CB AGENCY KEY

1

7

NUM/7

PREFIX

Department indicator and accounting code

ROLLUP CODE

8

11

NUM/4

AGENCY-ROLLUP-CODE

Chargeback agency rollup code

CASE NUMBER

12

20

NUM/9

CASE-NO

Unique numeric identifier for each case

RECORD TYPE

21

21

NUM/1

REC TYPE

Appropriate record type

1 – SUMMARY

2 – DETAIL

DISTRICT OFFICE

22

23

NUM/2

LAST-PYMT-DIST

Owning district office

LAST PAYMENT DATE

24

31

DATE/8

LAST-PYMT-DATE

Date of the latest transaction

YYYYMMDD

LAST SERVICE INDICATOR

32

32

CHAR/1

SRCE-CP-OR-BP

Latest transaction’s service type.

B - MEDICAL

C - COMPENSATION

X – CANCELLED CHECK (COMPENSATION)

LAST ROLL

33

33

CHAR/1

SRCE-CP-LAST-ROLL

Latest roll type for which the claimant was last paid

S - SUPPLEMENTAL

P – PERIODIC

D – DEATH

PAYMENT TYPE

34

34

CHAR/1

SRCE-PYMT-TYPE

Type of transaction for a case when it is a bill pay or compensation.  This is dependent upon the last service indicator

If Last Service Indicator is ‘B’, then payment type could be either:

B - NORMAL MEDICAL BILLS PAID BY        THE SYSTEM

C - CANCELLED CHECK

D - CASH DEPOSIT

M - MANUAL PAYMENT

If Last Service Indicator is ‘C’, then payment type could be either:

0 = ADJUSTMENT

1 = DISABILITY

2 = LEAVE BUY BACK

3 = WEC

4 = DIRECT PAYMENT

5 = INCARCERATED

6 = DEATH EXPENSES

7 = DEATH

8 = MANUAL PAYMENT

9 = SCHEDULED AWARD

A = DEATH LUMP SUM

B = CASH RECEIPT

C = FECS PAYMENTS ADJUSTMENT

SUMMARY RECORD

CASE NUMBER

35

43

NUM/9

CBSUM-CASE-PTR

Use the case type field to map the cases to the master case number. 

By default, if no master case number exists, then this section shall be blank.

If the case type is ‘S’ or ‘M’, then this section shall indicate the master case number.

CASE TYPE

44

44

CHAR/1

CASE-PTR-TYPE

Relationship between this case and any other cases in the file

I = INDEPENDENT

M = MASTER       

S = SUBSIDIARY

CLAIMANT NAME

45

87

CHAR/43

CLM-NAME

Claimant’s full name

LAST NAME   45 – 64

FIRST NAME  65 – 74

MIDDLE NAME 75 – 84

SOCIAL SECURITY

88

96

NUM/9

SSAN

Claimant’s social security number

GENDER

97

97

CHAR/1

SEX

Claimant’s gender

M – MALE

F – FEMALE

DATE OF BIRTH

98

105

DATE/8

DOB

Claimant’s date of birth

YYYYMMDD 

CLAIMANT’S ADDRESS

106

167

CHAR/50

CLM-ADDR

Claimant’s full address

CLM-ADDR-STREET  106 – 140

CLM-ADDR-CITY    141 – 160

CLM-ADDR-STATE   161 – 162

CLM-ADDR-ZIP     163 – 167

OCCUPATIONAL CODE

168

172

CHAR/5

OCC-CODE

Claimant’s job at the time of injury

AGENCY CODE

173

176

NUM/4

AGENCY-CODE

Employing agency code

BUILDING CODE

177

178

NUM/2

AGENCY-BLDG

Building location code

INTERNAL TO OWCP 

GEOGRAPHIC LOCATION

179

187

CHAR/9

GEO-LOC

Geographic location where the injury or death took place

DATE OF INJURY

188

195

DATE/8

DOI

Employee’s date of injury

YYYYMMDD 

DATE OF DEATH

196

203

DATE/8

DOD

Employee’s date of death

YYYYMMDD 

INJURY OF ZIP

204

208

NUM/5

INJ-ZIP

Zip code where the injury took place

EXTENT OF INJURY

209

209

CHAR/1

EXTENT-INJ

Seriousness of the injury

1 = NO TIME LOST

2 = FIRST AID      

8 = INOCULATION

X = NON-FATAL, LOST TIME

0 = FATAL

STATUS OF  INJURY

210

210

NUM/1

STATUS-INJ

Status of injury

0 = NON-FATAL

1 = FATAL

FATAL INDICATOR

211

211

NUM/1

FATAL-IND

Relationship between the employee’s death and the claimed injury

BLANK = NO DEATH

0 = DEATH NOT WORK RELATED

1 = DEATH RELATED TO WORK

2 = DEATH RELATED TO WORK, INITIALLY NOT SEVERE

ANATOMICAL LOCATION

212

213

CHAR/2

ANAT-LOC

Anatomical location of the injury

NATURE OF INJURY

214

215

CHAR/2

NATURE

Nature of injury

CAUSE OF  INJURY

216

217

NUM/2

CAUSE

Cause of injury

PREVIOUS OWNERS

218

224

NUM/7

CURR-PREV-OWNERS

NO LONGER USED

BLANK

DATE RECEIVED

225

232

DATE/8

DATE-REC

Date the initial claim form was received (date stamped)

YYYYMMDD 

FORMS RECEIVED

233

234

NUM/2

FORMS-RECVD

Type of claim form used at the time the case was created

1 = CA-1

2 = CA-2         

5 = CA-5

DATE CASE CREATED

235

242

DATE/8

DATE-CASE-CREATED

Date the case was created in the district office

YYYYMMDD 

ADJUDICATED STATUS

243

244

CHAR/2

ADJUD-STATUS

Case’s current adjudication status code

00 = NO STATUS

A0 = ACCEPTED - NO BENEFITS PAYABLE

AC = ACCEPTED AS COMPENSABLE - COP ONLY, MED BENEFITS AUTHORIZED

AD = ACCEPTED AS COMPENSABLE - DAILY ROLL & MED BENEFITS AUTHORIZED

AF = ACCEPTED AS COMPENSABLE – FATAL, DEPENDENT ON PERIODIC ROLL, NO MED BENEFITS

AL = ACCEPTED AS COMPENSABLE - LEAVE ELECTED MED BENEFITS AUTHORIZED   

AM = ACCEPTED AS COMPENSABLE - MED BENEFITS ONLY AUTHORIZED

AP = ACCEPTED AS COMPENSABLE - PERIODIC ROLL AND MED. BENEFITS AUTHORIZED

AR = ADMINISTRATIVE REVIEW

AT = ACCEPTED AS WORK-RELATED - WAGE LOSS COMP DENIED, MED BENEFITS AUTHORIZED

DO = DENIED; CASE ON APPEAL/RECON

D1 = DENIED;  UNTIMELY

D2 = DENIED; NOT CIVIL SERVICE EMPLOYEE

D3 = DENIED; NO FACT OF INJURY

D4 = DENIED: NOT IN PERFORMANCE OF DUTY

D5 = DENIED; NO CASUAL RELATIONSHIP

D6 = DENIED; BURDEN OF PROOF (NO LONGER USED)

D7 = DENIED: CASE ON APPEALS REMAND

D8 = DENIED; CASE ON HEARING REMAND

D9 = DENIED; CASE IN RECONSIDERATION

SU = SUSPENDED

UD = LEGACY CASES ONLY

UN = UNADJUDICATED

ADJUDICATED STATUS DATE

245

252

DATE/8

ADJUD-STATUS-DATE

Date of the most recent adjudication status.

YYYYMMDD 

CURRENT CASE STATUS

253

254

ALPHNUM/2

CURR-CASE-STATUS

Current case pay status

AR = ADMINISTRAVE REVIEWED

C1= CLOSED, NO TIME LOST

C2 = CLOSED, LEAVE ELECTED

C3 = CLOSED, BENEFITS DENIED

C4 = CLOSED, COP COVERED ALL TIME LOST

C5 = CLOSED, OTHER - ALL BENEFITS PAID

CL = CLOSED, ADMINISTRATIVE

DE = DEATH ROLL

DR = DAILY ROLL

MC = MEDICAL PAYMENTS ONLY

N  = PERIODIC ROLL W NO RE-EMPLOYMENT POTENTIAL (NO LONGER USED)

ON = OVERPAYMENT, NOT IN RECEIPT OF COMP

OP =  OVERPAYMENT, CASE ON COMP ROLL

PI = CASE ON INTERMEDIATE ROLL (USE PR)  (NO LONGER USED)

PN = PERIODIC ROLL, NO WAGE EARNING CAPACITY

PR = PERIODIC ROLL

PS = SCHEDULE AWARD

PW = PERIODIC ROLL, LWEC IN PLACE

PV = PERIODIC ROLL; IN VOC REHAB (USE PR) (NO LONGER USED)

RH = NO LONGER USED

RO = REOPEN (LEGACY DATA)

RT = CASE RETIRED OR AWAITING RETIREMENT

UD = CLAIM UNDER DEVELOPMENT

UN = CLAIM UNREVIEWED, PRIMARY

XX = DESTROYED

CURRENT CASE DATE

255

262

DATE/8

CURR-STATUS-DATE

Case’s current pay status date

YYYYMMDD

EARLY REFERENCE

263

264

CHAR/2

EARLY-REF

 NO LONGER USED

BLANK

CMF CODE

265

265

CHAR/1

CMF-CODE

 NO LONGER USED

BLANK

REP. ACCEPTANCE CONDITION

266

300

CHAR/35

REP-ACCPT-COND

 NO LONGER USED

BLANK

SOURCE OF  INJURY

 301

304

NUM/4

SOURCE-INJURY

OSHA injury site

CA1 SIGNATURE DATE

305

312

DATE/8

CA1-2-SIG-DATE

Date the submitted claim (CA1, CA2, or CA5) was signed

YYYYMMDD

ACCEPTED CONDITION FLAG

313

313

CHAR/1

REP-ACCPT-COND-FLAG

Whether the reported diagnosis was accepted as compensable

N = NOT ACCEPTED AS COMPENSABLE

Y = ACCEPTED AS COMPENSABLE

THIRD PARTY INDICATOR

314

314

CHAR/1

3RD-PARTY-IND

Latest third party insurance, if present

0 = NO 3RD PARTY INSURANCE

1 = NOT REFERRED TO SOL

2 = REFERRED TO SOL

4 = CLOSED; MINOR, NOT ECONOMICAL TO PURSUE

5 = CLOSED; OTHER

6 = SETTLED; NO REFUND DUE

7 = SETTLED; REFUND NOT RECEIVED

8 = SETTLED; REFUND RECEIVED, NO CREDIT DUE

9 = SETTLED; REFUND RECEIVED, CREDIT DUE AGAINST FUTURE COMPENSATION

REHABILITATION INDICATOR

315

315

CHAR/1

REHAB-IND

Case’s vocational rehabilitation status

1 = CLOSED ON REFERRAL

2 = CLOSED REHABILITATED

3 = CLOSED REHABILITATED, NEW EMPLOYER

4 = CLOSED REHABILITATED, PREV. REEMP

5 = CLOSED, NOT REHABILITATED,

6 = CLOSED WITH POST EMPLOYMENT SERVICES

7 = RETURNED TO WORK, NURSE INTERVENTION

8 = RETURNED TO WORK, W/OUT VR ASSISTANCE

9 = COP CLOSURE

A = INITIAL INTERVIEW HELD

B = NURSE INTERVENTION

C = RETURNED TO CE

D = PLAN DEVELOPMENT

E = EXTENSION

F = WORKING PART TIME OR TEMPORARY

G = PLACEMENT ASST. REEMPLOYMENT

H = EMPLOYED BY NURSE

I = PLAN APPROVED

K = NOT RTW, NI, WORK LIMITS ON FILE

L = LIGHT DUTY
M = MEDICAL REHABILITATION

N = PLACEMENT PREV. EMPLOYER

O = NO RTW, NI, RETURNED TO CE

P = PLACEMENT, NEW EMPLOYER

Q = SCREENED

R = REFERRED TO RS(DEFAULT ADD STATUS)

S = SELF-EMPLOYED

T = TRAINING

U = CLOSED BY NURSE, NOT RTW

V = EMPLOYED, ASST. REEMPLOYMENT

W = PLACEMENT PREV. EMPLOYER W/OTHER SERV.

X = SERVICES INTERRUPTED

Y = NURSE INTERRUPT

Z = POST EMPLOYMENT SERVICES

REHABILITATION DATE

316

323

DATE/8

REHAB-DATE

Case’s current vocational rehabilitation status date

YYYYMMDD

PAY DISPOSITION

324

324

CHAR/1

PYMT-DISP

Whether the agency has reported to OWCP that pay has been terminated

N = PAY NOT TERMINATED     

Y = PAY TERMINATED 

CONTINUATION OF PAY 

325

325

CHAR/1

COP-TYPE

Whether the claimant used COP benefits

N = COP BENEFIT NOT USED

Y = COP BENEFIT USED

CONTROVERSION IND,

326

326

CHAR/1

CNTRVTD-IND

If the claim was controverted

N = NOT CONTROVERTED

Y = CONTROVERTED

COMP CLAIM IND.

327

327

CHAR/1

CMP-CLM-IND

Whether a CA-7 is on file

Y = CA-7 FORM IS ON FILE

N = CA-7 FORM IS NOT ON FILE

COMP CLAIM DATE

328

335

DATE/8

CMP-CLM-DATE

Latest date when the compensation claim was received 

YYYYMMDD

ACTIVITY CODE

336

337

NUM/2

ACTIVITY-CODE

Whether coverage was by FECA or the FRINGE ACTS

01 = FEDERAL CIVILIAN

02 = RESERVISTS(NO MINS, NO CPI’S)

03 = CIVIL AIR PATROL

04 = RESERVE OFFICER TRAINING 

05 = MARITIME WAR RISK  

06 = EMERGENCY RELIEF WORKERS – FIRE HAZZARD

07 = WAR – CONNECTED

08 = CIVILIAN WAR BENEFITS

09 = TOTAL BENEFITS, WAR CLAIMS

10 = POVERTY PROGRAMS

11 = LAW ENFORCEMENT OFFICERS

12 = COAST GUARD AUX

13 = JOB CORPS

14 = NEIGHBORHOOD YOUTH ENROLLEES

15 = MILITARY RESERVISTS SURVIVORS

16 = MEMBERS OF THE WOMAN’S ARMY AUXILIARY CORPS

17 = PEACE CORP VOLUNTEERS LEADERS

99 = OTHER

RESPONSIBLE EXAMINER

338

340

CHAR/3

RESP-EXAM

Claims Examiner responsible for the claim

PRMS INDICATOR

341

341

CHAR/1

PRMS-IND

If a case is part of the Periodic Roll Management System (PRMS)

N = DEFAULT VALUE AT CASE CREATE, NOT PART OF  PRMS

Y = PART OF  THE PRMS UNIVERSE

TYPE INJURY

342

344

NUM/3

TYPE-INJURY

The type of OSHA injury

100 = STRUCK

110 = STRUCK BY

111 = STRUCK BY FALLING OBJECT

120 = STRUCK AGAINST

200 = FELL, SLIPPED, TRIPPED

210 = FELL, SAME LEVEL

220 = FELL, DIFFERENT LEVEL

230 = SLIPPED, TRIPPED, NO FALL

300 = CAUGHT

310 = CAUGHT ON

320 = CAUGHT IN

330 = CAUGHT BETWEEN

400 = PUNCTURED, LACERATED

410 = PUNCTURED BY

420 = CUT BY

430 = STUNG BY

440 = BITTEN BY

500 = CONTACT

510 = CONTACT WITH

520 = CONTACT BY

600 = EXERTION

610 = LIFTED, STRAINED BY

620 = STRESSED BY

700 = EXPOSURE

710 = INHALATION

720 = INGESTION

730 = ABSORPTION

800 = TRAVELING IN

999 = UNCLASSIFIED

BILLABLE FLAG

345

345

CHAR/1

BILLABLE-FLAG

INTERNAL USE ONLY

ERROR CODE COUNTER

346

347

NUM/2

ERROR-CODE-CNTR

INTERNAL USE ONLY

ERROR CODES

348

373

CHAR/26

ERRORS-CODES

INTERNAL USE ONLY

HBI OLI FLAG

374

374

CHAR/1

HBI-OLI-FLAG

INTERNAL USE ONLY

CANCELLED CHECK FLAG

375

375

CHAR/1

CANCEL-CK-FLAG

Whether the compensation check has or will be cancelled

Y = CANCELLATION ENTRY(LATER CHECK DATE)

DUPLICATE FLAG

376

376

CHAR/1

DUP-FLAG

INTERNAL USE ONLY

HBI/OLI ADJUSTMENTS

377

378

NUM/2

HBI-OLI-ADJ-CNT

INDICATES NUMBER OF HBI/OLI ADJUSTMENTS

No longer valid

CANCELLED CHECKS  ADJUSTMENTS

379

380

NUM/2

CANCEL-CK-ADJ-CNT

Number of compensation cancelled check adjustments

DUPLICATE ADJUSTMENTS

381

382

NUM/2

DUP-ADJ-CNT

INDICATES NUMBER OF DUPLICATE ADJUSTMENTS

No longer valid 

HBI/OLI  ADJUSTMENTS

383

392

NUM/10

HBI-OLI-ADJ-AMT

INDICATES AMOUNT OF HBI/OLI  ADJUSTMENTS

No longer valid 

CANCELLED CHECKS

393

402

NUM/10

CANCEL-CK-ADJ-AMT

This section shall indicate the amount of cancelled checks (Compensation only)

DUPLICATE ADJUSTMENTS

403

412

NUM/10

DUP-ADJ-AMT

INDICATES AMOUNT OF DUPLICATE ADJUSTMENTS

No longer valid

TOTAL AMOUNT PAID

413

421

NUM/9

TOTAL-AMT

Total Chargeback amount paid for bill pay and compensation payments

MEDICAL BILLS

422

426

NUM/5

BPS-NO

Total number of medical bills paid

MEDICAL BILLS PAID

427

435

NUM/9

BPS-AMT

Total amount of medical bills paid

COMPENSATION PAYMENTS

436

440

NUM/5

CP-NO

Total amount of compensation payments, fatal and non-fatal

COMPENSATION PAYMENTS PAID

441

449

NUM/9

CP-AMT

Total amount of compensation paid, fatal and non-fatal

COMPENSATION FLAG

450

450

CHAR/1

CP-FLAG

Whether the compensation payment was issued for a case

Y = Compensation Payment Was Issued

DETAIL RECORD

PAYING DISTRICT

35

36

NUM/2

PAYING-DIST

District office that made the payment

PAYMENT DATE

37

44

DATE/8

PYMT-DATE

Payment date

YYYYMMDD 

PAYMENT AMOUNT

45

52

NUM/8

PYMT-AMT

Chargeback amount paid

PAYMENT FROM DATE

53

60

DATE/8

PYMT-FROM-DATE

Starting date of the payment

YYYYMMDD 

PAYMENT TO DATE

61

68

DATE/8

PYMT-TO-DATE

Ending date of the payment

YYYYMMDD 

SSN

69

77

NUM/9

PAYEE-SSN-EIN

Payee’s social security number or EIN number

PAYEE NAME

78

112

CHAR/35

PAYEE-NAME

Payee’s name

PAYEE ADDRESS

113

245

CHAR/133

PAYEE-ADDR

Payee’s address or the EFT/account routing number

PAYEE ADDRESS LINE 1,2,3 = 113-218

PAYEE CITY = 219-238

PAYEE STATE = 239-240

PAYEE ZIP = 241-245 

PAYMENT TYPE

246

246

CHAR/1

CB-PAY-TYPE

Type of transaction for a case when it is a bill pay or compensation

If Service Indicator is ‘B’, then payment type could be either:

B - NORMAL MEDICAL BILLS PAID BY        THE SYSTEM

C - CANCELLED CHECK

D - CASH DEPOSIT

M - MANUAL PAYMENT

If Service Indicator is ‘C’, then payment type could be either:

0 = ADJUSTMENT

1 = DISABILITY

2 = LEAVE BUY BACK

3 = WEC

4 = DIRECT PAYMENT

5 = INCARCERATED

6 = BURIAL, TRANSPORTATION

7 = DEATH

8 = MANUAL PAYMENT

9 = SCHEDULED AWARD

A = DEATH LUMP SUM

B = CASH RECEIPT

C = FECS PAYMENTS ADJUSTMENT

BILL PAY REIMBURSEMENT CODE

247

247

CHAR/1

BP-REIMB-CODE

If payment has been made to the provider or claimant (Medical payments only)

P = PROVIDER     

C = CLAIMANT                  

ADJUSTMENT INDICATOR

248

248

CHAR/1

ADJ-IND

Whether the record is an adjustment record

N = NO

Y = YES 

TYPE INJURY

249

251

NUM/3

TYPE-INJURY

Type of injury

100 = STRUCK

110 = STRUCK BY

111 = STRUCK BY FALLING OBJECT

120 = STRUCK AGAINST

200 = FELL, SLIPPED, TRIPPED

210 = FELL, SAME LEVEL

220 = FELL, DIFFERENT LEVEL

230 = SLIPPED, TRIPPED, NO FALL

300 = CAUGHT

310 = CAUGHT ON

320 = CAUGHT IN

330 = CAUGHT BETWEEN

400 = PUNCTURED, LACERATED

410 = PUNCTURED BY

420 = CUT BY

430 = STUNG BY

440 = BITTEN BY

500 = CONTACT

510 = CONTACT WITH

520 = CONTACT BY

600 = EXERTION

610 = LIFTED, STRAINED BY

620 = STRESSED BY

700 = EXPOSURE

710 = INHALATION

720 = INGESTION

730 = ABSORPTION

800 = TRAVELING IN

999 = UNCLASSIFIED

SOURCE OF INJURY

252

255

NUM/3

SOURCE-INJURY

OSHA source of the injury

OSHA SITE CODE

256

264

CHAR/9

OSHA-SITE-CODE

OSHA injury site

PROCEDURE CODE

265

272

CHAR/8

PROC-CODE

Billed procedure code

BILL NUMBER

273

275

NUM/3

BILL-ID-NO

Sequential number of the medical bill.

BILL ITEM NUMBER

276

279

NUM/4

BILL-LINE-ITEM-NO

Sequential number of medical bill line item

AGENCY CODE

280

285

NUM/6

AGENCY-CODE

Agency code 

FILLER

286

451

CHAR/137

UNUSED-DATA-AREA