Schema xfs-cis.xsd


element submission
diagram xfs-cis_diagrams/xfs-cis_p1.png
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 xfs-cis_diagrams/xfs-cis_p2.png
used by
elements document document document document document document document document document
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 xfs-cis_diagrams/xfs-cis_p3.png
used by
elements document document document document document document document document document
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 xfs-cis_diagrams/xfs-cis_p4.png
annotation
documentation
Contains contents of a single page

element attachment-text/page/line
diagram xfs-cis_diagrams/xfs-cis_p5.png
type restriction of wcb:String
facets
Kind Value Annotation
minLength 0
maxLength 100
pattern [ -~]*
annotation
documentation
One line of text

element addr1
diagram xfs-cis_diagrams/xfs-cis_p6.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p7.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p8.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 20
pattern [ -~]*
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p9.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p10.png
used by
element document
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 xfs-cis_diagrams/xfs-cis_p11.png
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p12.png
type cis:CaseIDOld
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 xfs-cis_diagrams/xfs-cis_p13.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 25
pattern [ -~]*
annotation
documentation
Insurance Carrier's Case ID

element data/patient/gender
diagram xfs-cis_diagrams/xfs-cis_p14.png
type wcb:Gender
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 xfs-cis_diagrams/xfs-cis_p15.png
type wcb:Date
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p16.png
type wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p17.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p18.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 45
pattern [ -~]*
annotation
documentation
Patient's Job Title

element data/patient/work-activities
diagram xfs-cis_diagrams/xfs-cis_p19.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 200
pattern [ -~]*
annotation
documentation
Patient's Work Activities

element data/patient/patient-working
diagram xfs-cis_diagrams/xfs-cis_p20.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p21.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 15
pattern [ -~]*
annotation
documentation
Patient's Account No.

element data/employer
diagram xfs-cis_diagrams/xfs-cis_p22.png
annotation
documentation
Employer Information

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p23.png
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p24.png
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 xfs-cis_diagrams/xfs-cis_p25.png
type restriction of wcb:TextUpperCase
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 xfs-cis_diagrams/xfs-cis_p26.png
type restriction of wcb:TextUpperCase
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 xfs-cis_diagrams/xfs-cis_p27.png
type wcb:NPINumber
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 xfs-cis_diagrams/xfs-cis_p28.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -~]*
annotation
documentation
SSN or EIN

element data/doctor/federal-id-type
diagram xfs-cis_diagrams/xfs-cis_p29.png
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 xfs-cis_diagrams/xfs-cis_p30.png
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p31.png
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 xfs-cis_diagrams/xfs-cis_p32.png
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p33.png
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p34.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p35.png
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p36.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 6
pattern [ -`{-~]*
annotation
documentation
ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p37.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 75
pattern [ -~]*
annotation
documentation
ICD9 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p38.png
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p39.png
type wcb:Date
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p40.png
type wcb:Date
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 xfs-cis_diagrams/xfs-cis_p41.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -~]*
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p42.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 6
pattern [ -`{-~]*
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p43.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p44.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p45.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 7
pattern [ -`{-~]*
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p46.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p47.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 4
pattern [ -~]*
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p48.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 2
pattern [ -~]*
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p49.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -~]*
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p50.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p51.png
annotation
documentation
Doctor's Opinion

element data/opinion/competent-producing-cause
diagram xfs-cis_diagrams/xfs-cis_p52.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p53.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p54.png
type wcb:FlagUnknown
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 xfs-cis_diagrams/xfs-cis_p55.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p56.png
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 xfs-cis_diagrams/xfs-cis_p57.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p58.png
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 xfs-cis_diagrams/xfs-cis_p59.png
used by
element submission
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 xfs-cis_diagrams/xfs-cis_p60.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Name

element last-name
diagram xfs-cis_diagrams/xfs-cis_p61.png
type restriction of xs:string
used by
elements data/authorized-doctor data/doctor data/patient data/supervised-health-care-provider
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 xfs-cis_diagrams/xfs-cis_p62.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 1
pattern [ -~]*
annotation
documentation
Middle Initial

element name
diagram xfs-cis_diagrams/xfs-cis_p63.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Name

element name1
diagram xfs-cis_diagrams/xfs-cis_p64.png
type restriction of wcb:Text
used by
elements data/billing-information/carrier data/employer
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Name

element name2
diagram xfs-cis_diagrams/xfs-cis_p65.png
type restriction of wcb:Text
used by
elements data/billing-information/carrier data/employer
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Name

element specialty
diagram xfs-cis_diagrams/xfs-cis_p66.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Specialty

element state
diagram xfs-cis_diagrams/xfs-cis_p67.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
length 2
pattern [ -`{-~]*
annotation
documentation
State
documentation
Required if country is USA.

element telephone
diagram xfs-cis_diagrams/xfs-cis_p68.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/employer data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p69.png
type restriction of wcb:TextUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -`{-~]*
annotation
documentation
Zip Code
documentation
Required if country is USA or Canada.

element addr1
diagram xfs-cis_diagrams/xfs-cis_p70.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p71.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p72.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 20
pattern [ -~]*
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p73.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p74.png
used by
element document
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 xfs-cis_diagrams/xfs-cis_p75.png
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p76.png
type cis:CaseID
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 xfs-cis_diagrams/xfs-cis_p77.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 25
pattern [ -~]*
annotation
documentation
Insurance Carrier's Case ID

element data/patient/gender
diagram xfs-cis_diagrams/xfs-cis_p78.png
type wcb:Gender
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 xfs-cis_diagrams/xfs-cis_p79.png
type wcb:Date
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p80.png
type wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p81.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p82.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 45
pattern [ -~]*
annotation
documentation
Patient's Job Title

element data/patient/work-activities
diagram xfs-cis_diagrams/xfs-cis_p83.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 200
pattern [ -~]*
annotation
documentation
Patient's Work Activities

element data/patient/patient-working
diagram xfs-cis_diagrams/xfs-cis_p84.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p85.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 15
pattern [ -~]*
annotation
documentation
Patient's Account No.

element data/employer
diagram xfs-cis_diagrams/xfs-cis_p86.png
annotation
documentation
Employer Information

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p87.png
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p88.png
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 xfs-cis_diagrams/xfs-cis_p89.png
type restriction of wcb:WCBAuthorizationNumber
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 xfs-cis_diagrams/xfs-cis_p90.png
type restriction of wcb:TextUpperCase
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 xfs-cis_diagrams/xfs-cis_p91.png
type wcb:NYSLicenseNumber
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 xfs-cis_diagrams/xfs-cis_p92.png
type wcb:NPINumber
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 xfs-cis_diagrams/xfs-cis_p93.png
type extension of wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p94.png
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p95.png
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 xfs-cis_diagrams/xfs-cis_p96.png
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p97.png
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p98.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p99.png
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p100.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 6
pattern [ -`{-~]*
annotation
documentation
ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p101.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 75
pattern [ -~]*
annotation
documentation
ICD9 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p102.png
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p103.png
type wcb:Date
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p104.png
type wcb:Date
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 xfs-cis_diagrams/xfs-cis_p105.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -~]*
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p106.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 5
pattern [ -`{-~]*
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p107.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p108.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p109.png
type restriction of xs:string
facets
Kind Value Annotation
pattern 1?2?3?4?
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p110.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p111.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 4
pattern [ -~]*
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p112.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 2
pattern [ -~]*
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p113.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -~]*
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p114.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p115.png
annotation
documentation
Doctor's Opinion

element data/opinion/competent-producing-cause
diagram xfs-cis_diagrams/xfs-cis_p116.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p117.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p118.png
type wcb:FlagUnknown
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 xfs-cis_diagrams/xfs-cis_p119.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p120.png
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 xfs-cis_diagrams/xfs-cis_p121.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p122.png
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 xfs-cis_diagrams/xfs-cis_p123.png
used by
element submission
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 xfs-cis_diagrams/xfs-cis_p124.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Name

element last-name
diagram xfs-cis_diagrams/xfs-cis_p125.png
type restriction of xs:string
used by
elements data/authorized-doctor data/doctor data/patient data/authorized-doctor/supervised-health-care-provider
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 xfs-cis_diagrams/xfs-cis_p126.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 1
pattern [ -~]*
annotation
documentation
Middle Initial

element name
diagram xfs-cis_diagrams/xfs-cis_p127.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Name

element name1
diagram xfs-cis_diagrams/xfs-cis_p128.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Name

element name2
diagram xfs-cis_diagrams/xfs-cis_p129.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Name

element specialty
diagram xfs-cis_diagrams/xfs-cis_p130.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Specialty

element state
diagram xfs-cis_diagrams/xfs-cis_p131.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
length 2
pattern [ -`{-~]*
annotation
documentation
State
documentation
Required if country is USA.

element telephone
diagram xfs-cis_diagrams/xfs-cis_p132.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/employer data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p133.png
type restriction of wcb:TextUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -`{-~]*
annotation
documentation
Zip Code
documentation
Required if country is USA or Canada.

element addr1
diagram xfs-cis_diagrams/xfs-cis_p134.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p135.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p136.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 20
pattern [ -~]*
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p137.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p138.png
used by
element document
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 xfs-cis_diagrams/xfs-cis_p139.png
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p140.png
type cis:CaseID
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 xfs-cis_diagrams/xfs-cis_p141.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 25
pattern [ -~]*
annotation
documentation
Insurance Carrier's Case ID

element data/patient/gender
diagram xfs-cis_diagrams/xfs-cis_p142.png
type wcb:Gender
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 xfs-cis_diagrams/xfs-cis_p143.png
type wcb:Date
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p144.png
type wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p145.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p146.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 45
pattern [ -~]*
annotation
documentation
Patient's Job Title

element data/patient/work-activities
diagram xfs-cis_diagrams/xfs-cis_p147.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 200
pattern [ -~]*
annotation
documentation
Patient's Work Activities

element data/patient/patient-working
diagram xfs-cis_diagrams/xfs-cis_p148.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p149.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 15
pattern [ -~]*
annotation
documentation
Patient's Account No.

element data/employer
diagram xfs-cis_diagrams/xfs-cis_p150.png
annotation
documentation
Employer Information

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p151.png
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p152.png
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 xfs-cis_diagrams/xfs-cis_p153.png
type restriction of wcb:WCBAuthorizationNumber
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 xfs-cis_diagrams/xfs-cis_p154.png
type restriction of wcb:TextUpperCase
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 xfs-cis_diagrams/xfs-cis_p155.png
type wcb:NYSLicenseNumber
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 xfs-cis_diagrams/xfs-cis_p156.png
type wcb:NPINumber
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 xfs-cis_diagrams/xfs-cis_p157.png
type extension of wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p158.png
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p159.png
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 xfs-cis_diagrams/xfs-cis_p160.png
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p161.png
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p162.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p163.png
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p164.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 8
pattern [ -`{-~]*
annotation
documentation
ICD10 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p165.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 75
pattern [ -~]*
annotation
documentation
ICD10 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p166.png
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p167.png
type wcb:Date
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p168.png
type wcb:Date
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 xfs-cis_diagrams/xfs-cis_p169.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -~]*
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p170.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 5
pattern [ -`{-~]*
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p171.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p172.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p173.png
type restriction of xs:string
facets
Kind Value Annotation
pattern 1?2?3?4?
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p174.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p175.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 4
pattern [ -~]*
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p176.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 2
pattern [ -~]*
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p177.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -~]*
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p178.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p179.png
annotation
documentation
Doctor's Opinion

element data/opinion/competent-producing-cause
diagram xfs-cis_diagrams/xfs-cis_p180.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p181.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p182.png
type wcb:FlagUnknown
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 xfs-cis_diagrams/xfs-cis_p183.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p184.png
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 xfs-cis_diagrams/xfs-cis_p185.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p186.png
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 xfs-cis_diagrams/xfs-cis_p187.png
used by
element submission
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 xfs-cis_diagrams/xfs-cis_p188.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Name

element last-name
diagram xfs-cis_diagrams/xfs-cis_p189.png
type restriction of xs:string
used by
elements data/authorized-doctor data/doctor data/patient data/authorized-doctor/supervised-health-care-provider
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 xfs-cis_diagrams/xfs-cis_p190.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 1
pattern [ -~]*
annotation
documentation
Middle Initial

element name
diagram xfs-cis_diagrams/xfs-cis_p191.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Name

element name1
diagram xfs-cis_diagrams/xfs-cis_p192.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Name

element name2
diagram xfs-cis_diagrams/xfs-cis_p193.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Name

element specialty
diagram xfs-cis_diagrams/xfs-cis_p194.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Specialty

element state
diagram xfs-cis_diagrams/xfs-cis_p195.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
length 2
pattern [ -`{-~]*
annotation
documentation
State
documentation
Required if country is USA.

element telephone
diagram xfs-cis_diagrams/xfs-cis_p196.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/employer data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p197.png
type restriction of wcb:TextUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/employer data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -`{-~]*
annotation
documentation
Zip Code
documentation
Required if country is USA or Canada.

element addr1
diagram xfs-cis_diagrams/xfs-cis_p198.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p199.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p200.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 20
pattern [ -~]*
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p201.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p202.png
used by
element document
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 xfs-cis_diagrams/xfs-cis_p203.png
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p204.png
type cis:CaseID
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 xfs-cis_diagrams/xfs-cis_p205.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 25
pattern [ -~]*
annotation
documentation
Insurance Carrier's Case ID

element data/patient/date-of-birth
diagram xfs-cis_diagrams/xfs-cis_p206.png
type wcb:Date
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p207.png
type wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p208.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p209.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 15
pattern [ -~]*
annotation
documentation
Patient's Account No.

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p210.png
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p211.png
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 xfs-cis_diagrams/xfs-cis_p212.png
type wcb:WCBAuthorizationNumber
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 xfs-cis_diagrams/xfs-cis_p213.png
type restriction of wcb:TextUpperCase
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 xfs-cis_diagrams/xfs-cis_p214.png
type wcb:NYSLicenseNumber
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 xfs-cis_diagrams/xfs-cis_p215.png
type wcb:NPINumber
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 xfs-cis_diagrams/xfs-cis_p216.png
type extension of wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p217.png
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p218.png
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 xfs-cis_diagrams/xfs-cis_p219.png
annotation
documentation
Referring Doctor's Name

element data/billing-information
diagram xfs-cis_diagrams/xfs-cis_p220.png
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p221.png
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p222.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p223.png
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p224.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 6
pattern [ -`{-~]*
annotation
documentation
ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p225.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 75
pattern [ -~]*
annotation
documentation
ICD9 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p226.png
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p227.png
type wcb:Date
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p228.png
type wcb:Date
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 xfs-cis_diagrams/xfs-cis_p229.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -~]*
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p230.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 5
pattern [ -`{-~]*
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p231.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p232.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p233.png
type restriction of xs:string
facets
Kind Value Annotation
minLength 1
pattern 1?2?3?4?
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p234.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p235.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 4
pattern [ -~]*
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p236.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 2
pattern [ -~]*
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p237.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -~]*
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p238.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p239.png
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 xfs-cis_diagrams/xfs-cis_p240.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p241.png
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 xfs-cis_diagrams/xfs-cis_p242.png
used by
element submission
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 xfs-cis_diagrams/xfs-cis_p243.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/doctor/referring-doctor data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Name

element last-name
diagram xfs-cis_diagrams/xfs-cis_p244.png
type restriction of xs:string
used by
elements data/authorized-doctor data/doctor data/patient data/doctor/referring-doctor data/authorized-doctor/supervised-health-care-provider
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 xfs-cis_diagrams/xfs-cis_p245.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/doctor data/patient data/doctor/referring-doctor data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 1
pattern [ -~]*
annotation
documentation
Middle Initial

element name
diagram xfs-cis_diagrams/xfs-cis_p246.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Name

element name1
diagram xfs-cis_diagrams/xfs-cis_p247.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Name

element name2
diagram xfs-cis_diagrams/xfs-cis_p248.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Name

element specialty
diagram xfs-cis_diagrams/xfs-cis_p249.png
type restriction of wcb:Text
used by
elements data/authorized-doctor data/authorized-doctor/supervised-health-care-provider
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Specialty

element state
diagram xfs-cis_diagrams/xfs-cis_p250.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
length 2
pattern [ -`{-~]*
annotation
documentation
State
documentation
Required if country is USA.

element telephone
diagram xfs-cis_diagrams/xfs-cis_p251.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p252.png
type restriction of wcb:TextUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -`{-~]*
annotation
documentation
Zip Code
documentation
Required if country is USA or Canada.

element addr1
diagram xfs-cis_diagrams/xfs-cis_p253.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p254.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 30
pattern [ -~]*
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p255.png
type restriction of wcb:Text
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
facets
Kind Value Annotation
minLength 1
maxLength 20
pattern [ -~]*
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p256.png
type restriction of wcb:StringUpperCase
used by
elements data/doctor/billing-address data/billing-information/carrier data/doctor/office-location data/patient
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 xfs-cis_diagrams/xfs-cis_p257.png
used by
element document
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 xfs-cis_diagrams/xfs-cis_p258.png
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p259.png
type cis:CaseID
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 xfs-cis_diagrams/xfs-cis_p260.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 25
pattern [ -~]*
annotation
documentation
Insurance Carrier's Case ID

element data/patient/date-of-birth
diagram xfs-cis_diagrams/xfs-cis_p261.png
type wcb:Date
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p262.png
type wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p263.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p264.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 15
pattern [ -~]*
annotation
documentation
Patient's Account No.

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p265.png
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p266.png
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 xfs-cis_diagrams/xfs-cis_p267.png
type wcb:WCBAuthorizationNumber
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 xfs-cis_diagrams/xfs-cis_p268.png
type restriction of wcb:TextUpperCase
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 xfs-cis_diagrams/xfs-cis_p269.png
type wcb:NYSLicenseNumber
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 xfs-cis_diagrams/xfs-cis_p270.png
type wcb:NPINumber
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 xfs-cis_diagrams/xfs-cis_p271.png
type extension of wcb:SSN
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 xfs-cis_diagrams/xfs-cis_p272.png
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p273.png
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 xfs-cis_diagrams/xfs-cis_p274.png
annotation
documentation
Referring Doctor's Name

element data/billing-information
diagram xfs-cis_diagrams/xfs-cis_p275.png
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p276.png
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p277.png
type restriction of xs:string
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 xfs-cis_diagrams/xfs-cis_p278.png
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p279.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 6
pattern [ -`{-~]*
annotation
documentation
ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p280.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 75
pattern [ -~]*
annotation
documentation
ICD9 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p281.png
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p282.png
type wcb:Date
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p283.png
type wcb:Date
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 xfs-cis_diagrams/xfs-cis_p284.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -~]*
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p285.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 5
pattern [ -`{-~]*
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p286.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p287.png
type restriction of wcb:TextUpperCase
facets
Kind Value Annotation
minLength 1
maxLength 3
pattern [ -`{-~]*
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p288.png
type restriction of xs:string
facets
Kind Value Annotation
minLength 1
pattern 1?2?3?4?
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p289.png
type restriction of wcb:Decimal
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 xfs-cis_diagrams/xfs-cis_p290.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 4
pattern [ -~]*
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p291.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 2
pattern [ -~]*
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p292.png
type restriction of wcb:Text
facets
Kind Value Annotation
minLength 1
maxLength 9
pattern [ -~]*
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p293.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p294.png
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 xfs-cis_diagrams/xfs-cis_p295.png
type wcb:Flag
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 xfs-cis_diagrams/xfs-cis_p296.png
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 xfs-cis_diagrams/xfs-cis_p297.png
used by
element submission
attributes
Name  Type  Use  Default  Fixed  Annotation
wcb:bp-document-id  derived by: wcb:Text  required