Schema xfs-cis.xsd


element submission

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
properties	content  complex
children	c4amr_0908:document c4amr_1012:document c4amr_1510:document c4narr_0812:document c4narr_1012:document c4narr_1510:document cms1500_1202:document otpt4_1012:document otpt4_1510:document
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:application-id   wcb:Text   required      CIS   documentation Value is fixed at 'CIS' for this submission type. wcb:production-test-indicator   derived by: wcb:Text   required         documentation Indicates submission was for production use or testing only (values P or T) wcb:bp-submission-id   derived by: wcb:Text   required         documentation Business Partner's Internal Submission ID Attribute documentation This is the business partner's identifier for the entire submission. wcb:bp-submission-comment   derived by: wcb:Text   optional         documentation Business Partner's Comment Attribute documentation Optional comment for business partner's use.
annotation	documentation XML Form Submission (Root Element)

element attachment-binary

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:content-type   wcb:Text   required         documentation Conent Type (MIME Type) -- only 'image/tiff' is currently allowed wcb:ref   wcb:Text   required         documentation A reference to the binary attachment.  This must be the filename only with no path or other prefix/suffix.
annotation	documentation Document Attachment - Binary documentation This element is a placeholder which references a binary attachment which is to be inserted at the current point in the list of all attachments (binary and text).

element attachment-text

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
properties	content  complex
children	wcb:page
annotation	documentation Document Attachment - Text (Embedded) documentation This element contains text for one or more pages to be inserted at the current point in the list of all attachments (binary and text). documentation Each page can contain up to 56 lines with 100 characters each.  Note that the 'Courier 9' fixed-space font is used to create the viewable page.

element attachment-text/page

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
properties	minOcc  1 maxOcc  unbounded content  complex
children	wcb:line
annotation	documentation Contains contents of a single page

element attachment-text/page/line

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:String
properties	minOcc  1 maxOcc  56 content  simple
facets	Kind  Value  Annotation minLength  0 maxLength  100 pattern  [ -~]*
annotation	documentation One line of text

element form-image

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:content-type   wcb:Text   required         documentation Conent Type (MIME Type) -- only 'image/tiff' is currently allowed wcb:ref   wcb:Text   required         documentation A reference to the form image.  This must be the filename only with no path or other prefix/suffix.
annotation	documentation Form Image documentation This element is a placeholder which references a form image which is to be inserted into the document ahead of all attachments.  If the form contains multiple pages, there should be one image per page and, therefore, one of these elements per image.

complexType Flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation WCB Flag Type (Y/N)

complexType FlagUnknown

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: wcb:String   required         documentation Value must be 'Y', 'N', or 'U'.
annotation	documentation WCB Flag Type (Y/N/U)

complexType Gender

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/wcb
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'M' or 'F'.
annotation	documentation WCB Gender Type (M/F)

simpleType Date

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	xs:date
properties	base  xs:date
annotation	documentation WCB Date Type

simpleType Decimal

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	xs:decimal
properties	base  xs:decimal
annotation	documentation WCB Decimal Type

simpleType NonNegativeInteger

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	xs:nonNegativeInteger
properties	base  xs:nonNegativeInteger
annotation	documentation WCB NonNegativeInteger Type

simpleType NPINumber

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier Type

simpleType NYSLicenseNumber

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number Type

simpleType SSN

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Social Security Number Type

simpleType String

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [ -~]*
annotation	documentation WCB String Type

simpleType StringUpperCase

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [ -`{-~]*
annotation	documentation WCB String Type

simpleType Text

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:String
properties	base  wcb:String
facets	Kind  Value  Annotation minLength  1 pattern  [ -~]*
annotation	documentation WCB Text Type

simpleType TextUpperCase

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:StringUpperCase
properties	base  wcb:StringUpperCase
facets	Kind  Value  Annotation minLength  1 pattern  [ -`{-~]*
annotation	documentation WCB Text Type

simpleType Time

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	xs:time
properties	base  xs:time
annotation	documentation WCB Time Type

simpleType WCBAuthorizationNumber

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]?
annotation	documentation WCB Authorization Number

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:patient c4narr_0812:employer c4narr_0812:doctor c4narr_0812:billing-information c4narr_0812:opinion c4narr_0812:authorized-doctor c4narr_0812:supervised-health-care-provider
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      C-4NARR   documentation Form ID Attribute documentation Value is fixed at 'C-4NARR' for this document type. wcb:version-number   derived by: wcb:Text   required      0812   documentation Version Number Attribute documentation Value is fixed at '0812' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation C-4NARR Discrete Data Elements (December 2008)

element data/patient

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone c4narr_0812:wcb-case-number c4narr_0812:carrier-case-number c4narr_0812:gender c4narr_0812:date-of-birth c4narr_0812:ssn c4narr_0812:date-of-injury c4narr_0812:job-title c4narr_0812:work-activities c4narr_0812:patient-working c4narr_0812:patient-account-no
annotation	documentation Patient Information

element data/patient/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	cis:CaseIDOld
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9A-Z][0-9A-Z][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID documentation 1st and 2nd characters must be alphanumeric.  3rd - 8th characters must be numeric.

element data/patient/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/patient/gender

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Gender
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'M' or 'F'.
annotation	documentation Patient's Gender

element data/patient/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Date
properties	content  simple
annotation	documentation Patient's Date of Birth documentation Must be <= Accident-Date.

element data/patient/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Patient's Social Security Number

element data/patient/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/job-title

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  45 pattern  [ -~]*
annotation	documentation Patient's Job Title

element data/patient/work-activities

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  200 pattern  [ -~]*
annotation	documentation Patient's Work Activities

element data/patient/patient-working

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Patient Working Flag

element data/patient/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/employer

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:name1 c4narr_0812:name2 c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone
annotation	documentation Employer Information

element data/doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:profession c4narr_0812:wcb-authorization-number c4narr_0812:wcb-rating-code c4narr_0812:npi-number c4narr_0812:federal-id-number c4narr_0812:federal-id-type c4narr_0812:office-location c4narr_0812:billing-address
annotation	documentation Doctor's Information

element data/doctor/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation c4narr_0812:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -`{-~]*
annotation	documentation WCB Authorization Number documentation For WCB-authorized providers, this element must be populated with the number assigned to that provider by WCB.  For unauthorized, New York State-licensed providers, this element should be populated with the provider's six-digit state license number.  For non-New York State providers, this element should not be populated -- use the npi-number element instead.

element data/doctor/wcb-rating-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  unbounded content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -`{-~]*
annotation	documentation WCB Rating Code(s) documentation This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for any unauthorized provider.

element data/doctor/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation This element is required for non-New York State providers.

element data/doctor/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation SSN or EIN

element data/doctor/federal-id-type

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation c4narr_0812:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Type Indicator documentation Set 'value' attribute as follows:  1=SSN;  2=EIN

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone
annotation	documentation Office Location Information

element data/doctor/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone
annotation	documentation Billing Address Information documentation If billing inquires need to be sent to an entity other than the doctor, utilize the addr1 element for that name and addr2 for the address. The next version of the this schema will include discrete elements for billing name.

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:carrier c4narr_0812:diagnosis c4narr_0812:procedure c4narr_0812:wcb-ppo
annotation	documentation Billing Information

element data/billing-information/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	minOcc  0 maxOcc  1 content  complex
children	c4narr_0812:wcb-carrier-id c4narr_0812:name1 c4narr_0812:name2 c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country
annotation	documentation Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  W[0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Carrier ID Code

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	minOcc  1 maxOcc  4 content  complex
children	c4narr_0812:diagnosis-code c4narr_0812:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  6 pattern  [ -`{-~]*
annotation	documentation ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD9 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	minOcc  1 maxOcc  unbounded content  complex
children	c4narr_0812:service-from-date c4narr_0812:service-thru-date c4narr_0812:place-of-service c4narr_0812:procedure-code c4narr_0812:procedure-modifier-a c4narr_0812:procedure-modifier-b c4narr_0812:service-diagnosis-code c4narr_0812:service-charge-amount c4narr_0812:service-days-or-units c4narr_0812:service-cob c4narr_0812:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= injury-date.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  6 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  7 pattern  [ -`{-~]*
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/billing-information/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/opinion

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:competent-producing-cause c4narr_0812:history-consistent-complaint c4narr_0812:history-consistent-findings c4narr_0812:percent-temp-impairment
annotation	documentation Doctor's Opinion

element data/opinion/competent-producing-cause

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Competent Producing Cause Flag documentation Indicates whether or not the occurrence or occupational history described in prior elements (or in a previous report which gave this information) is the competent producing cause of the injury or disease and disability (if any) sustained.

element data/opinion/history-consistent-complaint

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation History Consistent With Complaint Flag documentation Indicates whether or not the patient's complaints are consistent with the history of the injury/illness.

element data/opinion/history-consistent-findings

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:FlagUnknown
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: wcb:String   required         documentation Value must be 'Y', 'N', or 'U'.
annotation	documentation History Consistent With Findings Flag documentation Indicates whether or not the patient's history of the injury/illness is consistent with the doctor's objective findings.

element data/opinion/percent-temp-impairment

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 maxInclusive  100.00 totalDigits  5 fractionDigits  2
annotation	documentation Percentage of Temporary Impairment

element data/authorized-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:provided-services c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:specialty
annotation	documentation Authorized Doctor documentation Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Provided Services Flag documentation Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/supervised-health-care-provider

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	minOcc  0 maxOcc  1 content  complex
children	c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:specialty
annotation	documentation Supervised Health Care Provider documentation This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	content  complex
children	c4narr_0812:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation C-4NARR Document (December 2008)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Name

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element specialty

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Specialty

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:patient c4narr_1012:employer c4narr_1012:doctor c4narr_1012:billing-information c4narr_1012:opinion c4narr_1012:authorized-doctor
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      C-4NARR   documentation Form ID Attribute documentation Value is fixed at 'C-4NARR' for this document type. wcb:version-number   derived by: wcb:Text   required      1012   documentation Version Number Attribute documentation Value is fixed at '1012' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation C-4NARR Discrete Data Elements (December 2010)

element data/patient

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone c4narr_1012:wcb-case-number c4narr_1012:carrier-case-number c4narr_1012:gender c4narr_1012:date-of-birth c4narr_1012:ssn c4narr_1012:date-of-injury c4narr_1012:job-title c4narr_1012:work-activities c4narr_1012:patient-working c4narr_1012:patient-account-no
annotation	documentation Patient Information

element data/patient/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID documentation 1st and 2nd characters must be alphanumeric.  3rd - 8th characters must be numeric.

element data/patient/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/patient/gender

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Gender
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'M' or 'F'.
annotation	documentation Patient's Gender

element data/patient/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Date
properties	content  simple
annotation	documentation Patient's Date of Birth documentation Must be <= Accident-Date.

element data/patient/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Patient's Social Security Number

element data/patient/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/job-title

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  45 pattern  [ -~]*
annotation	documentation Patient's Job Title

element data/patient/work-activities

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  200 pattern  [ -~]*
annotation	documentation Patient's Work Activities

element data/patient/patient-working

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Patient Working Flag

element data/patient/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/employer

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:name1 c4narr_1012:name2 c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone
annotation	documentation Employer Information

element data/doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:profession c4narr_1012:wcb-authorization-number c4narr_1012:wcb-rating-code c4narr_1012:nys-license-number c4narr_1012:npi-number c4narr_1012:federal-id-number c4narr_1012:office-location c4narr_1012:billing-address
annotation	documentation Doctor's Information

element data/doctor/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation c4narr_1012:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:WCBAuthorizationNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]?
annotation	documentation WCB Authorization Number documentation Provider's WCB Authorization Number.  This field is required for WCB-authorized providers. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/wcb-rating-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  unbounded content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -`{-~]*
annotation	documentation WCB Rating Code(s) documentation This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for unauthorized providers.

element data/doctor/nys-license-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:NYSLicenseNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number documentation Provider's New York State License Number.  This field is required for New York State providers that are not WCB-authorized. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation Provider's National Provider Identifier.  This element is required for providers outside of New York State.  It should always be populated when the data is available. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation c4narr_1012:type   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Number documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone
annotation	documentation Office Location Information

element data/doctor/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:name1 c4narr_1012:name2 c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone
annotation	documentation Billing Address Information documentation If billing inquires need to be sent to an entity other than the doctor, utilize the addr1 element for that name and addr2 for the address. The next version of the this schema will include discrete elements for billing name.

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:carrier c4narr_1012:diagnosis c4narr_1012:procedure c4narr_1012:wcb-ppo
annotation	documentation Billing Information

element data/billing-information/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	minOcc  0 maxOcc  1 content  complex
children	c4narr_1012:wcb-carrier-id c4narr_1012:name1 c4narr_1012:name2 c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country
annotation	documentation Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  W[0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Carrier ID Code

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	minOcc  1 maxOcc  4 content  complex
children	c4narr_1012:diagnosis-code c4narr_1012:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  6 pattern  [ -`{-~]*
annotation	documentation ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD9 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	minOcc  1 maxOcc  unbounded content  complex
children	c4narr_1012:service-from-date c4narr_1012:service-thru-date c4narr_1012:place-of-service c4narr_1012:procedure-code c4narr_1012:procedure-modifier-a c4narr_1012:procedure-modifier-b c4narr_1012:service-diagnosis-code c4narr_1012:service-charge-amount c4narr_1012:service-days-or-units c4narr_1012:service-cob c4narr_1012:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= injury-date.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  5 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  1?2?3?4?
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/billing-information/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/opinion

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:competent-producing-cause c4narr_1012:history-consistent-complaint c4narr_1012:history-consistent-findings c4narr_1012:percent-temp-impairment
annotation	documentation Doctor's Opinion

element data/opinion/competent-producing-cause

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Competent Producing Cause Flag documentation Indicates whether or not the occurrence or occupational history described in prior elements (or in a previous report which gave this information) is the competent producing cause of the injury or disease and disability (if any) sustained.

element data/opinion/history-consistent-complaint

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation History Consistent With Complaint Flag documentation Indicates whether or not the patient's complaints are consistent with the history of the injury/illness.

element data/opinion/history-consistent-findings

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:FlagUnknown
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: wcb:String   required         documentation Value must be 'Y', 'N', or 'U'.
annotation	documentation History Consistent With Findings Flag documentation Indicates whether or not the patient's history of the injury/illness is consistent with the doctor's objective findings.

element data/opinion/percent-temp-impairment

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 maxInclusive  100.00 totalDigits  5 fractionDigits  2
annotation	documentation Percentage of Temporary Impairment

element data/authorized-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:specialty c4narr_1012:provided-services c4narr_1012:supervised-health-care-provider
annotation	documentation Authorized Doctor documentation Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Provided Services Flag documentation Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/authorized-doctor/supervised-health-care-provider

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	minOcc  0 maxOcc  1 content  complex
children	c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:specialty
annotation	documentation Supervised Health Care Provider documentation This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	content  complex
children	c4narr_1012:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation C-4NARR Document (December 2010)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Name

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element specialty

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Specialty

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:patient c4narr_1510:employer c4narr_1510:doctor c4narr_1510:billing-information c4narr_1510:opinion c4narr_1510:authorized-doctor
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      C-4NARR   documentation Form ID Attribute documentation Value is fixed at 'C-4NARR' for this document type. wcb:version-number   derived by: wcb:Text   required      1510   documentation Version Number Attribute documentation Value is fixed at '1510' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation C-4NARR Discrete Data Elements (October 2015)

element data/patient

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:last-name c4narr_1510:first-name c4narr_1510:middle-initial c4narr_1510:addr1 c4narr_1510:addr2 c4narr_1510:city c4narr_1510:state c4narr_1510:zip c4narr_1510:country c4narr_1510:telephone c4narr_1510:wcb-case-number c4narr_1510:carrier-case-number c4narr_1510:gender c4narr_1510:date-of-birth c4narr_1510:ssn c4narr_1510:date-of-injury c4narr_1510:job-title c4narr_1510:work-activities c4narr_1510:patient-working c4narr_1510:patient-account-no
annotation	documentation Patient Information

element data/patient/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID documentation 1st and 2nd characters must be alphanumeric.  3rd - 8th characters must be numeric.

element data/patient/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/patient/gender

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Gender
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'M' or 'F'.
annotation	documentation Patient's Gender

element data/patient/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Date
properties	content  simple
annotation	documentation Patient's Date of Birth documentation Must be <= Accident-Date.

element data/patient/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Patient's Social Security Number

element data/patient/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/job-title

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  45 pattern  [ -~]*
annotation	documentation Patient's Job Title

element data/patient/work-activities

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  200 pattern  [ -~]*
annotation	documentation Patient's Work Activities

element data/patient/patient-working

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Patient Working Flag

element data/patient/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/employer

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:name1 c4narr_1510:name2 c4narr_1510:addr1 c4narr_1510:addr2 c4narr_1510:city c4narr_1510:state c4narr_1510:zip c4narr_1510:country c4narr_1510:telephone
annotation	documentation Employer Information

element data/doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:last-name c4narr_1510:first-name c4narr_1510:middle-initial c4narr_1510:profession c4narr_1510:wcb-authorization-number c4narr_1510:wcb-rating-code c4narr_1510:nys-license-number c4narr_1510:npi-number c4narr_1510:federal-id-number c4narr_1510:office-location c4narr_1510:billing-address
annotation	documentation Doctor's Information

element data/doctor/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation c4narr_1510:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:WCBAuthorizationNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]?
annotation	documentation WCB Authorization Number documentation Provider's WCB Authorization Number.  This field is required for WCB-authorized providers. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/wcb-rating-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  unbounded content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -`{-~]*
annotation	documentation WCB Rating Code(s) documentation This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for unauthorized providers.

element data/doctor/nys-license-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:NYSLicenseNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number documentation Provider's New York State License Number.  This field is required for New York State providers that are not WCB-authorized. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation Provider's National Provider Identifier.  This element is required for providers outside of New York State.  It should always be populated when the data is available. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation c4narr_1510:type   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Number documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:addr1 c4narr_1510:addr2 c4narr_1510:city c4narr_1510:state c4narr_1510:zip c4narr_1510:country c4narr_1510:telephone
annotation	documentation Office Location Information

element data/doctor/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:name1 c4narr_1510:name2 c4narr_1510:addr1 c4narr_1510:addr2 c4narr_1510:city c4narr_1510:state c4narr_1510:zip c4narr_1510:country c4narr_1510:telephone
annotation	documentation Billing Address Information documentation If billing inquires need to be sent to an entity other than the doctor, utilize the addr1 element for that name and addr2 for the address. The next version of the this schema will include discrete elements for billing name.

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:carrier c4narr_1510:diagnosis c4narr_1510:procedure c4narr_1510:wcb-ppo
annotation	documentation Billing Information

element data/billing-information/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	minOcc  0 maxOcc  1 content  complex
children	c4narr_1510:wcb-carrier-id c4narr_1510:name1 c4narr_1510:name2 c4narr_1510:addr1 c4narr_1510:addr2 c4narr_1510:city c4narr_1510:state c4narr_1510:zip c4narr_1510:country
annotation	documentation Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  W[0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Carrier ID Code

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	minOcc  1 maxOcc  4 content  complex
children	c4narr_1510:diagnosis-code c4narr_1510:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  8 pattern  [ -`{-~]*
annotation	documentation ICD10 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD10 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	minOcc  1 maxOcc  unbounded content  complex
children	c4narr_1510:service-from-date c4narr_1510:service-thru-date c4narr_1510:place-of-service c4narr_1510:procedure-code c4narr_1510:procedure-modifier-a c4narr_1510:procedure-modifier-b c4narr_1510:service-diagnosis-code c4narr_1510:service-charge-amount c4narr_1510:service-days-or-units c4narr_1510:service-cob c4narr_1510:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= injury-date.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  5 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  1?2?3?4?
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/billing-information/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/opinion

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:competent-producing-cause c4narr_1510:history-consistent-complaint c4narr_1510:history-consistent-findings c4narr_1510:percent-temp-impairment
annotation	documentation Doctor's Opinion

element data/opinion/competent-producing-cause

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Competent Producing Cause Flag documentation Indicates whether or not the occurrence or occupational history described in prior elements (or in a previous report which gave this information) is the competent producing cause of the injury or disease and disability (if any) sustained.

element data/opinion/history-consistent-complaint

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation History Consistent With Complaint Flag documentation Indicates whether or not the patient's complaints are consistent with the history of the injury/illness.

element data/opinion/history-consistent-findings

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:FlagUnknown
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: wcb:String   required         documentation Value must be 'Y', 'N', or 'U'.
annotation	documentation History Consistent With Findings Flag documentation Indicates whether or not the patient's history of the injury/illness is consistent with the doctor's objective findings.

element data/opinion/percent-temp-impairment

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 maxInclusive  100.00 totalDigits  5 fractionDigits  2
annotation	documentation Percentage of Temporary Impairment

element data/authorized-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:last-name c4narr_1510:first-name c4narr_1510:middle-initial c4narr_1510:specialty c4narr_1510:provided-services c4narr_1510:supervised-health-care-provider
annotation	documentation Authorized Doctor documentation Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Provided Services Flag documentation Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/authorized-doctor/supervised-health-care-provider

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	minOcc  0 maxOcc  1 content  complex
children	c4narr_1510:last-name c4narr_1510:first-name c4narr_1510:middle-initial c4narr_1510:specialty
annotation	documentation Supervised Health Care Provider documentation This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
properties	content  complex
children	c4narr_1510:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation C-4NARR Document (October 2015)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Name

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element specialty

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Specialty

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:patient c4amr_0908:doctor c4amr_0908:billing-information c4amr_0908:authorized-doctor
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      C-4AMR   documentation Form ID Attribute documentation Value is fixed at 'C-4AMR' for this document type. wcb:version-number   derived by: wcb:Text   required      0908   documentation Version Number Attribute documentation Value is fixed at '0908' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation C-4AMR Discrete Data Elements (August 2009)

element data/patient

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country c4amr_0908:telephone c4amr_0908:wcb-case-number c4amr_0908:carrier-case-number c4amr_0908:date-of-birth c4amr_0908:ssn c4amr_0908:date-of-injury c4amr_0908:patient-account-no
annotation	documentation Patient Information

element data/patient/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID

element data/patient/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/patient/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:Date
properties	content  simple
annotation	documentation Patient's Date of Birth documentation Must be <= Accident-Date.

element data/patient/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Patient's Social Security Number

element data/patient/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:profession c4amr_0908:wcb-authorization-number c4amr_0908:wcb-rating-code c4amr_0908:nys-license-number c4amr_0908:npi-number c4amr_0908:federal-id-number c4amr_0908:office-location c4amr_0908:billing-address c4amr_0908:referring-doctor
annotation	documentation Doctor's Information

element data/doctor/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation c4amr_0908:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:WCBAuthorizationNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]?
annotation	documentation WCB Authorization Number documentation Provider's WCB Authorization Number.  This field is required for WCB-authorized providers. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/wcb-rating-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  unbounded content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -`{-~]*
annotation	documentation WCB Rating Code(s) documentation This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for unauthorized providers.

element data/doctor/nys-license-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:NYSLicenseNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number documentation Provider's New York State License Number.  This field is required for New York State providers that are not WCB-authorized. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation Provider's National Provider Identifier.  This element is required for providers outside of New York State.  It should always be populated when the data is available. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation c4amr_0908:type   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Number documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country c4amr_0908:telephone
annotation	documentation Office Location Information

element data/doctor/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:name1 c4amr_0908:name2 c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country c4amr_0908:telephone
annotation	documentation Billing Address Information documentation If billing inquires should be made to an entity other than the doctor, utilize the optional elements name1 and name2 to identify the name of that entity and use the address elements to specify that entity's address. Otherwise, it is only necessary to populate the address elements with the doctor's address.

element data/doctor/referring-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial
annotation	documentation Referring Doctor's Name

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:carrier c4amr_0908:diagnosis c4amr_0908:procedure c4amr_0908:wcb-ppo
annotation	documentation Billing Information

element data/billing-information/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	minOcc  0 maxOcc  1 content  complex
children	c4amr_0908:wcb-carrier-id c4amr_0908:name1 c4amr_0908:name2 c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country
annotation	documentation Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  W[0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Carrier ID Code

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	minOcc  1 maxOcc  4 content  complex
children	c4amr_0908:diagnosis-code c4amr_0908:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  6 pattern  [ -`{-~]*
annotation	documentation ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD9 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	minOcc  1 maxOcc  unbounded content  complex
children	c4amr_0908:service-from-date c4amr_0908:service-thru-date c4amr_0908:place-of-service c4amr_0908:procedure-code c4amr_0908:procedure-modifier-a c4amr_0908:procedure-modifier-b c4amr_0908:service-diagnosis-code c4amr_0908:service-charge-amount c4amr_0908:service-days-or-units c4amr_0908:service-cob c4amr_0908:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= injury-date.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  5 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 pattern  1?2?3?4?
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/billing-information/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/authorized-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:specialty c4amr_0908:provided-services c4amr_0908:supervised-health-care-provider
annotation	documentation Authorized Doctor documentation Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Provided Services Flag documentation Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/authorized-doctor/supervised-health-care-provider

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	minOcc  0 maxOcc  1 content  complex
children	c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:specialty
annotation	documentation Supervised Health Care Provider documentation This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	content  complex
children	c4amr_0908:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation C-4AMR Document (August 2009)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Name

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element specialty

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Specialty

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:patient c4amr_1012:doctor c4amr_1012:billing-information c4amr_1012:authorized-doctor
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      C-4AMR   documentation Form ID Attribute documentation Value is fixed at 'C-4AMR' for this document type. wcb:version-number   derived by: wcb:Text   required      1012   documentation Version Number Attribute documentation Value is fixed at '1012' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation C-4AMR Discrete Data Elements (December 2010)

element data/patient

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:last-name c4amr_1012:first-name c4amr_1012:middle-initial c4amr_1012:addr1 c4amr_1012:addr2 c4amr_1012:city c4amr_1012:state c4amr_1012:zip c4amr_1012:country c4amr_1012:telephone c4amr_1012:wcb-case-number c4amr_1012:carrier-case-number c4amr_1012:date-of-birth c4amr_1012:ssn c4amr_1012:date-of-injury c4amr_1012:patient-account-no
annotation	documentation Patient Information

element data/patient/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID

element data/patient/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/patient/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:Date
properties	content  simple
annotation	documentation Patient's Date of Birth documentation Must be <= Accident-Date.

element data/patient/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Patient's Social Security Number

element data/patient/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:last-name c4amr_1012:first-name c4amr_1012:middle-initial c4amr_1012:profession c4amr_1012:wcb-authorization-number c4amr_1012:wcb-rating-code c4amr_1012:nys-license-number c4amr_1012:npi-number c4amr_1012:federal-id-number c4amr_1012:office-location c4amr_1012:billing-address c4amr_1012:referring-doctor
annotation	documentation Doctor's Information

element data/doctor/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation c4amr_1012:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:WCBAuthorizationNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]?
annotation	documentation WCB Authorization Number documentation Provider's WCB Authorization Number.  This field is required for WCB-authorized providers. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/wcb-rating-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  unbounded content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -`{-~]*
annotation	documentation WCB Rating Code(s) documentation This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for unauthorized providers.

element data/doctor/nys-license-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:NYSLicenseNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number documentation Provider's New York State License Number.  This field is required for New York State providers that are not WCB-authorized. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation Provider's National Provider Identifier.  This element is required for providers outside of New York State.  It should always be populated when the data is available. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation c4amr_1012:type   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Number documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:addr1 c4amr_1012:addr2 c4amr_1012:city c4amr_1012:state c4amr_1012:zip c4amr_1012:country c4amr_1012:telephone
annotation	documentation Office Location Information

element data/doctor/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:name1 c4amr_1012:name2 c4amr_1012:addr1 c4amr_1012:addr2 c4amr_1012:city c4amr_1012:state c4amr_1012:zip c4amr_1012:country c4amr_1012:telephone
annotation	documentation Billing Address Information documentation If billing inquires should be made to an entity other than the doctor, utilize the optional elements name1 and name2 to identify the name of that entity and use the address elements to specify that entity's address. Otherwise, it is only necessary to populate the address elements with the doctor's address.

element data/doctor/referring-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:last-name c4amr_1012:first-name c4amr_1012:middle-initial
annotation	documentation Referring Doctor's Name

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:carrier c4amr_1012:diagnosis c4amr_1012:procedure c4amr_1012:wcb-ppo
annotation	documentation Billing Information

element data/billing-information/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	minOcc  0 maxOcc  1 content  complex
children	c4amr_1012:wcb-carrier-id c4amr_1012:name1 c4amr_1012:name2 c4amr_1012:addr1 c4amr_1012:addr2 c4amr_1012:city c4amr_1012:state c4amr_1012:zip c4amr_1012:country
annotation	documentation Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  W[0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Carrier ID Code

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	minOcc  1 maxOcc  4 content  complex
children	c4amr_1012:diagnosis-code c4amr_1012:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  6 pattern  [ -`{-~]*
annotation	documentation ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD9 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	minOcc  1 maxOcc  unbounded content  complex
children	c4amr_1012:service-from-date c4amr_1012:service-thru-date c4amr_1012:place-of-service c4amr_1012:procedure-code c4amr_1012:procedure-modifier-a c4amr_1012:procedure-modifier-b c4amr_1012:service-diagnosis-code c4amr_1012:service-charge-amount c4amr_1012:service-days-or-units c4amr_1012:service-cob c4amr_1012:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= injury-date.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  5 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 pattern  1?2?3?4?
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/billing-information/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/authorized-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:last-name c4amr_1012:first-name c4amr_1012:middle-initial c4amr_1012:specialty c4amr_1012:provided-services c4amr_1012:supervised-health-care-provider
annotation	documentation Authorized Doctor documentation Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Provided Services Flag documentation Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/authorized-doctor/supervised-health-care-provider

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	minOcc  0 maxOcc  1 content  complex
children	c4amr_1012:last-name c4amr_1012:first-name c4amr_1012:middle-initial c4amr_1012:specialty
annotation	documentation Supervised Health Care Provider documentation This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties	content  complex
children	c4amr_1012:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation C-4AMR Document (December 2010)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Name

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element specialty

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Specialty

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:patient c4amr_1510:doctor c4amr_1510:billing-information c4amr_1510:authorized-doctor
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      C-4AMR   documentation Form ID Attribute documentation Value is fixed at 'C-4AMR' for this document type. wcb:version-number   derived by: wcb:Text   required      1510   documentation Version Number Attribute documentation Value is fixed at '1510' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation C-4AMR Discrete Data Elements (October 2015)

element data/patient

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:last-name c4amr_1510:first-name c4amr_1510:middle-initial c4amr_1510:addr1 c4amr_1510:addr2 c4amr_1510:city c4amr_1510:state c4amr_1510:zip c4amr_1510:country c4amr_1510:telephone c4amr_1510:wcb-case-number c4amr_1510:carrier-case-number c4amr_1510:date-of-birth c4amr_1510:ssn c4amr_1510:date-of-injury c4amr_1510:patient-account-no
annotation	documentation Patient Information

element data/patient/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID

element data/patient/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/patient/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:Date
properties	content  simple
annotation	documentation Patient's Date of Birth documentation Must be <= Accident-Date.

element data/patient/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Patient's Social Security Number

element data/patient/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:last-name c4amr_1510:first-name c4amr_1510:middle-initial c4amr_1510:profession c4amr_1510:wcb-authorization-number c4amr_1510:wcb-rating-code c4amr_1510:nys-license-number c4amr_1510:npi-number c4amr_1510:federal-id-number c4amr_1510:office-location c4amr_1510:billing-address c4amr_1510:referring-doctor
annotation	documentation Doctor's Information

element data/doctor/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation c4amr_1510:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:WCBAuthorizationNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]?
annotation	documentation WCB Authorization Number documentation Provider's WCB Authorization Number.  This field is required for WCB-authorized providers. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/wcb-rating-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  unbounded content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -`{-~]*
annotation	documentation WCB Rating Code(s) documentation This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for unauthorized providers.

element data/doctor/nys-license-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:NYSLicenseNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number documentation Provider's New York State License Number.  This field is required for New York State providers that are not WCB-authorized. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation Provider's National Provider Identifier.  This element is required for providers outside of New York State.  It should always be populated when the data is available. One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation c4amr_1510:type   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Number documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:addr1 c4amr_1510:addr2 c4amr_1510:city c4amr_1510:state c4amr_1510:zip c4amr_1510:country c4amr_1510:telephone
annotation	documentation Office Location Information

element data/doctor/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:name1 c4amr_1510:name2 c4amr_1510:addr1 c4amr_1510:addr2 c4amr_1510:city c4amr_1510:state c4amr_1510:zip c4amr_1510:country c4amr_1510:telephone
annotation	documentation Billing Address Information documentation If billing inquires should be made to an entity other than the doctor, utilize the optional elements name1 and name2 to identify the name of that entity and use the address elements to specify that entity's address. Otherwise, it is only necessary to populate the address elements with the doctor's address.

element data/doctor/referring-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:last-name c4amr_1510:first-name c4amr_1510:middle-initial
annotation	documentation Referring Doctor's Name

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:carrier c4amr_1510:diagnosis c4amr_1510:procedure c4amr_1510:wcb-ppo
annotation	documentation Billing Information

element data/billing-information/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	minOcc  0 maxOcc  1 content  complex
children	c4amr_1510:wcb-carrier-id c4amr_1510:name1 c4amr_1510:name2 c4amr_1510:addr1 c4amr_1510:addr2 c4amr_1510:city c4amr_1510:state c4amr_1510:zip c4amr_1510:country
annotation	documentation Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  W[0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Carrier ID Code

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	minOcc  1 maxOcc  4 content  complex
children	c4amr_1510:diagnosis-code c4amr_1510:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  8 pattern  [ -`{-~]*
annotation	documentation ICD10 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD10 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	minOcc  1 maxOcc  unbounded content  complex
children	c4amr_1510:service-from-date c4amr_1510:service-thru-date c4amr_1510:place-of-service c4amr_1510:procedure-code c4amr_1510:procedure-modifier-a c4amr_1510:procedure-modifier-b c4amr_1510:service-diagnosis-code c4amr_1510:service-charge-amount c4amr_1510:service-days-or-units c4amr_1510:service-cob c4amr_1510:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= injury-date.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  5 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 pattern  1?2?3?4?
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/billing-information/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/authorized-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:last-name c4amr_1510:first-name c4amr_1510:middle-initial c4amr_1510:specialty c4amr_1510:provided-services c4amr_1510:supervised-health-care-provider
annotation	documentation Authorized Doctor documentation Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Provided Services Flag documentation Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/authorized-doctor/supervised-health-care-provider

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	minOcc  0 maxOcc  1 content  complex
children	c4amr_1510:last-name c4amr_1510:first-name c4amr_1510:middle-initial c4amr_1510:specialty
annotation	documentation Supervised Health Care Provider documentation This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
properties	content  complex
children	c4amr_1510:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation C-4AMR Document (October 2015)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Name

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element specialty

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Specialty

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:carrier cms1500_1202:payer cms1500_1202:patient cms1500_1202:insured cms1500_1202:reserved-field-9b cms1500_1202:physician-or-supplier cms1500_1202:additional-claim-information
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      CMS-1500   documentation Form ID Attribute documentation Value is fixed at 'CMS-1500' for this document type. wcb:version-number   derived by: wcb:Text   required      1202   documentation Version Number Attribute documentation Value is fixed at '1202' for this document type.
annotation	documentation CMS-1500 Discrete Data Elements (February 2012)

element data/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:wcb-carrier-id
annotation	documentation Carrier Information

element data/carrier/wcb-carrier-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  W[0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Carrier ID (Field 0)

element data/payer

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:name cms1500_1202:addr1 cms1500_1202:addr2 cms1500_1202:city-state-zip
annotation	documentation Payer Information

element data/payer/name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  41 pattern  [ -~]*
annotation	documentation Name (Field 0)

element data/payer/addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  41 pattern  [ -~]*
annotation	documentation Address Line 1 (Field 0)

element data/payer/addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  41 pattern  [ -~]*
annotation	documentation Address Line 2 (Field 0)

element data/payer/city-state-zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  41 pattern  [ -~]*
annotation	documentation City State and Zip (Field 0)

element data/patient

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:name-address cms1500_1202:date-of-birth cms1500_1202:gender cms1500_1202:relationship-to-insured cms1500_1202:employment-flag cms1500_1202:auto-accident-flag cms1500_1202:other-accident-flag cms1500_1202:claim-codes cms1500_1202:date-of-current-illness-injury-or-pregnancy cms1500_1202:other-date cms1500_1202:dates-patient-unable-to-work-in-current-operation cms1500_1202:signature
annotation	documentation Patient Information

element data/patient/name-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:last-name-first-name-middle-initial cms1500_1202:address cms1500_1202:city cms1500_1202:state cms1500_1202:zip cms1500_1202:telephone
annotation	documentation Name and Address (Fields 2 and 5) documentation Required if value on relationship-to-insured is anything other than 1.

element data/patient/name-address/last-name-first-name-middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  60 pattern  [ -~]*
annotation	documentation Last Name, First Name, Middle Initial (Field 2)

element data/patient/name-address/address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  28 pattern  [ -~]*
annotation	documentation Address (Field 5)

element data/patient/name-address/city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  24 pattern  [ -~]*
annotation	documentation City (Field 5)

element data/patient/name-address/state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation State (Field 5)

element data/patient/name-address/zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  12 pattern  [ -~]*
annotation	documentation Zip Code (Field 5)

element data/patient/name-address/telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:area-code cms1500_1202:phone-number
annotation	documentation Telephone Number (Field 5)

element data/patient/name-address/telephone/area-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9]
annotation	documentation Area Code (Field 5)

element data/patient/name-address/telephone/phone-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Phone Number (Field 5)

element data/patient/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	content  simple
annotation	documentation Date of Birth (Field 3) documentation Must be <= Accident-Date.

element data/patient/gender

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Gender
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'M' or 'F'.
annotation	documentation Gender (Field 3)

element data/patient/relationship-to-insured

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation cms1500_1202:value   derived by: wcb:NonNegativeInteger   required         documentation Value must be 4.
annotation	documentation Relationship to Insured (Field 6) documentation Set 'value' attribute as follows:  1=Self;  2=Spouse;  3=Child;  4=Other

element data/patient/employment-flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation cms1500_1202:value   derived by: xs:string   required         documentation Value must be 'Y'.
annotation	documentation Employment Flag (Field 10a)

element data/patient/auto-accident-flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	extension of wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'. cms1500_1202:place   derived by: wcb:String            documentation Place (state)
annotation	documentation Auto Accident Flag (Field 10b) documentation If value is 'Y', then place must contain a valid 2-character US state code.

element data/patient/other-accident-flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Other Accident Flag (Field 10c)

element data/patient/claim-codes

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  19 pattern  [ -~]*
annotation	documentation Claim Codes (Field 10d)

element data/patient/date-of-current-illness-injury-or-pregnancy

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:qualifier cms1500_1202:date
annotation	documentation Date of Current Illness, Injury, or Pregnancy (LMP) (Field 14)

element data/patient/date-of-current-illness-injury-or-pregnancy/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  431
annotation	documentation Qualifier (Field 14)

element data/patient/date-of-current-illness-injury-or-pregnancy/date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[01][0-9]-[0-3][0-9]
annotation	documentation Date (Field 14) documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.

element data/patient/other-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:qualifier cms1500_1202:date
annotation	documentation Other Date (Field 15)

element data/patient/other-date/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  454 enumeration  304 enumeration  453 enumeration  439 enumeration  455 enumeration  471 enumeration  90 enumeration  91 enumeration  444
annotation	documentation Qualifier (Field 15)

element data/patient/other-date/date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	content  simple
annotation	documentation Date (Field 15)

element data/patient/dates-patient-unable-to-work-in-current-operation

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:from-date cms1500_1202:to-date
annotation	documentation Dates Patient Unable to Work in Current Occupation (Field 16)

element data/patient/dates-patient-unable-to-work-in-current-operation/from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation From Date (Field 16)

element data/patient/dates-patient-unable-to-work-in-current-operation/to-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation To Date (Field 16)

element data/patient/signature

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:signed-name cms1500_1202:signed-date
annotation	documentation Signature (Field 12)

element data/patient/signature/signed-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Signed Name (Field 12)

element data/patient/signature/signed-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Signed Date (Field 12)

element data/insured

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:program cms1500_1202:id-number cms1500_1202:name-address cms1500_1202:other-insured cms1500_1202:policy-group-or-feca-number cms1500_1202:other-claim-id cms1500_1202:insurance-plan-name-or-program-name cms1500_1202:another-health-benefit-plan-flag
annotation	documentation Insured Information

element data/insured/program

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation cms1500_1202:value   derived by: wcb:NonNegativeInteger   required         documentation Value must be 7 (Other).
annotation	documentation Insurance Program (Field 1) documentation Set 'value' attribute as follows:  1=Medicare;  2=Medicaid;  3=TRICARE;  4=CHAMPVA;  5=Group Health Plan;  6=FECA/Black Lung;  7=Other

element data/insured/id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Insured's ID Number (Field 1a) documentation Use Claimant's nine-digit Social Security Number.

element data/insured/name-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:last-name-first-name-middle-initial cms1500_1202:address cms1500_1202:city cms1500_1202:state cms1500_1202:zip cms1500_1202:telephone
annotation	documentation Name and Address (Fields 4 and 7)

element data/insured/name-address/last-name-first-name-middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  40 pattern  [ -~]*
annotation	documentation Last Name, First Name, Middle Initial (Field 4)

element data/insured/name-address/address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  29 pattern  [ -~]*
annotation	documentation Address (Field 7)

element data/insured/name-address/city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  23 pattern  [ -~]*
annotation	documentation City (Field 7)

element data/insured/name-address/state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation State (Field 7)

element data/insured/name-address/zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  12 pattern  [ -~]*
annotation	documentation Zip Code (Field 7)

element data/insured/name-address/telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:area-code cms1500_1202:phone-number
annotation	documentation Telephone Number (Field 7)

element data/insured/name-address/telephone/area-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9]
annotation	documentation Area Code (Field 7)

element data/insured/name-address/telephone/phone-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Phone Number (Field 7)

element data/insured/other-insured

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:last-name-first-name-middle-initial cms1500_1202:policy-or-group-number cms1500_1202:insurance-plan-name-or-program-name
annotation	documentation Other Insured (Fields 9, 9a, and 9d) documentation If value on another-health-benefit-plan-flag is 'Y', then this is required.

element data/insured/other-insured/last-name-first-name-middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  28 pattern  [ -~]*
annotation	documentation Last Name, First Name, Middle Initial (Field 9) documentation Required if different than Insured and Patient names.

element data/insured/other-insured/policy-or-group-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Policy or Group Number (Field 9a)

element data/insured/other-insured/insurance-plan-name-or-program-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  28 pattern  [ -~]*
annotation	documentation Insurance Plan Name or Program Name (Field 9d)

element data/insured/policy-group-or-feca-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  29 pattern  [ -~]*
annotation	documentation Policy, Group, or FECA Number (Field 11)

element data/insured/other-claim-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:qualifier cms1500_1202:identifier
annotation	documentation Other Claim ID (Field 11b)

element data/insured/other-claim-id/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  Y4
annotation	documentation Qualifier (Field 11b) documentation Set to 'Y4'.

element data/insured/other-claim-id/identifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  28 pattern  [ -~]*
annotation	documentation Identifier (Field 11b) documentation Use Carrier's Case Identifier.

element data/insured/insurance-plan-name-or-program-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  29 pattern  [ -~]*
annotation	documentation Insurance Plan Name or Program Name (Field 11c)

element data/insured/another-health-benefit-plan-flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Another Health Benefit Plan Flag (Field 11d)

element data/reserved-field-9b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:claimant-first-name cms1500_1202:claimant-last-name
annotation	documentation Reserved for WCB use (Field 9b)

element data/reserved-field-9b/claimant-first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Claimant First Name (Field 9b)

element data/reserved-field-9b/claimant-last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Claimant Last Name (Field 9b)

element data/physician-or-supplier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:referring-provider-or-other-source cms1500_1202:hospitalization-dates-related-to-current-services cms1500_1202:outside-lab-flag cms1500_1202:diagnosis-or-nature-of-illness-or-injury cms1500_1202:resubmission cms1500_1202:prior-authorization-number cms1500_1202:procedure-service-or-supply cms1500_1202:federal-tax-id-number cms1500_1202:patients-account-no cms1500_1202:accept-assignment-flag cms1500_1202:total-charge cms1500_1202:amount-paid cms1500_1202:signature cms1500_1202:service-facility cms1500_1202:billing-provider
annotation	documentation Physician or Supplier

element data/physician-or-supplier/referring-provider-or-other-source

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:qualifier cms1500_1202:name cms1500_1202:other-id-number cms1500_1202:npi-number
annotation	documentation Referring Provider or Other Source (Fields 17, 17a, and 17b)

element data/physician-or-supplier/referring-provider-or-other-source/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  DN enumeration  DK enumeration  DQ
annotation	documentation Qualifier (Field 17)

element data/physician-or-supplier/referring-provider-or-other-source/name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  24 pattern  [ -~]*
annotation	documentation Name (Field 17)

element data/physician-or-supplier/referring-provider-or-other-source/other-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:qualifier cms1500_1202:id-number
annotation	documentation Other ID Number (Field 17a)

element data/physician-or-supplier/referring-provider-or-other-source/other-id-number/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  0B
annotation	documentation Qualifier (Field 17a)

element data/physician-or-supplier/referring-provider-or-other-source/other-id-number/id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  17 pattern  [ -~]*
annotation	documentation ID Number (Field 17a)

element data/physician-or-supplier/referring-provider-or-other-source/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation NPI Number (Field 17b) appinfo <altova:exampleValues> <altova:example value="0000000000"/> <altova:example value="1234567890"/> </altova:exampleValues>

element data/physician-or-supplier/hospitalization-dates-related-to-current-services

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:from-date cms1500_1202:to-date
annotation	documentation Hospitalization Dates Related to Current Services (Field 18)

element data/physician-or-supplier/hospitalization-dates-related-to-current-services/from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation From Date (Field 18)

element data/physician-or-supplier/hospitalization-dates-related-to-current-services/to-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation To Date (Field 18)

element data/physician-or-supplier/outside-lab-flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	extension of wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'. cms1500_1202:charges   derived by: wcb:Decimal            documentation Charges (Field 20)
annotation	documentation Outside Lab Flag (Field 20)

element data/physician-or-supplier/diagnosis-or-nature-of-illness-or-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:diagnosis-code
attributes	Name   Type   Use   Default   Fixed   Annotation cms1500_1202:ICD-indicator   derived by: xs:string   required         documentation ICD Indicator (Field 21) Value must be 0.
annotation	documentation Diagnosis or Nature of Illness or Injury (Field 21)

element data/physician-or-supplier/diagnosis-or-nature-of-illness-or-injury/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:TextUpperCase
properties	minOcc  1 maxOcc  12 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  7 pattern  [ -`{-~]*
annotation	documentation Diagnosis Code (Field 21)

element data/physician-or-supplier/resubmission

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:code cms1500_1202:original-reference-number
annotation	documentation Resubmission (Field 22)

element data/physician-or-supplier/resubmission/code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  7 enumeration  8
annotation	documentation Code (Field 22)

element data/physician-or-supplier/resubmission/original-reference-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  18 pattern  [ -~]*
annotation	documentation Original Reference Number (Field 22)

element data/physician-or-supplier/prior-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  29 pattern  [ -~]*
annotation	documentation Prior Authorization Number (Field 23)

element data/physician-or-supplier/procedure-service-or-supply

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  1 maxOcc  unbounded content  complex
children	cms1500_1202:supplemental-information cms1500_1202:from-date cms1500_1202:to-date cms1500_1202:place-of-service cms1500_1202:emergency-flag cms1500_1202:cpt-hcpcs-code cms1500_1202:modifier-a cms1500_1202:modifier-b cms1500_1202:modifier-c cms1500_1202:modifier-d cms1500_1202:diagnosis-pointer cms1500_1202:charges cms1500_1202:days-or-units cms1500_1202:rendering-provider-id-number cms1500_1202:rendering-provider-npi-number
annotation	documentation Procedures, Services, or Supplies (Field 24)

element data/physician-or-supplier/procedure-service-or-supply/supplemental-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  61 pattern  [ -~]*
annotation	documentation Supplemental Information (Field 24)

element data/physician-or-supplier/procedure-service-or-supply/from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	content  simple
annotation	documentation From Date (Field 24a) documentation Must be >= injury-date.

element data/physician-or-supplier/procedure-service-or-supply/to-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	content  simple
annotation	documentation To Date (Field 24a) documentation Must be >= service-from-date and <= current date.

element data/physician-or-supplier/procedure-service-or-supply/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9]
annotation	documentation Place of Service (Field 24b)

element data/physician-or-supplier/procedure-service-or-supply/emergency-flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Emergency Flag (Fields 24c)

element data/physician-or-supplier/procedure-service-or-supply/cpt-hcpcs-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  6 pattern  [ -`{-~]*
annotation	documentation CPT/HCPCS Code (Field 24d)

element data/physician-or-supplier/procedure-service-or-supply/modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:String
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation Modifier A (Field 24d)

element data/physician-or-supplier/procedure-service-or-supply/modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:String
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation Modifier B (Field 24d)

element data/physician-or-supplier/procedure-service-or-supply/modifier-c

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:String
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation Modifier C (Field 24d)

element data/physician-or-supplier/procedure-service-or-supply/modifier-d

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:String
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation Modifier D (Field 24d)

element data/physician-or-supplier/procedure-service-or-supply/diagnosis-pointer

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [A-L][A-L]?[A-L]?[A-L]?
annotation	documentation Diagnosis Pointer (Field 24e)

element data/physician-or-supplier/procedure-service-or-supply/charges

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  8 fractionDigits  2
annotation	documentation Charges (Field 24f) documentation Must be >= $0.00.

element data/physician-or-supplier/procedure-service-or-supply/days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:String
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Days or Units (Field 24g)

element data/physician-or-supplier/procedure-service-or-supply/rendering-provider-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:qualifier cms1500_1202:id-number
annotation	documentation Rendering Provider ID Number (Fields 24i and 24j)

element data/physician-or-supplier/procedure-service-or-supply/rendering-provider-id-number/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  0B
annotation	documentation Qualifier (Field 24i)

element data/physician-or-supplier/procedure-service-or-supply/rendering-provider-id-number/id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  11 pattern  [ -~]*
annotation	documentation ID Number (Field 24j)

element data/physician-or-supplier/procedure-service-or-supply/rendering-provider-npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Rendering Provider NPI Number (Field 24j)

element data/physician-or-supplier/federal-tax-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation cms1500_1202:type   derived by: wcb:NonNegativeInteger   required         documentation Type must be 1 for SSN or 2 for EIN
annotation	documentation Federal Tax ID Number (Field 25) documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/physician-or-supplier/patients-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  14 pattern  [ -~]*
annotation	documentation Patient's Account No. (Field 26)

element data/physician-or-supplier/accept-assignment-flag

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation cms1500_1202:value   derived by: xs:string   required         documentation Value must be 'Y'.
annotation	documentation Accept Assignment Flag (Field 27)

element data/physician-or-supplier/total-charge

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Total Charge (Field 28)

element data/physician-or-supplier/amount-paid

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Decimal
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Amount Paid (Field 29)

element data/physician-or-supplier/signature

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:signed-name cms1500_1202:signed-date
annotation	documentation Signature (Field 31)

element data/physician-or-supplier/signature/signed-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Signed Name (Field 31)

element data/physician-or-supplier/signature/signed-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	content  simple
annotation	documentation Signed Date (Field 31)

element data/physician-or-supplier/service-facility

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:name cms1500_1202:address cms1500_1202:city-state-zip cms1500_1202:npi-number cms1500_1202:other-id-number
annotation	documentation Service Facility (Fields 32, 32a, and 32b)

element data/physician-or-supplier/service-facility/name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  60 pattern  [ -~]*
annotation	documentation Name (Field 32)

element data/physician-or-supplier/service-facility/address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  60 pattern  [ -~]*
annotation	documentation Address (Field 32)

element data/physician-or-supplier/service-facility/city-state-zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  60 pattern  [ -~]*
annotation	documentation City State and Zip (Field 32)

element data/physician-or-supplier/service-facility/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation NPI Number (Fields 32a)

element data/physician-or-supplier/service-facility/other-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:qualifier cms1500_1202:id-number
annotation	documentation Other ID Number (Field 32b)

element data/physician-or-supplier/service-facility/other-id-number/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  0B
annotation	documentation Qualifier (Field 32b)

element data/physician-or-supplier/service-facility/other-id-number/id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  12 pattern  [ -~]*
annotation	documentation ID Number (Field 32b)

element data/physician-or-supplier/billing-provider

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:name cms1500_1202:address cms1500_1202:city-state-zip cms1500_1202:telephone cms1500_1202:npi-number cms1500_1202:other-id-number
annotation	documentation Billing Provider (Fields 33, 33a, and 33b)

element data/physician-or-supplier/billing-provider/name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  60 pattern  [ -~]*
annotation	documentation Name (Field 33)

element data/physician-or-supplier/billing-provider/address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  60 pattern  [ -~]*
annotation	documentation Address (Field 33)

element data/physician-or-supplier/billing-provider/city-state-zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  60 pattern  [ -~]*
annotation	documentation City State and Zip (Field 33)

element data/physician-or-supplier/billing-provider/telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:area-code cms1500_1202:phone-number
annotation	documentation Telephone Number (Field 33)

element data/physician-or-supplier/billing-provider/telephone/area-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9]
annotation	documentation Area Code (Field 33)

element data/physician-or-supplier/billing-provider/telephone/phone-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Phone Number (Field 33)

element data/physician-or-supplier/billing-provider/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation NPI Number (Field 33a)

element data/physician-or-supplier/billing-provider/other-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	minOcc  0 maxOcc  1 content  complex
children	cms1500_1202:qualifier cms1500_1202:id-number
annotation	documentation Other ID Number (Field 33b)

element data/physician-or-supplier/billing-provider/other-id-number/qualifier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  0B
annotation	documentation Qualifier (Field 33b)

element data/physician-or-supplier/billing-provider/other-id-number/id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation ID Number (Field 33b)

element data/additional-claim-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:wcb-authorization-number cms1500_1202:wcb-rating-code cms1500_1202:report-type-code cms1500_1202:transmission-type-code cms1500_1202:attachment-control-id cms1500_1202:nteadd-txt cms1500_1202:carrier-received-date
annotation	documentation Additional Claim Information (Field 19)

element data/additional-claim-information/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  REFX5([0-9CSPL][0-9]{5}-[0-9][IBW]?|(PT|OT|PA|SW|AC|N)[0-9]{6}-[0-9])
annotation	documentation WCB Authorization Number (Field 19)

element data/additional-claim-information/wcb-rating-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  12 pattern  [ -`{-~]*
annotation	documentation WCB Rating Code (Field 19)

element data/additional-claim-information/report-type-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  PWK[A-Z0-9][A-Z0-9]
annotation	documentation Report Type Code (Field 19)

element data/additional-claim-information/transmission-type-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  E
annotation	documentation Transmission Type Code (Field 19)

element data/additional-claim-information/attachment-control-id

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Attachment Control ID (Field 19)

element data/additional-claim-information/nteadd-txt

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation enumeration  NTEADD
annotation	documentation NTEADD Text (Field 19)

element data/additional-claim-information/carrier-received-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
type	wcb:Date
properties	content  simple
annotation	documentation Carrier Received Date (Field 19)

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/cms1500_1202
properties	content  complex
children	cms1500_1202:data wcb:form-image wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation CMS-1500 Document (February 2012)

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:report-type otpt4_1012:liable-party otpt4_1012:claimant otpt4_1012:employer otpt4_1012:carrier otpt4_1012:referring-doctor otpt4_1012:history otpt4_1012:evaluation-treatment otpt4_1012:billing-information otpt4_1012:therapist
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      OT/PT-4   documentation Form ID Attribute documentation Value is fixed at 'OT/PT-4' for this document type. wcb:version-number   derived by: wcb:Text   required      1012   documentation Version Number Attribute documentation Value is fixed at '1012' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation OT/PT-4 Discrete Data Elements (December 2010)

element data/report-type

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1012:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Report Type Indicator documentation Set 'value' attribute as follows:  1=48-Hour Initial;  2=15-Day Initial;  3=45-Day Progress

element data/liable-party

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1012:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Liable Party Indicator documentation Set 'value' attribute as follows:  1=VFBL;  2=VAWBL

element data/claimant

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:last-name otpt4_1012:first-name otpt4_1012:middle-initial otpt4_1012:addr1 otpt4_1012:addr2 otpt4_1012:city otpt4_1012:state otpt4_1012:zip otpt4_1012:country otpt4_1012:telephone otpt4_1012:ssn otpt4_1012:date-of-birth otpt4_1012:wcb-case-number otpt4_1012:carrier-case-number otpt4_1012:date-of-injury otpt4_1012:time-of-injury otpt4_1012:injury-location
annotation	documentation Claimant Information

element data/claimant/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Claimant's Social Security Number

element data/claimant/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	content  simple
annotation	documentation Claimant's Date of Birth documentation Must be <= date-of-injury.

element data/claimant/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID

element data/claimant/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/claimant/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/claimant/time-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Time
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Time of Injury

element data/claimant/injury-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  40 pattern  [ -~]*
annotation	documentation Location Where Injury Occurred

element data/employer

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:name1 otpt4_1012:name2 otpt4_1012:addr1 otpt4_1012:addr2 otpt4_1012:city otpt4_1012:state otpt4_1012:zip otpt4_1012:country
annotation	documentation Employer Information

element data/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	minOcc  0 maxOcc  1 content  complex
children	otpt4_1012:name1 otpt4_1012:name2 otpt4_1012:addr1 otpt4_1012:addr2 otpt4_1012:city otpt4_1012:state otpt4_1012:zip otpt4_1012:country
annotation	documentation Insurance Carrier Information

element data/referring-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:last-name otpt4_1012:first-name otpt4_1012:middle-initial otpt4_1012:addr1 otpt4_1012:addr2 otpt4_1012:city otpt4_1012:state otpt4_1012:zip otpt4_1012:country otpt4_1012:telephone
annotation	documentation Referring Doctor Information

element data/history

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:previous-report-date otpt4_1012:referring-doctor-diagnosis otpt4_1012:history-of-preexisting-injury
annotation	documentation History Information

element data/history/previous-report-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Date of previous report documentation If there is a previous report which details the diagnosis of the referring physician/podiatrist, the date of that report goes here.  It must be >= date-of-injury and <= today.  Note:  At least one of previous-report-date and referring-doctor-diagnosis is required.

element data/history/referring-doctor-diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Referring Doctor's Diagnosis documentation Provide the diagnosis of the referring physician/podiatrist.  Note:  At least one of previous-report-date and referring-doctor-diagnosis is required.

element data/history/history-of-preexisting-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation History/Evidence of pre-existing injury

element data/evaluation-treatment

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:referral-reason otpt4_1012:evaluation otpt4_1012:condition-progress otpt4_1012:authorization-required otpt4_1012:treatment otpt4_1012:referring-doctor-treatment-plan otpt4_1012:treatment-frequency otpt4_1012:treatment-period otpt4_1012:visits-from-date otpt4_1012:visits-thru-date otpt4_1012:first-visit-date otpt4_1012:patient-returning otpt4_1012:patient-return-date otpt4_1012:referred-attending-doctor otpt4_1012:patient-working otpt4_1012:rtw-limitations-date otpt4_1012:rtw-date
annotation	documentation Evaluation/Treatment Information

element data/evaluation-treatment/referral-reason

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1012:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Referral Reason documentation Set 'value' attribute as follows:  1=Referral for Evaluation Only;  2=Referral for Treatment Only;  3=Referral for Evaluation and Treatment

element data/evaluation-treatment/evaluation

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Evaluation documentation This element is required if referral-reason = 1 or referral-reason = 3.

element data/evaluation-treatment/condition-progress

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Patient's condition and progress documentation This element is required if referral-reason = 2 or referral-reason = 3.

element data/evaluation-treatment/authorization-required

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Treatment Authorization Required Flag documentation If value is Y, at least one binary attachment is required (scanned TIFF image of authorizing document).

element data/evaluation-treatment/treatment

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Description of treatment rendered and planned future treatment documentation This element is required if referral-reason = 2 or referral-reason = 3.

element data/evaluation-treatment/referring-doctor-treatment-plan

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Referring Doctor Treatment Plan Flag documentation This element is required if referral-reason = 2 or referral-reason = 3.

element data/evaluation-treatment/treatment-frequency

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Frequency of Treatment documentation This element is required if referring-doctor-treatment-plan = 'Y'.

element data/evaluation-treatment/treatment-period

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Period of Treatment documentation This element is required if referring-doctor-treatment-plan = 'Y'.

element data/evaluation-treatment/visits-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	content  simple
annotation	documentation Dates of visits on which this report is based (start of date range) documentation Must be >= first-visit-date and <= today.

element data/evaluation-treatment/visits-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	content  simple
annotation	documentation Dates of visits on which this report is based (end of date range) documentation Must be >= visits-from-date and <= today.

element data/evaluation-treatment/first-visit-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	content  simple
annotation	documentation Date of first visit documentation Must be >= date-of-injury and <= today.

element data/evaluation-treatment/patient-returning

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Patient Returning Flag

element data/evaluation-treatment/patient-return-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Patient Return Date documentation This element is required if patient-returning = 'Y'.  Must be >= today.

element data/evaluation-treatment/referred-attending-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Referred Back to Attending Doctor Flag documentation This element is required if patient-returning = 'N'.

element data/evaluation-treatment/patient-working

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Patient Working Flag

element data/evaluation-treatment/rtw-limitations-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Date patient resumed work of any kind documentation Must be >= date-of-injury and <= today.

element data/evaluation-treatment/rtw-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Date patient resumed regular work documentation Must be >= date-of-injury and <= today.

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:diagnosis otpt4_1012:procedure
annotation	documentation Billing Information

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	minOcc  1 maxOcc  4 content  complex
children	otpt4_1012:diagnosis-code otpt4_1012:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  6 pattern  [ -`{-~]*
annotation	documentation ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD9 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	minOcc  1 maxOcc  unbounded content  complex
children	otpt4_1012:service-from-date otpt4_1012:service-thru-date otpt4_1012:place-of-service otpt4_1012:procedure-code otpt4_1012:procedure-modifier-a otpt4_1012:procedure-modifier-b otpt4_1012:service-diagnosis-code otpt4_1012:service-charge-amount otpt4_1012:service-days-or-units otpt4_1012:service-cob otpt4_1012:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= date-of-injury.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= today.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  5 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 pattern  1?2?3?4?
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/therapist

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:profession otpt4_1012:wcb-ppo otpt4_1012:nys-license-number otpt4_1012:npi-number otpt4_1012:federal-id-number otpt4_1012:patient-account-no otpt4_1012:name-and-office-location otpt4_1012:billing-address otpt4_1012:affirmed-by-therapist
annotation	documentation Therapist's Information

element data/therapist/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1012:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Occupational Therapist;  2=Physical Therapist

element data/therapist/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/therapist/nys-license-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:NYSLicenseNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number documentation Provider's New York State License Number.  This field is required for providers licensed by New York State. At least one of the nys-license-number and npi-number elements must be populated.

element data/therapist/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation Provider's National Provider Identifier.  This element is required for providers licensed outside of New York State.  It should always be populated when the data is available. At least one of the nys-license-number and npi-number elements must be populated.

element data/therapist/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1012:type   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Number documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/therapist/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/therapist/name-and-office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:last-name otpt4_1012:first-name otpt4_1012:middle-initial otpt4_1012:addr1 otpt4_1012:addr2 otpt4_1012:city otpt4_1012:state otpt4_1012:zip otpt4_1012:country otpt4_1012:telephone
annotation	documentation Therapist's Name and Office Location Information

element data/therapist/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:name1 otpt4_1012:name2 otpt4_1012:addr1 otpt4_1012:addr2 otpt4_1012:city otpt4_1012:state otpt4_1012:zip otpt4_1012:country otpt4_1012:telephone
annotation	documentation Billing Address Information documentation If billing inquires should be made to an entity other than the doctor, utilize the optional elements name1 and name2 to identify the name of that entity and use the address elements to specify that entity's address. Otherwise, it is only necessary to populate the address elements with the doctor's address.

element data/therapist/affirmed-by-therapist

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  50 pattern  [ -~]*
annotation	documentation Therapist's Signature documentation Putting therapist's name here is equivalent to signing the paper OT/PT-4.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
properties	content  complex
children	otpt4_1012:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation OT/PT-4 Document (December 2010)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1012
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

element addr1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Street Address

element addr2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Street Address

element city

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  20 pattern  [ -~]*
annotation	documentation City

element country

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  3 pattern  [ -`{-~]*
annotation	documentation 3-character Country Code documentation Required if the associated Zip field is blank.  Element optional if country is USA.

element data

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:report-type otpt4_1510:liable-party otpt4_1510:claimant otpt4_1510:employer otpt4_1510:carrier otpt4_1510:referring-doctor otpt4_1510:history otpt4_1510:evaluation-treatment otpt4_1510:billing-information otpt4_1510:therapist
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:form-id   derived by: wcb:Text   required      OT/PT-4   documentation Form ID Attribute documentation Value is fixed at 'OT/PT-4' for this document type. wcb:version-number   derived by: wcb:Text   required      1510   documentation Version Number Attribute documentation Value is fixed at '1510' for this document type. wcb:source-code   wcb:Text   required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. wcb:maintenance-type-code   wcb:Text   required      050   documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.
annotation	documentation OT/PT-4 Discrete Data Elements (October 2015)

element data/report-type

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1510:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Report Type Indicator documentation Set 'value' attribute as follows:  1=48-Hour Initial;  2=15-Day Initial;  3=45-Day Progress

element data/liable-party

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1510:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Liable Party Indicator documentation Set 'value' attribute as follows:  1=VFBL;  2=VAWBL

element data/claimant

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:last-name otpt4_1510:first-name otpt4_1510:middle-initial otpt4_1510:addr1 otpt4_1510:addr2 otpt4_1510:city otpt4_1510:state otpt4_1510:zip otpt4_1510:country otpt4_1510:telephone otpt4_1510:ssn otpt4_1510:date-of-birth otpt4_1510:wcb-case-number otpt4_1510:carrier-case-number otpt4_1510:date-of-injury otpt4_1510:time-of-injury otpt4_1510:injury-location
annotation	documentation Claimant Information

element data/claimant/ssn

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:SSN
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Claimant's Social Security Number

element data/claimant/date-of-birth

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	content  simple
annotation	documentation Claimant's Date of Birth documentation Must be <= date-of-injury.

element data/claimant/wcb-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	cis:CaseID
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation WCB Case ID

element data/claimant/carrier-case-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Insurance Carrier's Case ID

element data/claimant/date-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation pattern  [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9]
annotation	documentation Date of Injury documentation This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/claimant/time-of-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Time
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Time of Injury

element data/claimant/injury-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  40 pattern  [ -~]*
annotation	documentation Location Where Injury Occurred

element data/employer

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:name1 otpt4_1510:name2 otpt4_1510:addr1 otpt4_1510:addr2 otpt4_1510:city otpt4_1510:state otpt4_1510:zip otpt4_1510:country
annotation	documentation Employer Information

element data/carrier

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	minOcc  0 maxOcc  1 content  complex
children	otpt4_1510:name1 otpt4_1510:name2 otpt4_1510:addr1 otpt4_1510:addr2 otpt4_1510:city otpt4_1510:state otpt4_1510:zip otpt4_1510:country
annotation	documentation Insurance Carrier Information

element data/referring-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:last-name otpt4_1510:first-name otpt4_1510:middle-initial otpt4_1510:addr1 otpt4_1510:addr2 otpt4_1510:city otpt4_1510:state otpt4_1510:zip otpt4_1510:country otpt4_1510:telephone
annotation	documentation Referring Doctor Information

element data/history

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:previous-report-date otpt4_1510:referring-doctor-diagnosis otpt4_1510:history-of-preexisting-injury
annotation	documentation History Information

element data/history/previous-report-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Date of previous report documentation If there is a previous report which details the diagnosis of the referring physician/podiatrist, the date of that report goes here.  It must be >= date-of-injury and <= today.  Note:  At least one of previous-report-date and referring-doctor-diagnosis is required.

element data/history/referring-doctor-diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Referring Doctor's Diagnosis documentation Provide the diagnosis of the referring physician/podiatrist.  Note:  At least one of previous-report-date and referring-doctor-diagnosis is required.

element data/history/history-of-preexisting-injury

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation History/Evidence of pre-existing injury

element data/evaluation-treatment

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:referral-reason otpt4_1510:evaluation otpt4_1510:condition-progress otpt4_1510:authorization-required otpt4_1510:treatment otpt4_1510:referring-doctor-treatment-plan otpt4_1510:treatment-frequency otpt4_1510:treatment-period otpt4_1510:visits-from-date otpt4_1510:visits-thru-date otpt4_1510:first-visit-date otpt4_1510:patient-returning otpt4_1510:patient-return-date otpt4_1510:referred-attending-doctor otpt4_1510:patient-working otpt4_1510:rtw-limitations-date otpt4_1510:rtw-date
annotation	documentation Evaluation/Treatment Information

element data/evaluation-treatment/referral-reason

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1510:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Referral Reason documentation Set 'value' attribute as follows:  1=Referral for Evaluation Only;  2=Referral for Treatment Only;  3=Referral for Evaluation and Treatment

element data/evaluation-treatment/evaluation

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Evaluation documentation This element is required if referral-reason = 1 or referral-reason = 3.

element data/evaluation-treatment/condition-progress

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Patient's condition and progress documentation This element is required if referral-reason = 2 or referral-reason = 3.

element data/evaluation-treatment/authorization-required

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Treatment Authorization Required Flag documentation If value is Y, at least one binary attachment is required (scanned TIFF image of authorizing document).

element data/evaluation-treatment/treatment

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  300 pattern  [ -~]*
annotation	documentation Description of treatment rendered and planned future treatment documentation This element is required if referral-reason = 2 or referral-reason = 3.

element data/evaluation-treatment/referring-doctor-treatment-plan

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Referring Doctor Treatment Plan Flag documentation This element is required if referral-reason = 2 or referral-reason = 3.

element data/evaluation-treatment/treatment-frequency

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Frequency of Treatment documentation This element is required if referring-doctor-treatment-plan = 'Y'.

element data/evaluation-treatment/treatment-period

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  25 pattern  [ -~]*
annotation	documentation Period of Treatment documentation This element is required if referring-doctor-treatment-plan = 'Y'.

element data/evaluation-treatment/visits-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	content  simple
annotation	documentation Dates of visits on which this report is based (start of date range) documentation Must be >= first-visit-date and <= today.

element data/evaluation-treatment/visits-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	content  simple
annotation	documentation Dates of visits on which this report is based (end of date range) documentation Must be >= visits-from-date and <= today.

element data/evaluation-treatment/first-visit-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	content  simple
annotation	documentation Date of first visit documentation Must be >= date-of-injury and <= today.

element data/evaluation-treatment/patient-returning

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Patient Returning Flag

element data/evaluation-treatment/patient-return-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Patient Return Date documentation This element is required if patient-returning = 'Y'.  Must be >= today.

element data/evaluation-treatment/referred-attending-doctor

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Referred Back to Attending Doctor Flag documentation This element is required if patient-returning = 'N'.

element data/evaluation-treatment/patient-working

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Flag
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Patient Working Flag

element data/evaluation-treatment/rtw-limitations-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Date patient resumed work of any kind documentation Must be >= date-of-injury and <= today.

element data/evaluation-treatment/rtw-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	minOcc  0 maxOcc  1 content  simple
annotation	documentation Date patient resumed regular work documentation Must be >= date-of-injury and <= today.

element data/billing-information

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:diagnosis otpt4_1510:procedure
annotation	documentation Billing Information

element data/billing-information/diagnosis

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	minOcc  1 maxOcc  4 content  complex
children	otpt4_1510:diagnosis-code otpt4_1510:diagnosis-desc
annotation	documentation Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  8 pattern  [ -`{-~]*
annotation	documentation ICD10 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  75 pattern  [ -~]*
annotation	documentation ICD10 Diagnosis Description

element data/billing-information/procedure

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	minOcc  1 maxOcc  unbounded content  complex
children	otpt4_1510:service-from-date otpt4_1510:service-thru-date otpt4_1510:place-of-service otpt4_1510:procedure-code otpt4_1510:procedure-modifier-a otpt4_1510:procedure-modifier-b otpt4_1510:service-diagnosis-code otpt4_1510:service-charge-amount otpt4_1510:service-days-or-units otpt4_1510:service-cob otpt4_1510:service-zip-code
annotation	documentation Medical Procedure Information

element data/billing-information/procedure/service-from-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (start of date range) documentation Must be >= date-of-injury.

element data/billing-information/procedure/service-thru-date

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Date
properties	content  simple
annotation	documentation Procedure Dates of Service (end of date range) documentation Must be >= service-from-date and <= today.

element data/billing-information/procedure/place-of-service

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -~]*
annotation	documentation Place of Service

element data/billing-information/procedure/procedure-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  5 pattern  [ -`{-~]*
annotation	documentation Procedure Code

element data/billing-information/procedure/procedure-modifier-a

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:TextUpperCase
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  3 pattern  [ -`{-~]*
annotation	documentation Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 pattern  1?2?3?4?
annotation	documentation Diagnosis Code

element data/billing-information/procedure/service-charge-amount

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Decimal
properties	content  simple
facets	Kind  Value  Annotation minInclusive  0.00 totalDigits  9 fractionDigits  2
annotation	documentation Charge Amount documentation Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  4 pattern  [ -~]*
annotation	documentation Days or Units

element data/billing-information/procedure/service-cob

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  2 pattern  [ -~]*
annotation	documentation COB

element data/billing-information/procedure/service-zip-code

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -~]*
annotation	documentation Zip Code where service was rendered

element data/therapist

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:profession otpt4_1510:wcb-ppo otpt4_1510:nys-license-number otpt4_1510:npi-number otpt4_1510:federal-id-number otpt4_1510:patient-account-no otpt4_1510:name-and-office-location otpt4_1510:billing-address otpt4_1510:affirmed-by-therapist
annotation	documentation Therapist's Information

element data/therapist/profession

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1510:value   derived by: wcb:NonNegativeInteger   required
annotation	documentation Profession Indicator documentation Set 'value' attribute as follows:  1=Occupational Therapist;  2=Physical Therapist

element data/therapist/wcb-ppo

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:Flag
properties	minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:value   derived by: xs:string   required         documentation Value must be 'Y' or 'N'.
annotation	documentation Preferred Provider Organization Flag

element data/therapist/nys-license-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:NYSLicenseNumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation New York State License Number documentation Provider's New York State License Number.  This field is required for providers licensed by New York State. At least one of the nys-license-number and npi-number elements must be populated.

element data/therapist/npi-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	wcb:NPINumber
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation National Provider Identifier documentation Provider's National Provider Identifier.  This element is required for providers licensed outside of New York State.  It should always be populated when the data is available. At least one of the nys-license-number and npi-number elements must be populated.

element data/therapist/federal-id-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	extension of wcb:SSN
properties	content  complex
facets	Kind  Value  Annotation pattern  [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9]
attributes	Name   Type   Use   Default   Fixed   Annotation otpt4_1510:type   derived by: wcb:NonNegativeInteger   required
annotation	documentation Federal ID Number documentation Set the 'type' attribute as follows:  1=SSN;  2=EIN

element data/therapist/patient-account-no

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	minOcc  0 maxOcc  1 content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  15 pattern  [ -~]*
annotation	documentation Patient's Account No.

element data/therapist/name-and-office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:last-name otpt4_1510:first-name otpt4_1510:middle-initial otpt4_1510:addr1 otpt4_1510:addr2 otpt4_1510:city otpt4_1510:state otpt4_1510:zip otpt4_1510:country otpt4_1510:telephone
annotation	documentation Therapist's Name and Office Location Information

element data/therapist/billing-address

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:name1 otpt4_1510:name2 otpt4_1510:addr1 otpt4_1510:addr2 otpt4_1510:city otpt4_1510:state otpt4_1510:zip otpt4_1510:country otpt4_1510:telephone
annotation	documentation Billing Address Information documentation If billing inquires should be made to an entity other than the doctor, utilize the optional elements name1 and name2 to identify the name of that entity and use the address elements to specify that entity's address. Otherwise, it is only necessary to populate the address elements with the doctor's address.

element data/therapist/affirmed-by-therapist

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  50 pattern  [ -~]*
annotation	documentation Therapist's Signature documentation Putting therapist's name here is equivalent to signing the paper OT/PT-4.

element document

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
properties	content  complex
children	otpt4_1510:data wcb:attachment-text wcb:attachment-binary
attributes	Name   Type   Use   Default   Fixed   Annotation wcb:bp-document-id   derived by: wcb:Text   required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. wcb:bp-document-comment   derived by: wcb:Text   optional         documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.
annotation	documentation OT/PT-4 Document (October 2015)

element first-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Name

element last-name

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of xs:string
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [A-Za-z][ -~]*
annotation	documentation Last Name documentation First character must be alpahbetic.

element middle-initial

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  1 pattern  [ -~]*
annotation	documentation Middle Initial

element name1

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation First Line of Name

element name2

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Second Line of Name

element state

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:StringUpperCase
properties	content  simple
facets	Kind  Value  Annotation length  2 pattern  [ -`{-~]*
annotation	documentation State documentation Required if country is USA.

element telephone

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:Text
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  30 pattern  [ -~]*
annotation	documentation Telephone Number documentation Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/otpt4_1510
type	restriction of wcb:TextUpperCase
properties	content  simple
facets	Kind  Value  Annotation minLength  1 maxLength  9 pattern  [ -`{-~]*
annotation	documentation Zip Code documentation Required if country is USA or Canada.

simpleType CaseID

namespace	http://www.wcb.state.ny.us/xml/ns/cis
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Case ID Type documentation 1st character must be alphanumeric (B, C, E, I, and O are not allowed).  2nd character must be alphanumeric (I and O are not allowed).  3rd - 8th characters must be numeric.

simpleType CaseIDOld

namespace	http://www.wcb.state.ny.us/xml/ns/cis
type	restriction of xs:string
properties	base  xs:string
facets	Kind  Value  Annotation pattern  [0-9A-Z][0-9A-Z][0-9][0-9][0-9][0-9][0-9][0-9]
annotation	documentation Case ID Type documentation 1st and 2nd characters must be alphanumeric.  3rd - 8th characters must be numeric.

XML Schema documentation generated by XMLSpy Schema Editor http://www.altova.com/xmlspy