NAME
|
START |
END |
FIELD TYPE |
FIELD NAME |
DESCRIPTION |
VALUES |
Case Number |
1 |
9 |
$9 |
CASE-NUMBER |
Unique identifier for each
case assigned by the responsible District Office |
|
Case Type |
10 |
10 |
$1 |
CASE-TYPE |
Indicates the relationship
between this case and any other cases in the file. |
I = Independent M = Master S = Subsidiary D = Duplicate |
Case Pointer |
11 |
19 |
$9 |
CASE-PTR |
Uses the Case Type field to
map cases to the master case |
If Case
Type = M; Case Pointer = total number
of subsidiary cases associated with this master case. If Case
Type = S; Case pointer = Master Case Number |
Employee Name |
20 |
62 |
$43 |
EMP-NAME |
Employee’s $Claimant Name |
Last Name 20-39 First Name 40-49 Middle Name 50-59 Title 60-62 |
Priority Correspondence |
63 |
63 |
$1 |
PRTY-INQUIRY-TYPE |
Indicates type of priority
correspondence |
blank |
Sex |
64 |
64 |
$1 |
EMP-SEX |
Employee’s Gender |
M,F |
Social Security Number |
65 |
73 |
$9 |
EMP-SSN |
Employee’s SSN |
|
Date of Birth |
74 |
81 |
$8 |
EMP-DOB |
Employee’s Date of Birth |
YYYYMMDD |
Date of Death |
82 |
89 |
$8 |
EMP-DOD |
Employee’s Date of Death |
YYYYMMDD |
Address |
90 |
124 |
$35 |
ADDR |
Claimant’s Street Address |
|
City |
125 |
144 |
$20 |
CITY |
Claimant’s City Address |
|
State |
145 |
146 |
$2 |
STATE |
Claimant’s State |
|
Zip Code |
147 |
155 |
$9 |
ZIP |
Claimant’s Zip Code |
Zip Zip Reserve |
Telephone Number |
156 |
165 |
$10 |
TELENO |
Claimant’s Telephone Number |
Area Code Phone # |
Date of Injury |
166 |
173 |
$8 |
EMP-DOI |
Claimant’s Date of Injury |
YYYYMMDD |
Date Received |
174 |
181 |
$8 |
DATE-RECEIVED |
Date initial claim form was
received $date stamped |
YYYYMMDD |
Date Created |
182 |
189 |
$8 |
DATE-CASE-CREATED |
Date the case was created in
the District Office $case number assigned |
YYYYMMDD |
Case Review Date |
190 |
197 |
$8 |
DATE-REVIEWED |
Date that the case was most
recently reviewed |
YYYYMMDD |
Last Change Date |
198 |
205 |
$8 |
DATE-LAST-CHANGE |
Date the case status was
most recently changed |
YYYYMMDD |
Third Party Indicator |
206 |
206 |
$1 |
3RD -PARTY-IND |
Indicator of third party
status |
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 |
Third Party Date |
207 |
214 |
$8 |
3RD -PARTY-DATE |
Date the 3rd Party Indicator was Entered |
YYYYMMDD |
Date Closed |
215 |
222 |
$8 |
DATE CLOSED |
Date the case was closed |
YYYYMMDD |
Date Reopened |
223 |
230 |
$8 |
DATE-REOPEN |
Date the case was reopened |
YYYYMMDD |
Adjudication Status |
231 |
232 |
$2 |
ADJUD-STATUS |
Current Adjudication Status |
AC = Accepted as
compensable; COP only, medical benefits authorized AD = Accepted as
compensable; daily roll & medical benefits authorized AF = Death accepted as
compensable; dependent on periodic roll, no medical benefits AL = Accepted as compensable; leave elected medical
benefits authorized AM = Accepted as
compensable; only medical benefits authorized AO = Case previously
accepted; no benefits payable AP = Accepted as
compensable; periodic roll and medical benefits authorized AT = Accepted as
work-related; wage loss compensation denied, medical benefits authorized
DO = Denied; case on
appeal/reconsideration 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 D7 = Denied: case on appeals
remand D8 = Denied; case on hearing
remand D9 = Denied; case in
reconsideration SU = Suspended |
Adjudication Date |
233 |
240 |
$8 |
AJUD-DATE |
Date of most recent
adjudication |
YYYYMMDD |
Case Status |
241 |
242 |
$2 |
CURR-CASE-STATUS |
Current case pay status |
PI/PR = Case on Intermediate
Roll PV/PR = Periodic Roll; in
Vocational Rehab 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 RT = Case retired or
awaiting retirement |
Current Status |
243 |
250 |
$8 |
CURR-STATUS-DATE |
Current status date |
YYYYMMDD |
Previous Case Status |
251 |
252 |
$2 |
PREV-CASE-STATUS |
Previous case status |
See Case Status Values |
Previous Case Date |
253 |
260 |
$8 |
PREV-STATUS-DATE |
Date of previous status |
YYYYMMDD |
Current Case Location |
261 |
263 |
$3 |
CURR-CASE-LOCN |
Current location of case
file |
|
Current Case Location Date |
264 |
271 |
$8 |
CURR-CASE-LOCN-DATE |
Date of current case file
location |
YYYYMMDD |
Previous Case Location |
272 |
274 |
$3 |
PREV-CASE-LOCN |
Previous location of case
file |
|
Previous Location Date |
275 |
282 |
$8 |
PREV-CASE-LOCN-DATE |
Date file to previous
location |
YYYYMMDD |
Accepted Condition |
283 |
327 |
$45 |
REP-ACCPT-COND |
Accepted condition or
diagnosis |
Narrative or ICD-9, up to 6
times |
Accepted Condition Flag |
328 |
328 |
$1 |
REP-ACC-CONF-FLAG |
Indicates whether reported
diagnosis was accepted as compensable |
N = not accepted as
compensable Y = accepted as compensable |
Rehab Indicator |
329 |
329 |
$1 |
REHAB-IND |
Indicates vocational
rehabilitation status |
1 = Closed on referral 2 = Closed Rehabilitated 3 = Closed Rehabilitated,
New Employer 4 = Closed Rehabilitated,
Previously Reemployed 5 = Closed, not
rehabilitated, 6 = Closed with post
employment services 7 = Returned to work, nurse
intervention 8 = Returned to work,
without VR assistance A = Initial Interview held B = Nurse Intervention C = Returned to CE D = Plan Development E = Employed G = Placement Assisted
Reemployment I = Plan Approved L= Part time Light Duty M = Medical Rehabilitation N = Placement previous.
employer 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, assisted
reemployment W = Placement previous.
employer with other services. Y = Closed on referral Z = Post employment services |
Rehab Date |
330 |
337 |
$8 |
REHAB-DATE |
Date entered current
rehabilitation status |
YYYYMMDD |
COP Type |
338 |
338 |
$1 |
COP-TYPE |
Indicates whether claimant
used continuation of pay $COP benefits |
N = COP benefit not used Y = COP benefit used Blank |
Agency
Code |
339 |
344 |
$6 |
DEPT-AGENCY-CODE |
Employing agency Chargeback
code |
|
Injury Zip |
345 |
349 |
$5 |
INJ-ZIP |
Zip Code of location where
injury occurred |
|
Extent of Injury |
350 |
350 |
$1 |
EXTENT-OF-INJ |
Indicates seriousness of
injury |
1 = no time lost 2 = first aid 8 = inoculation X = non-fatal, lost time 0 = fatal |
Status of Injury |
351 |
351 |
$1 |
STATUS-OF-INJ |
Indicates fatal or not |
0 = non-fatal 1 = fatal |
Location of injury |
352 |
353 |
$2 |
ANAT-LOCN-CODE |
Indicates the anatomical
location of the injury/accepted condition |
C1 = Single Ear Internal C2 = Both Ears Internal C3 = Single Eye Internal C4 = Both Eyes Internal CB = Brain CC = Cranial Bones CD =Teeth CJ = Jaw Cl = Throat; Larynx CM = Mouth CN = Nose CR = Throat; Other CT = Tongue CZ = Not Otherwise
Classified H1 = Single Eye External H2 = Both Eyes External H3 = Single Ear External H4 = Both Ears External HC = Chin HF = Face HK = Neck/Throat HM = Mouth/Lips HN = Nose HS = Scalp BL = Lower Back BU = Upper Back B1 = Single Breast B2 = Both Breasts B3 = Single Testicle B4 = Both Testicles BA = Abdomen BC = Chest BP = Penis BS = Side BW = Waist BX = Undefined BZ = Not Otherwise
Classified R1 = Single Clavical Collar
Bone R2 = Both Clavicles Collar
Bones R3 = Single Scapula Shoulder
Blade R4 = Both Scapula Shoulder
Blades RB = Rib RS = Sternum Breast Bone RV = Vertebrae Spine; Disc RZ =Trunk, Bones
Unclassified VH = Heart V1 = Lung, Single V2 = Lung, Both V3 = Kidney, Single V4 = Kidney, Both VL = Liver VS = Stomach VI = Inguinal Hernia VV = Intestines VR = Reproductive Organs VZ = Trunk, Internal
Unclassified AB = Arm And Wrist AS = Arm Or Wrist EB = Both Elbows ES = Single Elbow F1 = Single First Finger F2 = Both First Fingers F3 = Single Second Finger F4 = Both Second Fingers F5 = Single Third Finger F6 = Both Third Fingers F7 = Single Fourth Finger F8 = Both Fourth Fingers MB = Both Hands MS = Single Hand SB = Both Shoulders SS = Single Shoulder TB = Both Thumbs TS = Single Thumb G1 = Single Great Toe G2 = Both Great Toes G3 = Single Other Toes G4 = Multiple Other Toes KB = Both Knees KS = Single Knee LB = Both
Legs/Hips/Ankles/Buttocks LS = Single Leg/Hip/Ankle/Buttock Pb = Both Feet PS = Single Foot 99 = Old Converted 00 = Mis-Coded 98 = Mis-Coded 98/All Other |
Nature of Injury |
354 |
355 |
$2 |
NATURE-CODE |
Nature of Injury Code |
C =
Cardiovascular/circulatory D = Non-traumatic R = Respiratory disease S = Skin disease or
condition T = Traumatic V = Virological, Infective |
Cause of Injury |
356 |
357 |
$2 |
CAUSE-CODE |
Indicates cause of injury Pre-OSHA coding system |
|
Forms Received |
358 |
359 |
$2 |
FORMS-RECVD |
Indicates the type of claim
form used at case create |
1 = CA-1 6 = CA-6 2 = CA-2 7 = CA-7 5 = CA-5 |
Responsible Examiner ID |
360 |
362 |
$2 |
RESP-EXMNR-ID |
Identifies the CE
responsible for the claim |
|
Comp Claim Ind. |
363 |
363 |
$1 |
CMP-CLM-IND |
Indicates whether a CA-7 is
on file |
7 = CA-7 form is on file |
Comp Claim Date |
364 |
371 |
$8 |
|
CA-7 claim date |
YYYYMMDD |
Pay Disposition |
372 |
372 |
$1 |
PAY-DISP |
Indicates whether agency has
reported to OWCP that pay has been terminated. |
N = pay not terminated Y = pay terminated |
Controversion Ind, |
373 |
373 |
$1 |
CNTRVTD-IND |
Indicates if claim was
controverted |
N = not controverted Y = controverted |
Wage Loss Date |
374 |
381 |
$8 |
WAGE-LOSS |
Indicates the date wage loss
began |
YYYYMMDD |
QCM Flag |
382 |
382 |
$1 |
QCM-FLAG |
Indicates if a QCM case. |
|
Recurrence Number |
383 |
384 |
$2 |
REOCURRENCE-NO |
Counter the increments 1
with each claim for recurrence |
Any integer from 1 - 99 |
RTW Code |
385 |
386 |
$2 |
RETURN-TO-WORK-CODE |
Indicates return to work
information |
blank = no RTW F4 = Full duty, 4 hr/day F6 = Full duty/ 6 hr/day FF = Full duty, full time FP = Full duty., part time L4 = Light duty, 4 hr/day L6 = Light duty, 6 hr/day LF = Light duty, full time,
w/out wage loss LP = Light duty, Part time L$ = Light duty, Full time,
wage loss NL = No lost tine PS = RTW, private sector XX = Final decision w/no RTW |
RTW date |
387 |
394 |
$8 |
RETURN-TO-WORK-DATE |
Date RTW code entered |
YYYYMMDD |
PRMS Flag |
395 |
395 |
$1 |
PRMS-FLAG |
Indicates if case is
included in Periodic Roll Management $PRM |
N Y BLANK |
Lost Time/No Lost Time OPN
Code |
396 |
396 |
$1 |
LT-NLT-OPN-CODE |
Lost Time/No Lost Time open
code |
1 -
reopened short form closure: medical bills exceed $1500 2 -
reopened short form closure: compensation claim received 3 -
reopened short form closure: case controverted 4 -
reopened short form closure: other reason 5 - no
lost time, no medical expense indicated in item 38 of ca-1 $generated at case
create 6 -
reopened no lost time, no medical expense: medical bills exceed $1500 7 -
reopened no lost time, no medical expense: compensation claim received 8 -
reopened no lost time, no medical expense: case controverted 9 -
reopened no lost time, no medical expense: other reason 0 -
reopened no lost time, no medical expense: "referred" cop/rtw case
with no rtw C -
reopened short form closure: "referred" cop/rtw case with no rtw |
Lost Time/No Lost Time OPN
Date |
397 |
404 |
$8 |
LT-NLT-OPN-DATE |
Date LT-NLT code entered |
YYYYMMDD |
Accession Number |
405 |
416 |
$12 |
ACCESSION-NO |
Indicates accession to
which case would be retired |
|
Fatal Indicator |
417 |
417 |
$1 |
FATAL-IND |
Indicates relationship
between claimant’s death and claimed injury |
For Death Cases only: 0 = Immediate Death with
Injury 1 = Not Related to Injury 2 = Relate to Injury |
Occupational Code |
418 |
422 |
$5 |
OCC-CODE |
Indicates claimants
occupation code at Date of Injury |
|
Type of Injury |
423 |
425 |
$3 |
TYPE-INJURY |
Indicates type of injury |
100 = Struck 110 = Struck by 111 - struck by falling
object 120 = Struck against 200 = Fall, Slip, Trip 210 = Fell, same level 220 = Fell, different level 230 = Slip, trip, 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 511 = Rubbed, abraded 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 |
426 |
429 |
$3 |
SOURCE-INJURY |
Indicates source of Injury;
OSHA |
|
Site of Injury |
430 |
438 |
$9 |
OSHA-SITE-CODE |
Indicates injury site; OSHA |
|
Date case was retired |
439 |
446 |
$8 |
CASE-RETIRE-DATE |
Date file was retired |
YYYYMMDD |
Assigned Number |
447 |
456 |
$10 |
CASE-RETIRE-NO |
FRC location number |
|
CA1 signature |
457 |
464 |
$8 |
CA1-2-SIG-DATE |
Date CA1 was signed |
YYYYMMDD |
Previous Adjudication Date |
465 |
472 |
$8 |
PREV-ADJUD-DATE |
Previous date file was
adjudicated |
YYYYMMDD |
Previous Adjudication Status |
473 |
474 |
$2 |
PREV-ADJUD-STATUS |
Previous Adjudication Status |
see Adjudication Status |
Current Adjudication |
475 |
477 |
$3 |
CURR-ADJ-RCE |
Responsible Examiner at the
time of initial adjudication |
|
Adjudication Status |
478 |
479 |
$2 |
ADJ-ST-POST-UD |
The status of adjudication
after case has been reopened |
see Adjudication Status |
Post Ud Adjud. Status |
480 |
487 |
$8 |
ADJ-DT-POST-UD |
The date of the first
adjudication after the case has been reopened |
YYYYMMDD |
Initial Adjudication Date |
488 |
495 |
$8 |
INIT-ADJUD-DATE |
Initial adjudication date |
YYYYMMDD |
Initial Adjudication Status |
496 |
497 |
$2 |
INIT-ADJUD-STATUS |
Status at initial
adjudication |
see Adjudication Status |
Initial Adjudicating ID |
498 |
500 |
$2 |
INIT-ADJUD-EXMNR-ID |
Examiner at initial
adjudication |
|
Service date |
501 |
508 |
$8 |
SVC-COMP-DATE |
The date employee entered
federal service |
YYYYMMDD |
Filler |
509 |
525 |
$17 |
|
|
Blank |
Adjud status number |
526 |
527 |
$2 |
ADJUD_STATUS_NUM |
|
01 = A0 02 = AC 03 = AD 04 = AL 05 = AM 06 = AP 07 = AF 08 = AT 09 = D0 10 = D1 11 = D2 12 = D3 13 = D4 14 = D5 16 = D7 17 = D8 18 = D9 20 =SU 99 =all other values |
Case Status Number |
528 |
529 |
$2 |
CASE_STATUS_NUM |
|
01 = UN 02 = UD 03 = MC 04 = DR 05 = PR 06 = PN 07 = PW 08 = PS 09 = DE 11 = OP 12 = CL 13 = C1 14 = C2 15 = C3 16 = C4 17 = C5 18 = RT 19 = XX 20 = ON 99 = all other values |
Case Location Number |
530 |
532 |
$3 |
CASE_LOCN_NUM |
|
001 = ADD 004 = DDD 005 = DDO 006 = DES 007 = FRC 008 = RDO 030 = XIN 032 = DCO 003 = location codes start
with C 002 = location codes start
with BP 007 = location codes start
with DM 008 = location codes start
with DP 009 = location codes starts
with FA 010 = location codes start
with FI 013 = location codes start
with IG 014 = location codes start
with IQ 015 = location codes start
with MR 016 = location codes start
with NA 017 = location codes start
with NB 018 = location codes start
with NP 020 = location codes start
with NS 021 = location codes start
with OL 022 = location codes start
with PY 025 = location codes start
with RH 026 = location codes start
with SO 027 = location codes start
with TA 028 = location codes start
with TC 029 = location codes start
with WP 031 = location codes start
with SN 023 = P48 to P57 999 = all other values |
District Office sequence
number |
533 |
534 |
$2 |
District Office sequence
number |
District Office number |
01 = 01 02 = 02 03 = 03 04 = 06 06 = 09 07 = 10 08 = 11 09 = 12 10 = 13 11 = 14 13 = 16 15 = 25 16 = 50 or 51 or 52 |
Central Delete Date |
535 |
542 |
$8 |
CENT_DELETE_DT |
|
00000000 |
District Office Alpha code |
543 |
543 |
$1 |
CENT-DIST-OWNERS |
|
A = 01 B = 02 C = 03 D = 06 F = 09 G = 10 H = 11 I = 12 J = 13 K = 14 M = 25 N = 50 or 51 or 52 P = 16 |
Filler |
543 |
549 |
$6 |
|
|
000000 |
Central Retire Date |
550 |
557 |
$8 |
CENT-RET-DATE |
|
00000000 |
Central Retire FRC Location |
558 |
560 |
$3 |
CENT-RET-FRC-LOCN |
|
000 |
Central FRC Box |
561 |
567 |
$7 |
CENT-FRC-BOX |
|
0000000 |
Central Error Date |
568 |
575 |
$8 |
CENT_ERROR_DATE |
|
00000000 |