DWC-21 REEMPLOYMENT SERVICES CLAIM FORM FILE LAYOUT FOR ELECTR

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					                              DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                           FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E
                                         RECORD LENGTH: 1215
                                        HEADER RECORD LAYOUT
FIELD   FORM    FORM FIELD   LOCATION   LENGTH DESCRIPTION                          EDITS
NO.     FIELD   NAME                    / TYPE
        ID
1A                           1-15       15 Num   CLAIM CONTROL NUMBER               REQUIRED
                                                 FORMAT: SSSSSYYJJJNNNNN            Must be numeric
                                                 SSSSS=Submitter No.                No duplicate claim control numbers
                                                 YY= Year submitted                 NNNNN Valid Values = 00001-99999
                                                 JJJ=Julian date of day submitted
                                                 NNNNN = Sequence number
2A                           16         1 Num    RECORD FLAG                        REQUIRED
                                                 FORMAT: N                          Must be numeric
                                                                                    Valid Value = 1 (indicating header record)
3A                           17         1 A/N    FORM REVISION INDICATOR            REQUIRED
                                                 FORMAT: (1 Letter, uppercase)      Must be “E”
4A                           18-19      2 Num    FORM ID                            REQUIRED
                                                 FORMAT: NN                         Must be numeric
                                                                                    Valid Value = 21
5A              INTERNAL     20-25      6 Num
                USE ONLY
6A      1       NAME         26-40      15 A/N   INJURED EMPLOYEE’S FIRST           REQUIRED
                                                 NAME                               Must be uppercase A-Z or a period, hyphen,
                                                                                       comma, apostrophe or space.
                                                                                    Left justify, pad with spaces.
7A      1       NAME         41         1 A/N    INJURED EMPLOYEE’S                 OPTIONAL
                                                 MIDDLE INITIAL                     Left Justify, space fill
                                                                                    Must be upper case A-Z.
8A      1       NAME         42-61      20 A/N   INJURED EMPLOYEE’S LAST            REQUIRED
                                                 NAME                               Must be uppercase A-Z or a period, hyphen, comma,
                                                                                    apostrophe or space.
                                                                                    Left justify, pad with spaces.


                                          DWC-21 FILE LAYOUT – PAGE 1 OF 13
                                             REVISION DATE: 09/01/2010
                               DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                            FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E

        FORM    FORM FIELD    LOCATION   LENGTH DESCRIPTION                    EDITS
FIELD   FIELD   NAME                     / TYPE
NO.     ID
9A      2       SOCIAL        62-70      9 A/N    CLAIMANT’S SOCIAL            REQUIRED
                SECURITY                          SECURITY NUMBER              The first character must be uppercase A-Z, 2nd and 3rd
                NUMBER                            FORMAT: NNNNNNNNN            characters must be spaces, last 6 characters must be
                                                  Or, If Alien Number –        numeric, OR
                                                  FORMAT: A NNNNNN             Must be all numeric
                                                                               1ST POSITION CANNOT BE > 8
10A     3       DATE OF       71-78      8 Date   DATE OF ACCIDENT             REQUIRED
                ACCIDENT                          FORMAT: CCYYMMDD             Must be a valid date in the correct format
                                                  CC = Century                 Must be less than or equal to the Carrier’s Date Stamp
                                                  YY = Year                    Must be less than or equal to current date
                                                  MM = Month                   Must be less than or equal to the Date of Referral
                                                  DD = Day
11A     4       DATE OF       79-86      8 Date   DATE OF REFERRAL             OPTIONAL
                REFERRAL                          FORMAT: CCYYMMDD             If present, must be a valid date in the correct format
                                                  CC = Century                 If present, must t be less than or equal to current date
                                                  YY = Year                    If present, must be greater than or equal to the Date of
                                                  MM = Month                      Accident
                                                  DD = Day                     If present, must be less than or equal to Date of
                                                                                  Service
                                                                               If present, must be less than or equal to the Carrier’s
                                                                                  Date Stamp
12A     5       TELEPHONE     87-89      3 Num    INJURED EMPLOYEE’S AREA      OPTIONAL
                NUMBER                            CODE                         Must be numeric
                                                                               May not begin with 0
13A     5       TELEPHONE     90-96      7 Num    INJURED EMPLOYEE’S           OPTIONAL
                NUMBER                            TELEPHONE NUMBER             Must be numeric
                                                                               May not begin with 0
14A     6A      CARRIER/TPA   97-156     60 A/N   CLAIM HANDLER (PAYER)        REQUIRED
                NAME                              COMPANY NAME                 Must be uppercase A-Z or a period, hyphen, comma,
                                                                               apostrophe, ampersand or space.
                                                                               Left justify, pad with spaces.

                                           DWC-21 FILE LAYOUT – PAGE 2 OF 13
                                              REVISION DATE: 09/01/2010
                               DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                            FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E

        FORM    FORM FIELD    LOCATION    LENGTH DESCRIPTION                    EDITS
FIELD   FIELD   NAME                      / TYPE
NO.     ID
15A     6E      CLAIM         157-171     15 A/N   CLAIM HANDLER (PAYER)        REQUIRED
                HANDLER’S                          CONTACT’S FIRST NAME         Must be uppercase A-Z or a period, hyphen, comma,
                CONTACT                                                         apostrophe or space.
                NAME                                                            Left justify, pad with spaces.
16A     6E      CLAIM         172-191     20 A/N   CLAIM HANDLER (PAYER)        REQUIRED
                HANDLER’S                          CONTACT’S LAST NAME          Must be uppercase A-Z or a period, hyphen, comma,
                CONTACT                                                         apostrophe or space.
                NAME                                                            Left justify, pad with spaces.
17A     6F      CLAIM         192-194     3 Num    CLAIM HANDLER (PAYER)        REQUIRED
                HANDLER’S                          CONTACT’S AREA CODE          Must be numeric
                CONTACT                                                         May not begin with 0
                TELEPHONE
                NUMBER
18A     6F      CLAIM         195-201     7 Num    CLAIM HANDLER (PAYER)        REQUIRED
                HANDLER’S                          CONTACT’S TELEPONE           Must be numeric
                CONTACT                            NUMBER                       May not begin with 0
                TELEPONE
                NUMBER
19A     6F      CLAIM         202-207     6 Num    CLAIM HANDLER (PAYER)        OPTIONAL
                HANDLER’S                          CONTACT’S TELEPONE           Must be numeric
                CONTACT                            NUMBER EXTENSION
                TELEPONE
                NUMBER
20A     6G      CLAIM         208-257     50 A/N   CLAIM HANDLER (PAYER)        OPTIONAL
                HANDLER’S                          CONTACT’S EMAIL ADDRESS      Left justify, pad with spaces
                CONTACT’S
                EMAIL
21A     6A      CLAIM         258 – 302   45 A/N   CLAIM HANDLER (PAYER)        REQUIRED
                HANDLER’S                          STREET ADDRESS 1             Must be uppercase A-Z or a number, period, hyphen,
                ADDRESS                                                         comma, apostrophe or space.
                                                                                Left justify, pad with spaces.

                                            DWC-21 FILE LAYOUT – PAGE 3 OF 13
                                               REVISION DATE: 09/01/2010
                               DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                            FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E


        FORM    FORM FIELD     LOCATION    LENGTH DESCRIPTION                        EDITS
FIELD   FIELD   NAME                       / TYPE
NO.     ID
22A     6A      CLAIM          303 – 347   45 A/N   CLAIM HANDLER (PAYER)            OPTIONAL
                HANDLER’S                           STREET ADDRESS 2                 Must be uppercase A-Z or a number, period, hyphen,
                ADDRESS                                                                comma, apostrophe or space.
                                                                                     Left justify, pad with spaces.
23A     6A      CLAIM          348 – 377   30 A/N   CLAIM HANDLER (PAYER)            REQUIRED
                HANDLER’S                           CITY                             Must be uppercase A-Z or a period, hyphen, comma,
                ADDRESS                                                              apostrophe or space.
                                                                                     Left justify, pad with spaces.
24A     6A      CLAIM          378 – 379   2 A/N    CLAIM HANDLER (PAYER)            REQUIRED
                HANDLER’S                           STATE ABBREVIATION               Must be uppercase A-Z
                ADDRESS
25A     6B      ZIP CODE       380 388     9 Num    CLAIM HANDLER (PAYER) ZIP        REQUIRED
                                                    CODE                             Must be numeric and 1:4 NOT = ZERO
                                                    FORMAT: NNNNN
26A     6C      SC/TPA CODE    389 – 392   4 Num    CLAIM HANDLER (PAYER)            REQUIRED
                                                    INTERNAL AUDIT NUMBER            If present, must be numeric
                                                    FORMAT: NNNN                     For DOE Sponsored Services, use 9999

27A     6C      SC/TPA FEIN#   393 – 401   9 Num    CLAIM HANDLER (PAYER)            REQUIRED
                                                    FEDERAL EMPLOYER                 Must be numeric
                                                    IDENTIFICATION NUMBER
                                                    FORMAT: NNNNNNNNN
28A             SPACE FILLER   402-461     60 A/N   SPACE FILLER                     N/A
                                                    (formerly Carrier Information)


29A             SPACE FILLER   462-476     15 A/N   SPACE FILLER                     N/A
                                                    (formerly Carrier Information)



                                             DWC-21 FILE LAYOUT – PAGE 4 OF 13
                                                REVISION DATE: 09/01/2010
                             DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                          FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E


        FORM    FORM FIELD     LOCATION   LENGTH DESCRIPTION                        EDITS
FIELD   FIELD   NAME                      / TYPE
NO.     ID
30A             SPACE FILLER   477-496    20 A/N   SPACE FILLER                     N/A
                                                   (formerly Carrier Information)


31A             SPACE FILLER   497-499    3 A/N    SPACE FILLER                     N/A
                                                   (formerly Carrier Information)


32A             SPACE FILLER   500-506    7 A/N    SPACE FILLER                     N/A
                                                   (formerly Carrier Information)


33A             SPACE FILLER   507-512    6 A/N    SPACE FILLER                     N/A
                                                   (formerly Carrier Information)


34A             SPACE FILLER   513-562    50 A/N   SPACE FILLER                     N/A
                                                   (formerly Carrier Information)


35A             SPACE FILLER   563-607    45 A/N   SPACE FILLER                     N/A
                                                   (formerly Carrier Information)


36A             SPACE FILLER   608-652    45 A/N   SPACE FILLER                     N/A
                                                   (formerly Carrier Information)




                                            DWC-21 FILE LAYOUT – PAGE 5 OF 13
                                               REVISION DATE: 09/01/2010
                               DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                            FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E

        FORM    FORM FIELD     LOCATION   LENGTH DESCRIPTION                        EDITS
FIELD   FIELD   NAME                      / TYPE
NO.     ID
37A             SPACE FILLER   653-682    30 A/N   SPACE FILLER                     N/A
                                                   (formerly Carrier Information)

38A             SPACE FILLER   683-684    2 A/N    SPACE FILLER                     N/A
                                                   (formerly Carrier Information)

39A             SPACE FILLER   685-693    9 A/N    SPACE FILLER                     N/A
                                                   (formerly Carrier Information)

40A     6D      SPACE FILLER   694-697    4 A/N    SPACE FILLER                     N/A
                                                   (formerly Carrier Information)

41A     6D      SPACE FILLER   698-706    9 A/N    SPACE FILLER                     N/A
                                                   (formerly Carrier Information)

42A     7A      REMIT TO       707-766    60 A/N   REMIT TO PARTY COMPANY           REQUIRED
                                                   NAME OR FIRST NAME +             Left justify, pad with spaces.
                                                   LAST NAME
43A             REMIT TO       767-781    15 A/N   REMIT TO PARTY                   REQUIRED
                CONTACT                            CONTACT’S FIRST NAME             Must be uppercase A-Z or a period, hyphen, comma,
                NAME                                                                apostrophe or space.
                                                                                    Left justify, pad with spaces.
44A             REMIT TO       782-796    15 A/N   REMIT TO PARTY                   REQUIRED
                CONTACT                            CONTACT’S LAST NAME              Must be uppercase A-Z or a period, hyphen, comma,
                NAME                                                                apostrophe or space.
                                                                                    Left justify, pad with spaces.
45A     7F      REMIT TO       797-799    3 Num    REMIT TO PARTY                   REQUIRED
                PARTY’S                            CONTACT’S AREA CODE              Must be numeric
                CONTACT
                TELEPHONE
                NUMBER
                                            DWC-21 FILE LAYOUT – PAGE 6 OF 13
                                               REVISION DATE: 09/01/2010
                               DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                            FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E

        FORM    FORM FIELD    LOCATION   LENGTH DESCRIPTION                    EDITS
FIELD   FIELD   NAME                     / TYPE
NO.     ID
46A     7F      REMIT TO      800-806    7 Num    REMIT TO PARTY               REQUIRED
                PARTY’S                           CONTACT’S TELEPONE           Must be numeric
                CONTACT                           NUMBER
                TELEPONE
                NUMBER
47A     7F      REMIT TO      807-812    6 Num    REMIT TO PARTY               OPTIONAL
                PARTY’S                           CONTACT’S TELEPONE           Left justify, pad with spaces
                CONTACT                           NUMBER EXTENSION
                TELEPONE
                NUMBER
48A     7G      REMIT TO      813-821    9 Num    REMIT TO PROVIDER FEIN       REQUIRED
                PROVIDER                          FORMAT: NNNNNNNNN            Must be numeric
                FEIN
49A             REMIT TO      822-871    50 A/N   REMIT TO PARTY               OPTIONAL
                PARTY’S                           CONTACT’S EMAIL ADDRESS      Left justify, pad with spaces
                CONTACT’S
                EMAIL
50A     7B      REMIT TO      872-916    45 A/N   REMIT TO PARTY’S STREET      REQUIRED
                PARTY’S                           ADDRESS 1                    Must be uppercase A-Z or a number, period, hyphen,
                ADDRESS                                                        comma, apostrophe or space.
                                                                               Left justify, pad with spaces.
51A     7B      REMIT TO      917-961    45 A/N   REMIT TO PARTY’S STREET      OPTIONAL
                PARTY’S                           ADDRESS 2                    Must be uppercase A-Z or a number, period, hyphen,
                ADDRESS                                                        comma, apostrophe or space.
                                                                               Left justify, pad with spaces.
52A     7C      REMIT TO      962-991    30 A/N   REMIT TO PARTY’S CITY        REQUIRED
                PARTY’S                                                        Must be uppercase A-Z or a number, period, hyphen,
                ADDRESS                                                        comma, apostrophe or space.
                                                                               Left justify, pad with spaces.
53A     7D      REMIT TO      992-993    2 A/N    REMIT TO PARTY’S STATE       REQUIRED
                PARTY’S                           ABBREVIATION                 Must be uppercase A-Z

                                           DWC-21 FILE LAYOUT – PAGE 7 OF 13
                                              REVISION DATE: 09/01/2010
                              DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                           FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E
                ADDRESS

FIELD   FORM    FORM FIELD    LOCATION    LENGTH DESCRIPTION                    EDITS
NO.     FIELD   NAME                      / TYPE
        ID
54A     7E      REMIT TO      994-1002    9 Num    REMIT TO PARTY’S ZIP CODE    REQUIRED
                PARTY’S ZIP                                                     Must be numeric
                CODE
55A     8       BILLING       1003-1010   8 Date   BILLING DATE                 REQUIRED
                DATE                               FORMAT: CCYYMMDD             Must be a valid date in the correct format
                                                   CC = Century                 Must be less than or equal to Current Date
                                                   YY = Year                    Must be greater than or equal to Date of Accident
                                                   MM = Month                   Must be greater than or equal to the Date of Referral
                                                   DD = Day                     Must be greater than or equal to the Date of Service

56A     9       PROVIDER      1011        1 A/N    PROVIDER STATUS              REQUIRED
                STATUS                             FORMAT: A                    Must be valid status code
                                                                                If marked a Facility/Company (Q) , Facility/Company
                                                   VALID VALUES:                   # must be present
                                                   I = Independent              If marked an Independent (I), Provider Number must
                                                   Q = Facility / Company          be present
                                                                                VALID VALUES ‘I’ ‘Q’
                                                                                I = Independent
                                                                                Q = Facility/Company.
57A     10A     PROVIDER      1012-1026   15 A/N   PROVIDER’S FIRST NAME        REQUIRED
                NAME                                                            Must be uppercase A-Z or a period, hyphen,
                                                                                   comma, apostrophe or space.
                                                                                Left justify, pad with spaces.
58A     10A     PROVIDER      1027-1046   20 A/N   PROVIER’S LAST NAME          REQUIRED
                NAME                                                            Must be uppercase A-Z or a period, hyphen, comma,
                                                                                apostrophe or space.
                                                                                Left justify, pad with spaces.
59A     10B     PROVIDER      1047-1055   9 A/N    DIVISION ASSIGNED            REQUIRED
                NUMBER                             PROVIDER NUMBER              Must be valid Provider Number, beginning with
                                                   FORMAT: AANNNNNNN              WC1NNNNNN or ZZ9999999
                                            DWC-21 FILE LAYOUT – PAGE 8 OF 13
                                               REVISION DATE: 09/01/2010
                                DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                             FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E
                                                                                 If Provider Status is marked as Independent (I), must
                                                                                    be present




        FORM    FORM FIELD     LOCATION    LENGTH DESCRIPTION                    EDITS
FIELD   FIELD   NAME                       / TYPE
NO.     ID
60A     11A     FACILITY /     1056-1115   60 A/N   FACILITY / COMPANY’S         OPTIONAL
                COMPANY                             NAME                         If Provider Status is marked as Facility/ Company (Q),
                NAME                                                                 must be present
                                                                                 If facility / company number present, must be present.
                                                                                 Must be uppercase A-Z or a period, hyphen, comma,
                                                                                     apostrophe, ampersand or space.
                                                                                 Left justify, pad with spaces.
61A     11B     FACILITY/CO    1116-1124   9 A/N    FACILITY/COMPANY             OPTIONAL
                MPANY                               NUMBER                       If present, must be valid Facility/ Company Number,
                NUMBER                              FORMAT: AANNNNNNN                beginning with WC2NNNNNNN or
                                                                                     WC3NNNNNN or ZZ9999999
                                                                                 If facility / company name is present, must be present.
                                                                                 If Provider Status is marked as Facility/ Company (Q),
                                                                                     must be present
62A     12      RETURN TO      1125-1132   8 Date   RETURN TO WORK DATE          OPTIONAL
                WORK DATE                           FORMAT: CCYYMMDD             If present, must be a valid date in the correct format
                                                    CC = Century                 If present, must be greater than or equal to Date of
                                                    YY = Year                        Accident
                                                    MM = Month                   If Starting Weekly Wage is present, must be present.
                                                    DD = Day
63A     13      STARTING       1133-1139   7 Num    STARTING WEEKLY WAGE         OPTIONAL
                WEEKLY                              FORMAT: $$$$$cc              If present, must be numeric. Implied 2 decimal places.
                WAGE                                                             If valid return to work date is present, must be present.
                                                                                 Right justify and space fill




                                             DWC-21 FILE LAYOUT – PAGE 9 OF 13
                                                REVISION DATE: 09/01/2010
                              DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                           FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E



FIELD   FORM    FORM FIELD   LOCATION    LENGTH DESCRIPTION                     EDITS
NO.     FIELD   NAME                     / TYPE
        ID
64A     20      DATE         1140-1147   8 Date   DATE CLAIM HANDLER            REQUIRED
                RECEIVED                          RECEIVED BILL FROM            Must be a valid date in the correct format
                                                  PROVIDER                      Must be less than or equal to Current Date
                                                  FORMAT: CCYYMMDD              Must be greater than or equal to Date of Accident
                                                  CC = Century                  Must be greater than the Date of Referral
                                                  YY = Year                     Must be greater than or equal to the last Date of
                                                  MM = Month                       Service
                                                  DD = Day                      Must be greater than or equal to Billing Date
65A     21      DATE         1148-1155   8 Date   DATE CLAIM HANDLER            REQUIRED
                REIMBURSED                        REIMBURSED PROVIDER           Must be a valid date in the correct format
                                                  FORMAT: CCYYMMDD              Must be less than or equal to Current Date
                                                  CC = Century                  Must be greater than or equal to Date of Accident
                                                  YY = Year                     Must be greater than the Date of Referral
                                                  MM = Month                    Must be greater than or equal to the last Date of
                                                  DD = Day                         Service
                                                                                Must be greater than or equal to Billing Date
                                                                                Must be greater than or equal to Date Received
66A     22      TOTALS –     1156-1166   11 Num   GRAND TOTAL – TOTAL           REQUIRED. Must be numeric. Implied 2 decimal
                TOTAL                             CHARGED                       places. Must be equal to the sum of Charges for all
                BILLED                            FORMAT: $$$$$$$$$cc           corresponding detail records. Right justify, space fill
67A     23      TOTALS –     1167-1177   11 Num   GRAND TOTAL – AMOUNT          REQUIRED. Must be numeric. Implied 2 decimal
                AMOUNT                            REIMBURSED                    places. Must be equal to the sum of Paid Amt. for all
                REIMBURSED                        FORMAT: $$$$$$$$$cc           corresponding detail records. Right justify, space fill
68A             N/A          1178-1200   23 A/N   CLAIM ADMINISTRATOR’S         OPTIONAL
                                                  CLAIM ID NUMBER               FORMAT: A/N
69A             N/A          1201-1215   15 A/N   PROVIDER’S INVOICE            OPTIONAL
                                                  NUMBER                        FORMAT: A/N



                                           DWC-21 FILE LAYOUT – PAGE 10 OF 13
                                              REVISION DATE: 09/01/2010
                             DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                          FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E
                                       DETAIL RECORD LAYOUT
                    (YOU MUST HAVE AT LEAST ONE DETAIL RECORD FOR EACH HEADER RECORD)

FIELD   FORM    FORM FIELD    LOCATION   LENGTH DESCRIPTION                          EDITS
NO      FIELD   NAME                     / TYPE
        ID
1B                            1-15       15 Num   CLAIM CONTROL NUMBER               REQUIRED
                                                  FORMAT: SSSSSYYJJJNNNNN            Must be numeric
                                                  SSSSS=Submitter No.                No duplicate claim control numbers
                                                  YY= Year submitted                 NNNNN Valid Values = 00001-99999
                                                  JJJ=Julian date of day submitted
                                                  NNNNN = Sequence number
2B                            16         1 Num    RECORD FLAG                        REQUIRED
                                                  FORMAT: N                          Must be numeric
                                                                                     Valid Value = 2
3B                            17-19      3 Num    DETAIL SEQUENCE NUMBER             REQUIRED
                                                  FORMAT: NNN                        Must be numeric
                                                                                     Right justify, zero pad on left. 001, 002, 003…
4B      14      DATE OF       20-27      8 Num    DATE OF SERVICE                    REQUIRED
                SERVICE                           FORMAT: CCYYMMDD                   At least one occurrence must be present
                                                  CC = Century                       Must be valid date in the correct format
                                                  YY = Year                          Must be greater than or equal to Date of Accident
                                                  MM = Month                         Must be greater than or equal to Date of Referral
                                                  DD = Day                           Must be less than or equal to the Billing Date
                                                                                     Must be less than or equal to Current Date
5B      15A     REEMPLOYM     28-31      4A/N     REEMPLOYMENT SERVICE               REQUIRED
                ENT SERVICE                       CODE                               At least one occurrence must be present
                CODE                              FORMAT: AAA                        Must be valid service code.
                                                                                     Valid Values are: “MCC” “RES” “REA” “VEV”
                                                  Valid Values:                         “MRR”
                                                  “MCC” “RES” “REA” “VEV”            Left justify, space fill
                                                  “MRR”




                                          DWC-21 FILE LAYOUT – PAGE 11 OF 13
                                             REVISION DATE: 09/01/2010
                              DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
                           FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E

FIELD   FORM    FORM FIELD   LOCATION    LENGTH DESCRIPTION                     EDITS
NO      FIELD   NAME                     / TYPE
        ID
6B      16      UNITS OF     32-38       7 Num      UNITS OF SERVICE            REQUIRED
                SERVICE                             FORMAT: NNNNN.N             At least one occurrence must be present
                                                                                Must have correct format
                                                                                Must be numeric
                                                                                Right justify and space fill

7B      17      CHARGE PER   39-49       11 Num     CHARGE PER UNIT             REQUIRED
                UNIT                                FORMAT: $$$$$$$$$cc         At least one occurrence must be present
                                                                                Must be numeric
                                                                                Must not be negative
                                                                                Implied 2 decimal places (Round up to or only give 2
                                                                                   decimal places)
                                                                                Right justify and space fill
8B      18      TOTAL        50-60       11 Num     TOTAL CHARGE                REQUIRED
                BILLED                              FORMAT: $$$$$$$$$cc         At least one occurrence must be present
                                                                                Must be numeric. Implied 2 decimal places
                                                                                Must not be negative
                                                                                Must be equal to Units of Service X Charge Per Unit
                                                                                Right justify and space fill
9B      19      AMOUNT       61-71       11 Num     AMOUNT REIMBURSED           REQUIRED
                REIMBURSED                          FORMAT: $$$$$$$$$cc         At least one occurrence must be present
                                                                                Must be numeric. Implied 2 decimal places
                                                                                Must not be negative
                                                                                Right justify and space fill
10B                          72-81       10 A/N     USER SUPPLIED ALTERNATE     OPTIONAL
                                                    CODE                        Right justify and space fill.
11B                          82-1081     1000 A/N   DESCRIPTION, ITEMIZATION    OPTIONAL
                                                    OF SERVICES RENDERED        Use tilde character (ASCII Code 126) to
                                                                                   separate multiple lines (instead of carraige
                                                                                   return, line feed).
12B                          1082-1215   134 A/N    SPACE FILL                  REQUIRED

                                           DWC-21 FILE LAYOUT – PAGE 12 OF 13
                                              REVISION DATE: 09/01/2010
   DWC-21 REEMPLOYMENT SERVICES CLAIM FORM
FILE LAYOUT FOR ELECTRONIC SUBMISSION, REVISION E




            DWC-21 FILE LAYOUT – PAGE 13 OF 13
               REVISION DATE: 09/01/2010