on the workman's comp tab in the Patient File (F3)

124-TY

Pay to Zip Code

Above person's zip code; located on the workman's comp tab in the Patient File (F3)

125-TZ

Generic Equivalent ID Qualifier

Indicates the ID qualifier if a generic equivalent will be used in the claim; located on the workman's comp tab in the Patient File (F3)

126-UA

Generic Equivalent Product ID

Indicates the product ID if a generic equivalent will be used in the claim, based on the qualifier above; located on the workman's comp tab in the Patient File (F3)