Header

 

CREATE TABLE [dbo].[EDI_Claims](

 [ID] [bigint] IDENTITY(1,1) NOT NULL,

 /*File Level Data*/

 [Filename] [varchar](100) NULL,

 [Version] [varchar](12) NULL,

 [ImageFilePath] [varchar](300) NULL,

 [ImageFilename] [varchar](100) NULL,

 [TradingPartnerIDType] [char](2) NULL,

 [TradingPartnerID] [varchar](15) NOT NULL,

 [TransactionDate] [date] NULL,

 [ReceiveDate] [date] NULL,

 [SubmitterName] [varchar](60) NULL,

 [SubmitterID] [varchar](30) NULL,

 [SubmitterContact] [varchar](60) NULL,

 [SubmitterTel] [varchar](20) NULL,

 [SubmitterTelExt] [varchar](10) NULL,

 [SubmitterFax] [varchar](20) NULL,

 [SubmitterEmail] [varchar](80) NULL,

 [ReceiverName] [varchar](60) NULL,

 [ReceiverID] [varchar](30) NULL,

 [TransactionType] [char](2) NULL,

 /*Billing Provider*/

 [FedTaxID] [varchar](15) NULL,

 [BillProvIDType] [char](2) NULL,

 [BillProvID] [varchar](80) NULL,

 [BillProvNPI] [varchar](12) NULL,

 [BillProvLast] [varchar](60) NULL,

 [BillProvFirst] [varchar](35) NULL,

 [BillProvMiddle] [varchar](25) NULL,

 [BillProvSuffix] [varchar](10) NULL,

 [BillProvSpecialty] [varchar](10) NULL,

 [BillProvAddress] [varchar](55) NULL,

 [BillProvAddress2] [varchar](55) NULL,

 [BillProvCity] [varchar](30) NULL,

 [BillProvState] [char](2) NULL,

 [BillProvZip] [varchar](15) NULL,

 [BillProvCountry] [varchar](3) NULL,

 [BillProvSubdivision] [varchar](3) NULL,

 [BillProvContact] [varchar](60) NULL,

 [BillProvTel] [varchar](80) NULL,

 [BillProvTelExt] [varchar](80) NULL,

 [BillProvFax] [varchar](80) NULL,

 [BillProvEmail] [varchar](80) NULL,

 [BillProvOtherIDQual1] [char](2) NULL,

 [BillProvOtherID1] [varchar](30) NULL,

 [BillProvOtherIDQual2] [char](2) NULL,

 [BillProvOtherID2] [varchar](30) NULL,

 [BillProvOtherIDQual3] [char](2) NULL,

 [BillProvOtherID3] [varchar](30) NULL,

 [BillProvOtherIDQual4] [char](2) NULL,

 [BillProvOtherID4] [varchar](30) NULL,

 [BillProvOtherIDQual5] [char](2) NULL,

 [BillProvOtherID5] [varchar](30) NULL,

 /*Pay-to Provider*/

 [PayToProvIDType] [char](2) NULL,

 [PayToProvID] [varchar](30) NULL,

 [PayToProvTaxID] [varchar](12) NULL,

 [PayToProvNPI] [varchar](12) NULL,

 [PayToProvLast] [varchar](60) NULL,

 [PayToProvFirst] [varchar](35) NULL,

 [PayToProvMiddle] [varchar](25) NULL,

 [PayToProvSuffix] [varchar](10) NULL,

 [PayToProvSpecialty] [varchar](10) NULL,

 [PayToProvAddress] [varchar](55) NULL,

 [PayToProvAddress2] [varchar](55) NULL,

 [PayToProvCity] [varchar](30) NULL,

 [PayToProvState] [char](2) NULL,

 [PayToProvZip] [varchar](15) NULL,

 /*Pay-to Payer*/

 [PayToPayerIDType] [char](2) NULL,

 [PayToPayerID] [varchar](80) NULL,

 [PayToPayerTaxID] [varchar](12) NULL,

 [PayToPayerLast] [varchar](60) NULL,

 [PayToPayerFirst] [varchar](35) NULL,

 [PayToPayerMiddle] [varchar](25) NULL,

 [PayToPayerSuffix] [varchar](10) NULL,

 [PayToPayerAddress] [varchar](55) NULL,

 [PayToPayerAddress2] [varchar](55) NULL,

 [PayToPayerCity] [varchar](30) NULL,

 [PayToPayerState] [char](2) NULL,

 [PayToPayerZip] [varchar](15) NULL,

 [PayToPayerOtherIDQual] [char](2) NULL,

 [PayToPayerOtherID] [varchar](30) NULL,

 /*Subscriber*/

 [SubscriberLast] [varchar](60) NULL,

 [SubscriberFirst] [varchar](35) NULL,

 [SubscriberMiddle] [varchar](25) NULL,

 [SubscriberSuffix] [varchar](10) NULL,

 [SubscriberIDType] [char](2) NULL,

 [SubscriberID] [varchar](30) NULL,

 [SubscriberAddress] [varchar](55) NULL,

 [SubscriberAddress2] [varchar](55) NULL,

 [SubscriberCity] [varchar](30) NULL,

 [SubscriberState] [char](2) NULL,

 [SubscriberZip] [varchar](15) NULL,

 [SubscriberCountry] [varchar](3) NULL,

 [SubscriberLocation] [varchar](30) NULL,

 [SubscriberSubdivision] [varchar](3) NULL,

 [SubscriberDOB] [varchar](10) NULL,

 [SubscriberSex] [char](1) NULL,

 [SubscriberEthnicity] [varchar](75) NULL,

 [SubscriberMaritalStatus] [char](1) NULL,

 [SubscriberCollectionMethod] [varchar](30) NULL,

 [SubscriberSSN] [varchar](12) NULL,

 [SubscriberAgencyClaimNo] [varchar](50) NULL,

 [SubscriberMemberID] [varchar](50) NULL,

 [SubscriberPersonalID] [varchar](50) NULL,

 [SubscriberContact] [varchar](60) NULL,

 [SubscriberTel] [varchar](15) NULL,

 [SubscriberTelExt] [varchar](10) NULL,

 /*Destination Payer*/

 [PayerName] [varchar](60) NULL,

 [PayerIDType] [char](2) NULL,

 [PayerID] [varchar](30) NULL,

 [PayerAddress] [varchar](55) NULL,

 [PayerAddress2] [varchar](55) NULL,

 [PayerCity] [varchar](30) NULL,

 [PayerState] [char](2) NULL,

 [PayerZip] [varchar](15) NULL,

 [PayerResponsibility] [char](1) NULL,

 [PayerOtherIDQual1] [char](2) NULL,

 [PayerOtherID1] [varchar](30) NULL,

 [PayerOtherIDQual2] [char](2) NULL,

 [PayerOtherID2] [varchar](30) NULL,

 [PayerOtherIDQual3] [char](2) NULL,

 [PayerOtherID3] [varchar](30) NULL,

 [GroupNo] [varchar](50) NULL,

 [GroupName] [varchar](60) NULL,

 [InsuranceType] [char](2) NULL,

 [FilingIndicator] [char](2) NULL,

 [COBIndicator] [char](1) NULL,

 /*Responsible*/

 [ResponsibleLast] [varchar](60) NULL,

 [ResponsibleFirst] [varchar](35) NULL,

 [ResponsibleMiddle] [varchar](25) NULL,

 [ResponsibleSuffix] [varchar](10) NULL,

 [ResponsibleAddress] [varchar](55) NULL,

 [ResponsibleAddress2] [varchar](55) NULL,

 [ResponsibleCity] [varchar](30) NULL,

 [ResponsibleState] [char](2) NULL,

 [ResponsibleZip] [varchar](15) NULL,

 [ResponsibleIDType] [char](2) NULL,

 [ResponsibleID] [varchar](80) NULL,

 /*Patient*/

 [PatientLast] [varchar](60) NULL,

 [PatientFirst] [varchar](35) NULL,

 [PatientMiddle] [varchar](25) NULL,

 [PatientSuffix] [varchar](10) NULL,

 [PatientAddress] [varchar](55) NULL,

 [PatientAddress2] [varchar](55) NULL,

 [PatientCity] [varchar](30) NULL,

 [PatientState] [char](2) NULL,

 [PatientZip] [varchar](15) NULL,

 [PatientCountry] [varchar](3) NULL,

 [PatientLocation] [varchar](30) NULL,

 [PatientSubdivision] [varchar](3) NULL,

 [PatientIDType] [char](2) NULL,

 [PatientID] [varchar](30) NULL,

 [PatientSSN] [varchar](12) NULL,

 [PatientMemberID] [varchar](50) NULL,

 [PatientPersonalID] [varchar](50) NULL,

 [PatientInsurancePolicy] [varchar](50) NULL,

 [PatientDOB] [varchar](50) NULL,

 [PatientSex] [char](1) NULL,

 [PatientEthnicity] [varchar](75) NULL,

 [PatientMaritalStatus] [char](1) NULL,

 [PatientCollectionMethod] [varchar](30) NULL,

 [PatientRelationship] [char](2) NULL,

 [PatientPaid] [varchar](10) NULL,

 [PregnancyIndicator] [char](1) NULL,

 /*Rendering Provider*/

 [RendProvIDType] [char](2) NULL,

 [RendProvID] [varchar](30) NULL,

 [RendProvNPI] [varchar](12) NULL,

 [RendProvTaxID] [varchar](12) NULL,

 [RendProvLast] [varchar](60) NULL,

 [RendProvFirst] [varchar](35) NULL,

 [RendProvMiddle] [varchar](25) NULL,

 [RendProvSuffix] [varchar](10) NULL,

 [RendProvSpecialty] [varchar](10) NULL,

 [RendProvOtherIDQual1] [char](2) NULL,

 [RendProvOtherID1] [varchar](30) NULL,

 [RendProvOtherIDQual2] [char](2) NULL,

 [RendProvOtherID2] [varchar](30) NULL,

 [RendProvOtherIDQual3] [char](2) NULL,

 [RendProvOtherID3] [varchar](30) NULL,

 /*Attending Provider*/

 [AttendProvLast] [varchar](60) NULL,

 [AttendProvFirst] [varchar](35) NULL,

 [AttendProvMiddle] [varchar](25) NULL,

 [AttendProvSuffix] [varchar](10) NULL,

 [AttendProvIDType] [char](2) NULL,

 [AttendProvID] [varchar](30) NULL,

 [AttendProvTaxID] [varchar](12) NULL,

 [AttendProvNPI] [varchar](12) NULL,

 [AttendProvOtherIDQual1] [char](2) NULL,

 [AttendProvOtherID1] [varchar](30) NULL,

 [AttendProvSpecialty] [varchar](10) NULL,

 /*Operating Provider*/

 [OperatingProvLast] [varchar](60) NULL,

 [OperatingProvFirst] [varchar](35) NULL,

 [OperatingProvMiddle] [varchar](25) NULL,

 [OperatingProvSuffix] [varchar](10) NULL,

 [OperatingProvIDType] [char](2) NULL,

 [OperatingProvID] [varchar](30) NULL,

 [OperatingProvNPI] [varchar](12) NULL,

 [OperatingProvTaxID] [varchar](12) NULL,

 [OperatingProvOtherIDQual1] [char](2) NULL,

 [OperatingProvOtherID1] [varchar](30) NULL,

 [OperatingProvSpecialty] [varchar](10) NULL,

 /*Other Provider*/

 [OtherProvLast] [varchar](60) NULL,

 [OtherProvFirst] [varchar](35) NULL,

 [OtherProvMiddle] [varchar](25) NULL,

 [OtherProvSuffix] [varchar](10) NULL,

 [OtherProvIDType] [char](2) NULL,

 [OtherProvID] [varchar](30) NULL,

 [OtherProvTaxID] [varchar](12) NULL,

 [OtherProvNPI] [varchar](12) NULL,

 [OtherProvOtherIDQual1] [char](2) NULL,

 [OtherProvOtherID1] [varchar](30) NULL,

 [OtherProvSpecialty] [varchar](50) NULL,

 /*Facility*/

 [FacilityType] [char](2) NULL,

 [FacilityIDType] [char](2) NULL,

 [FacilityID] [varchar](80) NULL,

 [FacilityNPI] [varchar](12) NULL,

 [FacilityTaxID] [varchar](12) NULL,

 [FacilityOtherIDQual1] [char](2) NULL,

 [FacilityOtherID1] [varchar](30) NULL,

 [FacilityName] [varchar](80) NULL,

 [FacilityAddress] [varchar](55) NULL,

 [FacilityAddress2] [varchar](55) NULL,

 [FacilityCity] [varchar](30) NULL,

 [FacilitySpecialty] [varchar](50) NULL,

 [FacilityState] [char](2) NULL,

 [FacilityZip] [varchar](15) NULL,

 /*Referring Provider*/

 [RefProvLast] [varchar](60) NULL,

 [RefProvFirst] [varchar](35) NULL,

 [RefProvMiddle] [varchar](25) NULL,

 [RefProvSuffix] [varchar](10) NULL,

 [RefProvIDType] [char](2) NULL,

 [RefProvID] [varchar](80) NULL,

 [RefProvTaxID] [varchar](12) NULL,

 [RefProvNPI] [varchar](12) NULL,

 [RefProvOtherIDQual1] [char](2) NULL,

 [RefProvOtherID1] [varchar](300) NULL,

 [RefProvSpecialty] [varchar](20) NULL,

 /*Supervising Provider*/

 [SupervProvLast] [varchar](60) NULL,

 [SupervProvFirst] [varchar](35) NULL,

 [SupervProvMiddle] [varchar](25) NULL,

 [SupervProvSuffix] [varchar](10) NULL,

 [SupervProvIDType] [char](2) NULL,

 [SupervProvID] [varchar](30) NULL,

 [SupervProvTaxID] [varchar](12) NULL,

 [SupervProvNPI] [varchar](12) NULL,

 [SupervProvOtherIDQual1] [char](2) NULL,

 [SupervProvOtherID1] [varchar](50) NULL,

 [SupervProvSpecialty] [varchar](20) NULL,

 /*Assistant Surgeon*/

 [AssistSurgLast] [varchar](60) NULL,

 [AssistSurgFirst] [varchar](35) NULL,

 [AssistSurgMiddle] [varchar](25) NULL,

 [AssistSurgSuffix] [varchar](10) NULL,

 [AssistSurgIDType] [char](2) NULL,

 [AssistSurgID] [varchar](30) NULL,

 [AssistSurgTaxID] [varchar](12) NULL,

 [AssistSurgNPI] [varchar](12) NULL,

 [AssistSurgOtherIDQual1] [varchar](3) NULL,

 [AssistSurgOtherID1] [varchar](50) NULL,

 [AssistSurgSpecialty] [varchar](10) NULL,

 /*Ambulance Pick-up Location*/

 [PickUpAddress] [varchar](55) NULL,

 [PickUpAddress2] [varchar](55) NULL,

 [PickUpCity] [varchar](30) NULL,

 [PickUpState] [char](2) NULL,

 [PickUpZip] [varchar](15) NULL,

 /*Ambulance Drop-off Location*/

 [DropOffName] [varchar](80) NULL,

 [DropOffAddress] [varchar](55) NULL,

 [DropOffAddress2] [varchar](55) NULL,

 [DropOffCity] [varchar](30) NULL,

 [DropOffState] [char](2) NULL,

 [DropOffZip] [varchar](15) NULL,

 /*COB Payer 1*/

 [OtherInsuredLast] [varchar](60) NULL,

 [OtherInsuredFirst] [varchar](35) NULL,

 [OtherInsuredMiddle] [varchar](25) NULL,

 [OtherInsuredSuffix] [varchar](10) NULL,

 [OtherInsuredIDQual] [char](2) NULL,

 [OtherInsuredID] [varchar](30) NULL,

 [OtherInsuredAddress] [varchar](55) NULL,

 [OtherInsuredAddress2] [varchar](55) NULL,

 [OtherInsuredCity] [varchar](30) NULL,

 [OtherInsuredState] [char](2) NULL,

 [OtherInsuredZip] [varchar](15) NULL,

 [OtherInsuredCountry] [varchar](3) NULL,

 [OtherInsuredSubdivision] [varchar](3) NULL,

 [OtherInsuredPolicy] [varchar](50) NULL,

 [OtherInsuredDOB] [varchar](10) NULL,

 [OtherInsuredSex] [char](1) NULL,

 [OtherInsuredRelationship] [char](2) NULL,

 [OtherInsuredOtherIDQual1] [char](3) NULL,

 [OtherInsuredOtherID1] [varchar](50) NULL,

 [OtherInsuredOtherIDQual2] [char](3) NULL,

 [OtherInsuredOtherID2] [varchar](50) NULL,

 [OtherInsuredOtherIDQual3] [char](3) NULL,

 [OtherInsuredOtherID3] [varchar](50) NULL,

 [OtherPayerResponsibility] [char](1) NULL,

 [OtherPayerName] [varchar](35) NULL,

 [OtherPayerIDQual] [char](2) NULL,

 [OtherPayerID] [varchar](30) NULL,

 [OtherPayerAddress1] [varchar](55) NULL,

 [OtherPayerAddress2] [varchar](55) NULL,

 [OtherPayerCity] [varchar](30) NULL,

 [OtherPayerState] [char](2) NULL,

 [OtherPayerZip] [varchar](15) NULL,

 [OtherPayerPaid] [varchar](10) NULL,

 [OtherPayerGroupName] [varchar](60) NULL,

 [OtherPayerGroupNo] [varchar](50) NULL,

 [OtherPayerInsuranceType] [char](2) NULL,

 [OtherPayerFilingIndicator] [char](2) NULL,

 [OtherPayerAdjustmentReasonGroup] [varchar](20) NULL,

 [OtherPayerAdjustmentReason] [varchar](50) NULL,

 [OtherPayerAdjustmentAmount] [varchar](120) NULL,

 [OtherPayerPaidDate] [date] NULL,

 [OtherPayerInfoRelease] [char](1) NULL,

 [OtherPayerBenefitAssign] [char](1) NULL,

 [OtherPayerDocControlNo] [varchar](50) NULL,

 [OtherPayerPriorAuth] [varchar](50) NULL,

 [OtherPayerOtherIDQual1] [char](3) NULL,

 [OtherPayerOtherID1] [varchar](50) NULL,

 [OtherPayerOtherIDQual2] [char](3) NULL,

 [OtherPayerOtherID2] [varchar](50) NULL,

 /*COB Payer 2*/

 [OtherInsured2Last] [varchar](60) NULL,

 [OtherInsured2First] [varchar](35) NULL,

 [OtherInsured2Middle] [varchar](25) NULL,

 [OtherInsured2Suffix] [varchar](10) NULL,

 [OtherInsured2IDQual] [char](2) NULL,

 [OtherInsured2ID] [varchar](30) NULL,

 [OtherInsured2Address] [varchar](55) NULL,

 [OtherInsured2Address2] [varchar](55) NULL,

 [OtherInsured2City] [varchar](30) NULL,

 [OtherInsured2State] [char](2) NULL,

 [OtherInsured2Zip] [varchar](15) NULL,

 [OtherInsured2Country] [varchar](3) NULL,

 [OtherInsured2Subdivision] [varchar](3) NULL,

 [OtherInsured2Policy] [varchar](50) NULL,

 [OtherInsured2DOB] [varchar](10) NULL,

 [OtherInsured2Sex] [char](1) NULL,

 [OtherInsured2Relationship] [char](2) NULL,

 [OtherInsured2OtherIDQual1] [char](3) NULL,

 [OtherInsured2OtherID1] [varchar](50) NULL,

 [OtherInsured2OtherIDQual2] [char](3) NULL,

 [OtherInsured2OtherID2] [varchar](50) NULL,

 [OtherInsured2OtherIDQual3] [char](3) NULL,

 [OtherInsured2OtherID3] [varchar](50) NULL,

 [OtherPayer2Responsibility] [char](1) NULL,

 [OtherPayer2Name] [varchar](35) NULL,

 [OtherPayer2IDQual] [char](2) NULL,

 [OtherPayer2ID] [varchar](80) NULL,

 [OtherPayer2Address1] [varchar](55) NULL,

 [OtherPayer2Address2] [varchar](55) NULL,

 [OtherPayer2City] [varchar](30) NULL,

 [OtherPayer2State] [char](2) NULL,

 [OtherPayer2Zip] [varchar](15) NULL,

 [OtherPayer2Paid] [varchar](10) NULL,

 [OtherPayer2GroupName] [varchar](60) NULL,

 [OtherPayer2GroupNo] [varchar](50) NULL,

 [OtherPayer2InsuranceType] [char](2) NULL,

 [OtherPayer2FilingIndicator] [char](2) NULL,

 [OtherPayer2AdjustmentReasonGroup] [char](20) NULL,

 [OtherPayer2AdjustmentReason] [varchar](50) NULL,

 [OtherPayer2AdjustmentAmount] [varchar](120) NULL,

 [OtherPayer2PaidDate] [date] NULL,

 [OtherPayer2InfoRelease] [char](1) NULL,

 [OtherPayer2BenefitAssign] [char](1) NULL,

 [OtherPayer2DocControlNo] [varchar](50) NULL,

 [OtherPayer2PriorAuth] [varchar](50) NULL,

 [OtherPayer2OtherIDQual1] [char](3) NULL,

 [OtherPayer2OtherID1] [varchar](50) NULL,

 [OtherPayer2OtherIDQual2] [char](3) NULL,

 [OtherPayer2OtherID2] [varchar](50) NULL,

 /*Claim Data*/

 [ClaimNo] [varchar](50) NOT NULL,

 [Amount] [money] NULL,

 [EstimatedAmountDue] [money] NULL,

 [PatientEstimatedAmountDue] [money] NULL,

 [PlaceOfService] [char](2) NULL,

 [ClaimFrequency] [char](1) NULL,

 [SubmitReason] [char](1) NULL,

 [ProviderSignature] [char](1) NULL,

 [ProviderAcceptsAssignment] [char](1) NULL,

 [BenefitAssignment] [char](1) NULL,

 [InfoReleaseCode] [char](1) NULL,

 [PatientSignatureCode] [char](1) NULL,

 [RelatedCauses] [char](2) NULL,

 [RelatedCauses2] [char](2) NULL,

 [RelatedCausesState] [char](2) NULL,

 [SpecialProgramCode] [char](3) NULL,

 [ProviderParticipation] [char](1) NULL,

 [EOBIndicator] [char](1) NULL,

 [DelayReasonCode] [char](2) NULL,

 [ServiceDateFrom] [date] NULL,

 [ServiceDateTo] [date] NULL,

 [OnsetDate] [date] NULL,

 [SimilarSymptomsDate] [date] NULL,

 [DisabilityBegin] [date] NULL,

 [DisabilityEnd] [date] NULL,

 [HospitalizationBegin] [date] NULL,

 [HospitalizationEnd] [date] NULL,

 [AccidentDate] [date] NULL,

 [LastMenstrualPeriod] [date] NULL,

 [RepricerReceivedDate] [date] NULL,

 [AdmissionDate] [date] NULL,

 [AdmissionHour] [time](7) NULL,

 [AdmissionType] [char](1) NULL,

 [AdmissionSource] [char](1) NULL,

 [DischargeHour] [time](7) NULL,

 [PatientStatus] [char](2) NULL,

 [CoveredDays] [varchar](4) NULL,

 [NonCoveredDays] [varchar](4) NULL,

 [COBDays] [varchar](4) NULL,

 [LifeTimeReserveDays] [varchar](4) NULL,

 [PriorAuthorization] [varchar](50) NULL,

 [ClearingHouseID] [varchar](50) NULL,

 [MedicalRecordNumber] [varchar](50) NULL,

 [MothersMedicalRecordNumber] [varchar](50) NULL,

 [ServiceAuthorizationException] [varchar](50) NULL,

 [ReferralNumber] [varchar](50) NULL,

 [PayerClaimControlNumber] [varchar](50) NULL,

 [AdjustedRepricedClaimNumber] [varchar](50) NULL,

 [AutoAccidentState] [varchar](50) NULL,

 [OrigRefNo] [varchar](50) NULL,

 [ClaimType] [char](1) NULL,

 [TypeOfBill] [varchar](20) NULL,

 [Remark1] [varchar](90) NULL,

 [Remark2] [varchar](90) NULL,

 [Remark3] [varchar](90) NULL,

 [Remark4] [varchar](90) NULL,

 [K3_1] [varchar](80) NULL,

 [K3_2] [varchar](80) NULL,

 [K3_3] [varchar](80) NULL,

 [K3_4] [varchar](80) NULL,

 [K3_5] [varchar](80) NULL,

 [K3_6] [varchar](80) NULL,

 [K3_7] [varchar](80) NULL,

 [K3_8] [varchar](80) NULL,

 [K3_9] [varchar](80) NULL,

 [K3_10] [varchar](80) NULL,

 [OutsideLab] [char](1) NULL,

 [LabCharge] [varchar](10) NULL,

 [Test_Prod] [char](1) NULL,

 [ReportTypeCode1] [char](2) NULL,

 [ReportTransmissionCode1] [varchar](2) NULL,

 [AttachmentControlNumber1] [varchar](80) NULL,

 /*Dental Claims*/

 [Predetermination] [char](2) NULL,

 [OrthodonticTotal] [varchar](5) NULL,

 [OrthodonticRemaining] [varchar](5) NULL,

 [OrthodonticYesNo] [char](1) NULL,

 [ToothStatus] [varchar](100) NULL,

 [AppliancePlacementDate] [date] NULL,

 /*Diagnosis Information*/

 [AdmitDiagnosis] [varchar](10) NULL,

 [ECode] [varchar](30) NULL,

 [ECode2] [varchar](30) NULL,

 [ECode3] [varchar](30) NULL,

 [ECode4] [varchar](30) NULL,

 [ECode5] [varchar](30) NULL,

 [ECode6] [varchar](30) NULL,

 [ECode7] [varchar](30) NULL,

 [ECode8] [varchar](30) NULL,

 --[ECode9] [varchar](30) NULL,

 --[ECode10] [varchar](30) NULL,

 --[ECode11] [varchar](30) NULL,

 --[ECode12] [varchar](30) NULL,

 [ReasonForVisit] [varchar](30) NULL,

 [ReasonForVisit2] [varchar](30) NULL,

 [ReasonForVisit3] [varchar](30) NULL,

 [PrincipalDiagnosis] [varchar](10) NULL,

 [Diag2] [varchar](10) NULL,

 [Diag3] [varchar](10) NULL,

 [Diag4] [varchar](10) NULL,

 [Diag5] [varchar](10) NULL,

 [Diag6] [varchar](10) NULL,

 [Diag7] [varchar](10) NULL,

 [Diag8] [varchar](10) NULL,

 [Diag9] [varchar](10) NULL,

 [Diag10] [varchar](10) NULL,

 [Diag11] [varchar](10) NULL,

 [Diag12] [varchar](10) NULL,

 [Diag13] [varchar](10) NULL,

 [Diag14] [varchar](10) NULL,

 [Diag15] [varchar](10) NULL,

 [Diag16] [varchar](10) NULL,

 [Diag17] [varchar](10) NULL,

 [Diag18] [varchar](10) NULL,

 [Diag19] [varchar](10) NULL,

 [Diag20] [varchar](10) NULL,

 [Diag21] [varchar](10) NULL,

 [Diag22] [varchar](10) NULL,

 [Diag23] [varchar](10) NULL,

 [Diag24] [varchar](10) NULL,

 [Diag25] [varchar](10) NULL,

 [DRG] [varchar](15) NULL,

 /*Procedure Information*/

 [PrincipalProcedure] [varchar](10) NULL,

 [PrincipalProcedureDate] [datetime2](0) NULL,

 [Proc2] [varchar](50) NULL,

 [Proc2Date] [datetime2](0) NULL,

 [Proc3] [varchar](10) NULL,

 [Proc3Date] [datetime2](0) NULL,

 [Proc4] [varchar](10) NULL,

 [Proc4Date] [datetime2](0) NULL,

 [Proc5] [varchar](10) NULL,

 [Proc5Date] [datetime2](0) NULL,

 [Proc6] [varchar](10) NULL,

 [Proc6Date] [datetime2](0) NULL,

 [Proc7] [varchar](10) NULL,

 [Proc7Date] [datetime2](0) NULL,

 [Proc8] [varchar](10) NULL,

 [Proc8Date] [datetime2](0) NULL,

 [Proc9] [varchar](10) NULL,

 [Proc9Date] [datetime2](0) NULL,

 [Proc10] [varchar](10) NULL,

 [Proc10Date] [datetime2](0) NULL,

 [Proc11] [varchar](10) NULL,

 [Proc11Date] [datetime2](0) NULL,

 [Proc12] [varchar](10) NULL,

 [Proc12Date] [datetime2](0) NULL,

 [Proc13] [varchar](10) NULL,

 [Proc13Date] [datetime2](0) NULL,

 [Proc14] [varchar](10) NULL,

 [Proc14Date] [datetime2](0) NULL,

 [Proc15] [varchar](10) NULL,

 [Proc15Date] [datetime2](0) NULL,

 [Proc16] [varchar](10) NULL,

 [Proc16Date] [datetime2](0) NULL,

 [Proc17] [varchar](10) NULL,

 [Proc17Date] [datetime2](0) NULL,

 [Proc18] [varchar](10) NULL,

 [Proc18Date] [datetime2](0) NULL,

 [Proc19] [varchar](10) NULL,

 [Proc19Date] [datetime2](0) NULL,

 [Proc20] [varchar](10) NULL,

 [Proc20Date] [datetime2](0) NULL,

 [Proc21] [varchar](10) NULL,

 [Proc21Date] [datetime2](0) NULL,

 [Proc22] [varchar](10) NULL,

 [Proc22Date] [datetime2](0) NULL,

 [Proc23] [varchar](10) NULL,

 [Proc23Date] [datetime2](0) NULL,

 [Proc24] [varchar](10) NULL,

 [Proc24Date] [datetime2](0) NULL,

 [Proc25] [varchar](10) NULL,

 [Proc25Date] [datetime2](0) NULL,

 /*Value Codes*/

 [ValueCode1] [char](3) NULL,

 [ValueAmount1] [varchar](10) NULL,

 [ValueCode2] [char](3) NULL,

 [ValueAmount2] [varchar](10) NULL,

 [ValueCode3] [char](3) NULL,

 [ValueAmount3] [varchar](10) NULL,

 [ValueCode4] [char](3) NULL,

 [ValueAmount4] [varchar](10) NULL,

 [ValueCode5] [char](3) NULL,

 [ValueAmount5] [varchar](10) NULL,

 [ValueCode6] [char](3) NULL,

 [ValueAmount6] [varchar](10) NULL,

 [ValueCode7] [varchar](10) NULL,

 [ValueAmount7] [varchar](10) NULL,

 [ValueCode8] [char](3) NULL,

 [ValueAmount8] [varchar](10) NULL,

 [ValueCode9] [char](3) NULL,

 [ValueAmount9] [varchar](10) NULL,

 [ValueCode10] [char](3) NULL,

 [ValueAmount10] [varchar](10) NULL,

 [ValueCode11] [char](3) NULL,

 [ValueAmount11] [varchar](10) NULL,

 [ValueCode12] [char](3) NULL,

 [ValueAmount12] [varchar](10) NULL,

 --[ValueCode13] [char](3) NULL,

 --[ValueAmount13] [varchar](10) NULL,

 --[ValueCode14] [char](3) NULL,

 --[ValueAmount14] [varchar](10) NULL,

 --[ValueCode15] [char](3) NULL,

 --[ValueAmount15] [varchar](10) NULL,

 --[ValueCode16] [char](3) NULL,

 --[ValueAmount16] [varchar](10) NULL,

 --[ValueCode17] [char](3) NULL,

 --[ValueAmount17] [varchar](10) NULL,

 --[ValueCode18] [char](3) NULL,

 --[ValueAmount18] [varchar](10) NULL,

 --[ValueCode19] [char](3) NULL,

 --[ValueAmount19] [varchar](10) NULL,

 --[ValueCode20] [char](3) NULL,

 --[ValueAmount20] [varchar](10) NULL,

 --[ValueCode21] [char](3) NULL,

 --[ValueAmount21] [varchar](10) NULL,

 --[ValueCode22] [char](3) NULL,

 --[ValueAmount22] [varchar](10) NULL,

 --[ValueCode23] [char](3) NULL,

 --[ValueAmount23] [varchar](10) NULL,

 --[ValueCode24] [char](3) NULL,

 --[ValueAmount24] [varchar](10) NULL,

 /*Condition Codes*/

 [ConditionCode1] [varchar](30) NULL,

 [ConditionCode2] [varchar](30) NULL,

 [ConditionCode3] [varchar](30) NULL,

 [ConditionCode4] [varchar](30) NULL,

 [ConditionCode5] [varchar](30) NULL,

 [ConditionCode6] [varchar](30) NULL,

 [ConditionCode7] [varchar](30) NULL,

 [ConditionCode8] [varchar](30) NULL,

 [ConditionCode9] [varchar](30) NULL,

 [ConditionCode10] [varchar](30) NULL,

 --[ConditionCode11] [varchar](30) NULL,

 --[ConditionCode12] [varchar](30) NULL,

 --[ConditionCode13] [varchar](30) NULL,

 --[ConditionCode14] [varchar](30) NULL,

 --[ConditionCode15] [varchar](30) NULL,

 --[ConditionCode16] [varchar](30) NULL,

 --[ConditionCode17] [varchar](30) NULL,

 --[ConditionCode18] [varchar](30) NULL,

 --[ConditionCode19] [varchar](30) NULL,

 --[ConditionCode20] [varchar](30) NULL,

 --[ConditionCode21] [varchar](30) NULL,

 --[ConditionCode22] [varchar](30) NULL,

 --[ConditionCode23] [varchar](30) NULL,

 --[ConditionCode24] [varchar](30) NULL,

 /*Occurrence Codes*/

 [OccurranceCode1] [char](3) NULL,

 [OccurranceDate1] [date] NULL,

 [OccurranceCode2] [char](3) NULL,

 [OccurranceDate2] [date] NULL,

 [OccurranceCode3] [char](3) NULL,

 [OccurranceDate3] [date] NULL,

 [OccurranceCode4] [char](3) NULL,

 [OccurranceDate4] [date] NULL,

 [OccurranceCode5] [char](3) NULL,

 [OccurranceDate5] [date] NULL,

 [OccurranceCode6] [char](3) NULL,

 [OccurranceDate6] [date] NULL,

 [OccurranceCode7] [char](3) NULL,

 [OccurranceDate7] [date] NULL,

 [OccurranceCode8] [char](3) NULL,

 [OccurranceDate8] [date] NULL,

 --[OccurranceCode9] [char](3) NULL,

 --[OccurranceDate9] [date] NULL,

 --[OccurranceCode10] [char](3) NULL,

 --[OccurranceDate10] [date] NULL,

 --[OccurranceCode11] [char](3) NULL,

 --[OccurranceDate11] [date] NULL,

 --[OccurranceCode12] [char](3) NULL,

 --[OccurranceDate12] [date] NULL,

 --[OccurranceCode13] [char](3) NULL,

 --[OccurranceDate13] [date] NULL,

 --[OccurranceCode14] [char](3) NULL,

 --[OccurranceDate14] [date] NULL,

 --[OccurranceCode15] [char](3) NULL,

 --[OccurranceDate15] [date] NULL,

 --[OccurranceCode16] [char](3) NULL,

 --[OccurranceDate16] [date] NULL,

 --[OccurranceCode17] [char](3) NULL,

 --[OccurranceDate17] [date] NULL,

 --[OccurranceCode18] [char](3) NULL,

 --[OccurranceDate18] [date] NULL,

 --[OccurranceCode19] [char](3) NULL,

 --[OccurranceDate19] [date] NULL,

 --[OccurranceCode20] [char](3) NULL,

 --[OccurranceDate20] [date] NULL,

 --[OccurranceCode21] [char](3) NULL,

 --[OccurranceDate21] [date] NULL,

 --[OccurranceCode22] [char](3) NULL,

 --[OccurranceDate22] [date] NULL,

 --[OccurranceCode23] [char](3) NULL,

 --[OccurranceDate23] [date] NULL,

 --[OccurranceCode24] [char](3) NULL,

 --[OccurranceDate24] [date] NULL,

 [OccurranceSpanCode1] [char](3) NULL,

 [OccurranceSpanFrom1] [date] NULL,

 [OccurranceSpanTo1] [date] NULL,

 [OccurranceSpanCode2] [char](3) NULL,

 [OccurranceSpanFrom2] [date] NULL,

 [OccurranceSpanTo2] [date] NULL,

 [OccurranceSpanCode3] [char](3) NULL,

 [OccurranceSpanFrom3] [date] NULL,

 [OccurranceSpanTo3] [date] NULL,

 [OccurranceSpanCode4] [char](3) NULL,

 [OccurranceSpanFrom4] [date] NULL,

 [OccurranceSpanTo4] [date] NULL,

 /*CR1*/

 [PatientWeight] [varchar](10) NULL,

 [AmbulanceTransportCode] [char](1) NULL,

 [AmbulanceTransportReasonCode] [char](1) NULL,

 [TransportDistance] [varchar](15) NULL,

 [RoundTripPurposeDescription] [varchar](80) NULL,

 [StretcherPurposeDescription] [varchar](80) NULL,

 /* CRC — Ambulance Certification */

 [AmbulanceConditionIndicator] [char](1) NULL,

 [AmbulanceConditionCode1] [char](3) NULL,

 [AmbulanceConditionCode2] [char](3) NULL,

 [AmbulanceConditionCode3] [char](3) NULL,

 [AmbulanceConditionCode4] [char](3) NULL,

 [AmbulanceConditionCode5] [char](3) NULL,

 /*Repricing*/

 [RepricedClaimNumber] [varchar](50) NULL,

 [RepricingMethodology] [varchar](3) NULL,

 [RepricedAmount] [money] NULL,

 [SavingsAmount] [money] NULL,

 [RepricerID] [varchar](30) NULL,

 [RepricingRate] [varchar](9) NULL,

 [APG_Code] [varchar](30) NULL,

 [APG_Amount] [money] NULL,

 [ApprovedRevenueCode] [varchar] (48) NULL,

 [ApprovedProcedureCode] [varchar] (48) NULL,

 [ApprovedUnitCode] [char](2) NULL,

 [ApprovedUnits] [bigint] NULL,

 [RejectReason] [varchar](3) NULL,

 [ComplianceCode] [varchar](2) NULL,

 [ExceptionCode] [varchar](2) NULL

 /*SQL To EDI*/

 --,[ClaimAction] [char](1) NULL,

 --[ErrorMessage] [varchar](1000) NULL

) ON [PRIMARY]

 

Detail

CREATE TABLE [dbo].[edi_ClaimDetail](

 [ID] [bigint] IDENTITY(1,1) NOT NULL,

 [ClaimID] [bigint] NOT NULL,

 [LineNumber] [decimal](18, 0) NULL,

 [LineID] [varchar](50) NULL,

 [ServiceDateFrom] [datetime2](0) NULL,

 [ServiceDateTo] [date] NULL,

 [AssessmentDate] [date] NULL,

 [FacilityCode] [char](2) NULL,

 [RevenueCode] [varchar](48) NULL,

 [ProcedureCode] [varchar](48) NULL,

 [Amount] [money] NULL,

 [Unit] [char](2) NULL,

 [Quantity] [float] NULL,

 [UnitRate] [money] NULL,

 [NonCovered] [money] NULL,

 [Paid] [money] NULL,

 [PlaceOfService] [char](3) NULL,

 [Modifier1] [char](3) NULL,

 [Modifier2] [char](3) NULL,

 [Modifier3] [char](3) NULL,

 [Modifier4] [char](3) NULL,

 [ProcedureDescription] [varchar](80) NULL,

 [OralCavityDesignation1] [char](3) NULL,

 [OralCavityDesignation2] [char](3) NULL,

 [OralCavityDesignation3] [char](3) NULL,

 [OralCavityDesignation4] [char](3) NULL,

 [OralCavityDesignation5] [char](3) NULL,

 [DiagPointer1] [char](1) NULL,

 [DiagPointer2] [char](1) NULL,

 [DiagPointer3] [char](1) NULL,

 [DiagPointer4] [char](1) NULL,

 [ToothNumber] [char](2) NULL,

 [Surface] [varchar](10) NULL,

 [EmergencyIndicator] [char](1) NULL,

 [ServiceTax] [money] NULL,

 [FacilityTax] [money] NULL,

 [SalesTax] [money] NULL,

 [ApprovedAmount] [money] NULL,

 [LineK3_01] [varchar](80) NULL,

 [LineK3_02] [varchar](80) NULL,

 [LineK3_03] [varchar](80) NULL,

 [LineK3_04] [varchar](80) NULL,

 [LineK3_05] [varchar](80) NULL,

 [LineK3_06] [varchar](80) NULL,

 [LineK3_07] [varchar](80) NULL,

 [LineK3_08] [varchar](80) NULL,

 [LineK3_09] [varchar](80) NULL,

 [LineK3_10] [varchar](80) NULL,

 [Remark] [varchar](100) NULL,

 [AmbulancePatientCount] [bigint] NULL,

 /****PWK****/

 [ReportType] [char](2) NULL,

 [ReportTransmission] [char](2) NULL,

 [AttachmentControlNumber] [varchar](80) NULL,

 /*HCP*/

 [RepricingMethodology] [varchar](3) NULL,

 [RepricedAmount] [money] NULL,

 [SavingsAmount] [money] NULL,

 [RepricerID] [varchar](30) NULL,

 [RepricingRate] [varchar](9) NULL,

 [APG_Code] [varchar](30) NULL,

 [APG_Amount] [money] NULL,

 [ApprovedRevenueCode] [varchar] (48) NULL,

 [ApprovedProcedureCode] [varchar] (48) NULL,

 [ApprovedUnitCode] [char](2) NULL,

 [ApprovedUnits] [bigint] NULL,

 [RejectReason] [varchar](3) NULL,

 [ComplianceCode] [varchar](2) NULL,

 [ExceptionCode] [varchar](2) NULL,

 /*  Drugs  */

 [DrugCode] [varchar](48) NULL,

 [DrugUnitPrice] [money] NULL,

 [DrugUnitCode] [char](2) NULL,

 [DrugUnits] [float] NULL,

 [PrescriptionNumber] [varchar](30) NULL,

 /* CR1 */

 [PatientWeight] [varchar](10) NULL,

 [AmbulanceTransportCode] [char](1) NULL,

 [AmbulanceTransportReasonCode] [char](1) NULL,

 [TransportDistance] [varchar](15) NULL,

 [RoundTripPurposeDescription] [varchar](80) NULL,

 [StretcherPurposeDescription] [varchar](80) NULL,

 /* CRC — Ambulance Certification */

 [AmbulanceConditionIndicator] [char](1) NULL,

 [AmbulanceConditionCode1] [char](3) NULL,

 [AmbulanceConditionCode2] [char](3) NULL,

 [AmbulanceConditionCode3] [char](3) NULL,

 [AmbulanceConditionCode4] [char](3) NULL,

 [AmbulanceConditionCode5] [char](3) NULL,

 /*  Attending Provider */

 [AttendingProviderLast] [varchar](35) NULL,

 [AttendingProviderFirst] [varchar](25) NULL,

 [AttendingProviderMiddle] [varchar](25) NULL,

 [AttendingProviderSuffix] [varchar](10) NULL,

 [AttendingProviderIDQual] [char](2) NULL,

 [AttendingProviderID] [varchar](35) NULL,

 [AttendingProviderOtherIDQual] [char](2) NULL,

 [AttendingProviderOtherID] [varchar](30) NULL,

 /*  Operating Provider */

 [OperatingProviderLast] [varchar](35) NULL,

 [OperatingProviderFirst] [varchar](25) NULL,

 [OperatingProviderMiddle] [varchar](25) NULL,

 [OperatingProviderSuffix] [varchar](10) NULL,

 [OperatingProviderIDQual] [char](2) NULL,

 [OperatingProviderID] [varchar](35) NULL,        

 [OperatingProviderOtherIDQual] [char](2) NULL,

 [OperatingProviderOtherID] [varchar](30) NULL,

 /*  Other Provider */

 [OtherProviderLast] [varchar](35) NULL,

 [OtherProviderFirst] [varchar](25) NULL,

 [OtherProviderMiddle] [varchar](25) NULL,

 [OtherProviderSuffix] [varchar](10) NULL,

 [OtherProviderIDQual] [char](2) NULL,

 [OtherProviderID] [varchar](35) NULL,

 [OtherProviderOtherIDQual] [char](2) NULL,

 [OtherProviderOtherID] [varchar](30) NULL,

 /*  Rendering Provider */

 [RenderingProviderLast] [varchar](35) NULL,

 [RenderingProviderFirst] [varchar](25) NULL,

 [RenderingProviderMiddle] [varchar](25) NULL,

 [RenderingProviderSuffix] [varchar](10) NULL,

 [RenderingProviderIDQual] [char](2) NULL,

 [RenderingProviderID] [varchar](35) NULL,

 [RenderingProviderOtherIDQual] [char](2) NULL,

 [RenderingProviderOtherID] [varchar](30) NULL,

 /*  PurchasedService Provider */

 [PurchasedServiceProviderLast] [varchar](35) NULL,

 [PurchasedServiceProviderFirst] [varchar](25) NULL,

 [PurchasedServiceProviderMiddle] [varchar](25) NULL,

 [PurchasedServiceProviderSuffix] [varchar](10) NULL,

 [PurchasedServiceProviderIDQual] [char](2) NULL,

 [PurchasedServiceProviderID] [varchar](35) NULL,

 [PurchasedServiceProviderOtherIDQual] [char](2) NULL,

 [PurchasedServiceProviderOtherID] [varchar](30) NULL,

 /*  Facility Provider */

 [FacilityName] [varchar](35) NULL,

 [FacilityIDQual] [char](2) NULL,

 [FacilityID] [varchar](35) NULL,

 [FacilityAddress1] [varchar](25) NULL,

 [FacilityAddress2] [varchar](25) NULL,

 [FacilityCity] [varchar](30) NULL,

 [FacilityState] [char](2) NULL,

 [FacilityZip] [varchar](15) NULL,

 [FacilityOtherIDQual] [char](2) NULL,

 [FacilityOtherID] [varchar](30) NULL,

 /*  Supervising Provider */

 [SupervisingProviderLast] [varchar](35) NULL,

 [SupervisingProviderFirst] [varchar](25) NULL,

 [SupervisingProviderMiddle] [varchar](25) NULL,

 [SupervisingProviderSuffix] [varchar](10) NULL,

 [SupervisingProviderIDQual] [char](2) NULL,

 [SupervisingProviderID] [varchar](35) NULL,

 [SupervisingProviderOtherIDQual] [char](2) NULL,

 [SupervisingProviderOtherID] [varchar](30) NULL,

 /*  Ordering Provider */

 [OrderingProviderLast] [varchar](35) NULL,

 [OrderingProviderFirst] [varchar](25) NULL,

 [OrderingProviderMiddle] [varchar](25) NULL,

 [OrderingProviderSuffix] [varchar](10) NULL,

 [OrderingProviderIDQual] [char](2) NULL,

 [OrderingProviderID] [varchar](35) NULL,

 [OrderingProviderOtherIDQual] [char](2) NULL,

 [OrderingProviderOtherID] [varchar](30) NULL,

 /*  Referring Provider */

 [ReferringProviderLast] [varchar](35) NULL,

 [ReferringProviderFirst] [varchar](25) NULL,

 [ReferringProviderMiddle] [varchar](25) NULL,

 [ReferringProviderSuffix] [varchar](10) NULL,

 [ReferringProviderIDQual] [char](2) NULL,

 [ReferringProviderID] [varchar](35) NULL,

 [ReferringProviderOtherIDQual] [char](2) NULL,

 [ReferringProviderOtherID] [varchar](30) NULL,

 /*COB 1 */

 [OtherPayer1ID] [varchar](30) NULL,

 [OtherPayer1Paid] [money] NULL,

 [OtherPayer1PaidProcedure] [varchar](30) NULL,

 [OtherPayer1PaidRevenueCode] [varchar](30) NULL,

 [OtherPayer1PaidQuantity] [bigint] NULL,

 [OtherPayer1BundledLine] [int] NULL,

 [OtherPayer1AdjustmentReasonGroup1] [char](2) NULL,

 [OtherPayer1AdjustmentReason1] [varchar](5) NULL,

 [OtherPayer1AdjustmentAmount1] [money] NULL,

 [OtherPayer1AdjustmentQuantity1] [bigint] NULL,

 [OtherPayer1AdjustmentReasonGroup2] [char](2) NULL,

 [OtherPayer1AdjustmentReason2] [varchar](5) NULL,

 [OtherPayer1AdjustmentAmount2] [money] NULL,

 [OtherPayer1AdjustmentQuantity2] [bigint] NULL,

 [OtherPayer1AdjustmentReasonGroup3] [char](2) NULL,

 [OtherPayer1AdjustmentReason3] [varchar](5) NULL,

 [OtherPayer1AdjustmentAmount3] [money] NULL,

 [OtherPayer1AdjustmentQuantity3] [bigint] NULL,

 [OtherPayer1AdjustmentReasonGroup4] [char](2) NULL,

 [OtherPayer1AdjustmentReason4] [varchar](5) NULL,

 [OtherPayer1AdjustmentAmount4] [money] NULL,

 [OtherPayer1AdjustmentQuantity4] [bigint] NULL,

 --[OtherPayer1AdjustmentReasonGroup5Plus] [varchar](77) NULL,

 --[OtherPayer1AdjustmentReason5Plus] [varchar](155) NULL,

 --[OtherPayer1AdjustmentAmount5Plus] [varchar](493) NULL,

 --[OtherPayer1AdjustmentQuantity5Plus] [varchar](415) NULL,

 [OtherPayer1PaidDate] [date] NULL,

 /*COB 2 */

 [OtherPayer2ID] [varchar](30) NULL,

 [OtherPayer2Paid] [money] NULL,

 [OtherPayer2PaidProcedure] [varchar](30) NULL,

 [OtherPayer2PaidRevenueCode] [varchar](30) NULL,

 [OtherPayer2PaidQuantity] [bigint] NULL,

 [OtherPayer2BundledLine] [int] NULL,

 [OtherPayer2AdjustmentReasonGroup1] [char](2) NULL,

 [OtherPayer2AdjustmentReason1] [varchar](5) NULL,

 [OtherPayer2AdjustmentAmount1] [money] NULL,

 [OtherPayer2AdjustmentQuantity1] [bigint] NULL,

 [OtherPayer2AdjustmentReasonGroup2] [char](2) NULL,

 [OtherPayer2AdjustmentReason2] [varchar](5) NULL,

 [OtherPayer2AdjustmentAmount2] [money] NULL,

 [OtherPayer2AdjustmentQuantity2] [bigint] NULL,

 [OtherPayer2AdjustmentReasonGroup3] [char](2) NULL,

 [OtherPayer2AdjustmentReason3] [varchar](5) NULL,

 [OtherPayer2AdjustmentAmount3] [money] NULL,

 [OtherPayer2AdjustmentQuantity3] [bigint] NULL,

 [OtherPayer2AdjustmentReasonGroup4] [char](2) NULL,

 [OtherPayer2AdjustmentReason4] [varchar](5) NULL,

 [OtherPayer2AdjustmentAmount4] [money] NULL,

 [OtherPayer2AdjustmentQuantity4] [bigint] NULL,

 --[OtherPayer2AdjustmentReasonGroup5Plus] [varchar](77) NULL,

 --[OtherPayer2AdjustmentReason5Plus] [varchar](155) NULL,

 --[OtherPayer2AdjustmentAmount5Plus] [varchar](493) NULL,

 --[OtherPayer2AdjustmentQuantity5Plus] [varchar](415) NULL,

 [OtherPayer2PaidDate] [date] NULL

) ON [PRIMARY]