APPENDIX J- SWIF TO PPO/MBR LAYOUTS

(Claims/Policy; Legal Entity; Risk Location; Provider Specialty)

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF GENERAL SERVICES

RFP# 6100022203

Claim/Policy Layouts
Field / Length / Data Type / Required / Format
Process Date / 8 / Date / N / YYYYMMDD
Batch ID / 6 / Number / Y
Claim Number / 12 / Varchar2 / Y
Bureau Code / 4 / Varchar2 / Y
Date of Loss / 8 / Date / Y / YYYYMMDD
Date Entered / 8 / Date / N / YYYYMMDD
Claim Type / 2 / Varchar2 / Y
Federal Black Lung Indicator / 1 / Char / Y
US Long Shore and Harbor Worker Indicator / 1 / Char / Y
Claim Status - Parent / 80 / Varchar2 / Y
Claim Status / 80 / Varchar2 / Y
Claim Reopen Date / 8 / Date / N / YYYYMMDD
Claim Close Date / 8 / Date / N / YYYYMMDD
Claim Owner Name / 40 / Varchar2 / Y
Claim Owner Phone / 16 / Varchar2 / N
Jurisdiction State / 2 / Varchar2 / N
Claimant Legal Entity ID / 10 / Number / Y
Claimant Signed Ack of Panel on Hire / 1 / Char / N
Claimant Signed Ack of Panel on Injury / 1 / Char / N
Panel Properly Posted / 1 / Char / N
Insured Legal Entity ID / 10 / Number / Y
Policy Number / 12 / Varchar2 / N
Policy Period Effective Date / 8 / Date / N / YYYYMMDD
Policy Period End Date / 8 / Date / N / YYYYMMDD
Employer Interested in Panel / 1 / Char / N
Risk Location ID / 10 / Number / N
Accident Description / 500 / Varchar2 / N
Nature of Injury Code / 2 / Varchar2 / Y
Nature of Injury / 80 / Varchar2 / Y
Active Litigation Indicator / 1 / Char / Y
Closed Litigation Indicator / 1 / Char / Y
Apportionment Indicator / 1 / Char / Y
Apportionment Percent / 4 / Number / N / ex 1.00 = 100%
No Medical Payment After This Date / 8 / Date / N / YYYYMMDD
OKTOPay Indicator / 1 / Char / Y
Last Date of Service / 8 / Number / N / YYYYMMDD
Legal Entity File Layout
Field / Length / Data Type / Required / Format
Process Date / 8 / Date / N / YYYYDDMM
Batch ID / 6 / Number / Y
Legal Entity ID / 10 / Number / Y
Prior Legal Entity ID / 10 / Number / Y
Entity Type / 1 / Varchar2 / Y
Legal Entity Tax ID / 15 / Varchar2 / N
Business FEIN Location / 3 / Varchar2 / N
Business Name / 120 / Varchar2 / Y - only for a business
Person Last Name / 75 / Varchar2 / Y - only for a person
Person First Name / 45 / Varchar2 / Y - only for a person
Person Middle Initial / 1 / Varchar2 / N
Person Name Suffix Code / 15 / Varchar2 / N
Person Name Suffix / 80 / Varchar2 / N
Legal Entity DBA/Alias Name / 120 / Varchar2 / N
Legal Entity Mailing Address Line 1 / 40 / Varchar2 / Y
Legal Entity Mailing Address Line 2 / 40 / Varchar2 / N
Legal Entity Mailing Address City / 80 / Varchar2 / Y
Legal Entity Mailing Address State / 2 / Varchar2 / N
Legal Entity Mailing Address ZIP/Postal Code / 15 / Varchar2 / Y
Legal Entity Mailing Address Country / 80 / Varchar2 / Y
Legal Entity Physical Address Line 1 / 40 / Varchar2 / Y
Legal Entity Physical Address Line 2 / 40 / Varchar2 / N
Legal Entity Physical Address City / 80 / Varchar2 / Y
Legal Entity Physical Address State / 2 / Varchar2 / N
Legal Entity Physical Address ZIP/Postal Code / 15 / Varchar2 / Y
Legal Entity Physical Address Country / 80 / Varchar2 / Y
Legal Entity Phone / 16 / Varchar2 / N
Legal Entity Fax / 16 / Varchar2 / N
Legal Entity Email / 80 / Varchar2 / N
Person Date of Birth / 8 / Date / N / YYYYDDMM
Person Date of Death / 8 / Date / N / YYYYDDMM
Person Gender / 1 / Varchar2 / N
Insured Last Active Date / 8 / Date / N / YYYYDDMM
Insured Employee Count / 8 / Number / N / 99999999
Insured Premium / 12 / Number / N / 999999999.99
Insured First EMOD Factor / 6 / Number / N / 9.9999
Insured Second EMOD Factor / 6 / Number / N / 9.9999
Insured Agency of Record Name / 120 / Varchar / N
Insured Agency of Record Mailing Address Line 1 / 40 / Varchar / N
Insured Agency of Record Mailing Address Line 2 / 40 / Varchar / N
Insured Agency of Record Mailing Address City / 80 / Varchar / N
Insured Agency of Record Mailing Address State / 2 / Varchar / N
Insured Agency of Record Mailing Address ZIP/Postal Code / 15 / Varchar / N
Insured Agency of Record Mailing Address Country / 80 / Varchar / N
Insured Agency of Record Contact Name / 40 / Varchar / N
Insured Agency of Record Phone / 16 / Varchar / N
Insured Agency of Record Fax / 16 / Varchar / N
Insured Agency of Record Email / 80 / Varchar / N
VA Medical Center Indicator / 1 / Varchar2 / y if legal entity is a provider
Risk Location File Layout
Field / Length / Data Type / Required / Format
Process Date / 8 / Date / N / YYYYMMDD
Batch ID / 6 / Number / Y
Legal Entity ID / 10 / Number / Y
Risk Location ID / 10 / Number / Y
Risk Location Effective Date / 8 / Date / Y / YYYYMMDD
Risk Location End Date / 8 / Date / N / YYYYMMDD
Risk Location Void Indicator / 1 / Char / Y
Risk Location Reference Number / 10 / Varchar2 / Y
Risk Location Name / 120 / Varchar2 / Y
Risk Location Address Line 1 / 40 / Varchar2 / Y
Risk Location Address Line 2 / 40 / Varchar2 / N
Risk Location Address City / 80 / Varchar2 / Y
Risk Location Address State / 2 / Varchar2 / Y
Risk Location Address ZIP / 15 / Varchar2 / Y
Risk Location Contact Phone / 16 / Varchar2 / N
Provider Speciality File Layout
Field / Length / Data Type / Required / Format
Process Date / 8 / Date / N / YYYYMMDD
Batch ID / 6 / Number / Y
Legal Entity ID / 10 / Number / Y
Provider Specialty Number / 3 / Number / Y
Provider Type / 80 / Varchar2 / Y
Provider Type Specialty / 256 / Varchar2 / Y

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