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 c4narr_0812:document c4narr_1012:document otpt4_1012:document
attributes	Name   Type   Use   Default   Fixed   annotation application-id required      CIS   documentation Value is fixed at 'CIS' for this submission type. production-test-indicator required         documentation Indicates submission was for production use or testing only (values P or T) bp-submission-id required         documentation Business Partner's Internal Submission ID Attribute documentation This is the business partner's identifier for the entire submission. bp-submission-comment optional         documentation Business Partner's Comment Attribute documentation Optional comment for business partner's use.
annotation	documentation XML Form Submission (Root Element)

attribute application-id

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	wcb:Text
facets	Kind  Value  annotation  minLength  1  pattern  [ -~]*
annotation	documentation WCB Application ID Attribute

attribute bp-document-comment

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:Text
facets	Kind  Value  annotation  minLength  1  maxLength  60  pattern  [ -~]*
annotation	documentation Business Partner's Document Comment Attribute documentation Optional document comment for business partner's use.

attribute bp-document-id

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:Text
facets	Kind  Value  annotation  minLength  1  maxLength  30  pattern  [ -~]*
annotation	documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document.

attribute bp-submission-comment

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:Text
facets	Kind  Value  annotation  minLength  1  maxLength  60  pattern  [ -~]*
annotation	documentation Business Partner's Submission Comment Attribute documentation Optional submission comment for business partner's use.

attribute bp-submission-id

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:Text
facets	Kind  Value  annotation  minLength  1  maxLength  30  pattern  [ -~]*
annotation	documentation Business Partner's Internal Submission ID Attribute documentation This is the business partner's identifier for the entire submission.

attribute form-id

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:Text
facets	Kind  Value  annotation  minLength  1  maxLength  10  pattern  [ -~]*
annotation	documentation Form ID Attribute documentation WCB form identifier.

attribute maintenance-type-code

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	wcb:Text
properties	fixed  050
facets	Kind  Value  annotation  minLength  1  pattern  [ -~]*
annotation	documentation Maintenance Type Code (ANSI) documentation Value is fixed at '050' which is the ANSI code for 'original form'.

attribute production-test-indicator

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:Text
facets	Kind  Value  annotation  minLength  1  pattern  [ -~]*  enumeration  P  enumeration  T
annotation	documentation Indicates submission was for production use or testing only (values P or T)

attribute source-code

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	wcb:Text
properties	fixed  X
facets	Kind  Value  annotation  minLength  1  pattern  [ -~]*
annotation	documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission.

attribute version-number

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:Text
facets	Kind  Value  annotation  minLength  1  maxLength  6  pattern  [ -~]*
annotation	documentation Version Number Attribute documentation WCB form version number (a date in YYMM format).

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).

attribute attachment-binary/@content-type

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	wcb:Text
properties	isRef  0 use  required
facets	Kind  Value  annotation  minLength  1  pattern  [ -~]*
annotation	documentation Conent Type (MIME Type) -- only 'image/tiff' is currently allowed

attribute attachment-binary/@ref

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	wcb:Text
properties	isRef  0 use  required
facets	Kind  Value  annotation  minLength  1  pattern  [ -~]*
annotation	documentation A reference to the binary attachment.  This must be the filename only with no path or other prefix/suffix.

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	isRef  0 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	isRef  0 minOcc  1 maxOcc  56 content  simple
facets	Kind  Value  annotation  minLength  0  maxLength  100  pattern  [ -~]*
annotation	documentation One line of text

complexType Flag

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' or 'N'.
annotation	documentation WCB Flag Type (Y/N)

attribute Flag/@value

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:String
properties	isRef  0 use  required
facets	Kind  Value  annotation  length  1  pattern  [ -~]*  enumeration  Y  enumeration  N
annotation	documentation Value must be 'Y' or '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)

attribute FlagUnknown/@value

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:String
properties	isRef  0 use  required
facets	Kind  Value  annotation  length  1  pattern  [ -~]*  enumeration  Y  enumeration  N  enumeration  U
annotation	documentation Value must be 'Y', 'N', or '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: wcb:String required         documentation Value must be 'M' or 'F'.
annotation	documentation WCB Gender Type (M/F)

attribute Gender/@value

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of wcb:String
properties	isRef  0 use  required
facets	Kind  Value  annotation  length  1  pattern  [ -~]*  enumeration  M  enumeration  F
annotation	documentation Value must be 'M' or 'F'.

simpleType Date

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

simpleType Decimal

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

simpleType NonNegativeInteger

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

simpleType NPINumber

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of 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
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
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
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
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
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
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
annotation	documentation WCB Time Type

simpleType WCBAuthorizationNumber

namespace	http://www.wcb.state.ny.us/xml/ns/wcb
type	restriction of 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 form-id required      C-4NARR   documentation Form ID Attribute documentation Value is fixed at 'C-4' for this document type. version-number required      0812   documentation Version Number Attribute documentation Value is fixed at '0812' for this document type. source-code required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. maintenance-type-code 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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

attribute data/doctor/profession/@value

namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:NonNegativeInteger
properties	isRef  0 use  required
facets	Kind  Value  annotation  minInclusive  1  maxInclusive  3

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:TextUpperCase
properties	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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

attribute data/doctor/federal-id-type/@value

namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type	restriction of wcb:NonNegativeInteger
properties	isRef  0 use  required
facets	Kind  Value  annotation  minInclusive  1  maxInclusive  2

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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 bp-document-id required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. bp-document-comment 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 form-id required      C-4NARR   documentation Form ID Attribute documentation Value is fixed at 'C-4' for this document type. version-number required      1012   documentation Version Number Attribute documentation Value is fixed at '1012' for this document type. source-code required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. maintenance-type-code 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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

attribute data/doctor/profession/@value

namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:NonNegativeInteger
properties	isRef  0 use  required
facets	Kind  Value  annotation  minInclusive  1  maxInclusive  3

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:WCBAuthorizationNumber
properties	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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

attribute data/doctor/federal-id-number/@type

namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type	restriction of wcb:NonNegativeInteger
properties	isRef  0 use  required
facets	Kind  Value  annotation  minInclusive  1  maxInclusive  2

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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 bp-document-id required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. bp-document-comment 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/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 form-id required      C-4AMR   documentation Form ID Attribute documentation Value is fixed at 'C-4AMR' for this document type. version-number required      0908   documentation Version Number Attribute documentation Value is fixed at '0908' for this document type. source-code required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. maintenance-type-code 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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

attribute data/doctor/profession/@value

namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:NonNegativeInteger
properties	isRef  0 use  required
facets	Kind  Value  annotation  minInclusive  1  maxInclusive  3

element data/doctor/wcb-authorization-number

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	wcb:WCBAuthorizationNumber
properties	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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

attribute data/doctor/federal-id-number/@type

namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type	restriction of wcb:NonNegativeInteger
properties	isRef  0 use  required
facets	Kind  Value  annotation  minInclusive  1  maxInclusive  2

element data/doctor/office-location

diagram
namespace	http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 minOcc  0 maxOcc  1 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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	isRef  0 content  complex
attributes	Name   Type   Use   Default   Fixed   annotation wcb:value derived by: wcb: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	isRef  0 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 bp-document-id required         documentation Business Partner's Internal Document ID Attribute documentation This is the business partner's 'serial number' for the document. bp-document-comment 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 form-id required      C-4AMR   documentation Form ID Attribute documentation Value is fixed at 'C-4AMR' for this document type. version-number required      1012   documentation Version Number Attribute documentation Value is fixed at '1012' for this document type. source-code required      X   documentation Source Code Attribute documentation Value is fixed at 'X' for XML Forms Submission. maintenance-type-code 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 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	isRef  0 minOcc  0 maxOcc  1 cont