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CREATE TABLE `EDI_Claims`(

 `ID`  int(11) NOT NULL auto_increment,

 /*File Level Data*/

 `Filename` varchar(100) default NULL,

 `ImageFilePath` varchar(300) default NULL,

 `ImageFilename` varchar(100) default NULL,

 `Version` varchar(12) default NULL,

 `TradingPartnerIDType` char(2) default NULL,

 `TradingPartnerID` varchar(15) NOT NULL,

 `TransactionDate` varchar(15) default NULL,

 `ReceiveDate` varchar(15) default NULL,

 `SubmitterName` varchar(60) default NULL,

 `SubmitterID` varchar(30) default NULL,

 `SubmitterContact` varchar(60) default NULL,

 `SubmitterTel` varchar(20) default NULL,

 `SubmitterTelExt` varchar(10) default NULL,

 `SubmitterFax` varchar(20) default NULL,

 `SubmitterEmail` varchar(80) default NULL,

 `ReceiverName` varchar(60) default NULL,

 `ReceiverID` varchar(30) default NULL,

 `TransactionType` char(2) default NULL,

 /*Billing Provider*/

 `FedTaxID` varchar(15) default NULL,

 `BillProvIDType` char(2) default NULL,

 `BillProvID` varchar(80) default NULL,

 `BillProvNPI` varchar(12) default NULL,

 `BillProvLast` varchar(60) default NULL,

 `BillProvFirst` varchar(35) default NULL,

 `BillProvMiddle` varchar(25) default NULL,

 `BillProvSuffix` varchar(10) default NULL,

 `BillProvSpecialty` varchar(10) default NULL,

 `BillProvAddress` varchar(55) default NULL,

 `BillProvAddress2` varchar(55) default NULL,

 `BillProvCity` varchar(30) default NULL,

 `BillProvState` char(2) default NULL,

 `BillProvZip` varchar(15) default NULL,

 `BillProvCountry` varchar(3) default NULL,

 `BillProvSubdivision` varchar(3) default NULL,

 `BillProvContact` varchar(60) default NULL,

 `BillProvTel` varchar(80) default NULL,

 `BillProvTelExt` varchar(80) default NULL,

 `BillProvFax` varchar(80) default NULL,

 `BillProvEmail` varchar(80) default NULL,

 `BillProvOtherIDQual1` varchar(100) default NULL,

 `BillProvOtherID1` varchar(100) default NULL,

 `BillProvOtherIDQual2` varchar(100) default NULL,

 `BillProvOtherID2` varchar(100) default NULL,

 `BillProvOtherIDQual3` varchar(100) default NULL,

 `BillProvOtherID3` varchar(100) default NULL,

 `BillProvOtherIDQual4` varchar(100) default NULL,

 `BillProvOtherID4` varchar(100) default NULL,

 `BillProvOtherIDQual5` varchar(100) default NULL,

 `BillProvOtherID5` varchar(100) default NULL,

 /*Pay-to Provider*/

 `PayToProvIDType` char(2) default NULL,

 `PayToProvID` varchar(80) default NULL,

 `PayToProvTaxID` varchar(12) default NULL,

 `PayToProvNPI` varchar(12) default NULL,

 `PayToProvLast` varchar(60) default NULL,

 `PayToProvFirst` varchar(35) default NULL,

 `PayToProvMiddle` varchar(25) default NULL,

 `PayToProvSuffix` varchar(10) default NULL,

 `PayToProvSpecialty` varchar(10) default NULL,

 `PayToProvAddress` varchar(55) default NULL,

 `PayToProvAddress2` varchar(55) default NULL,

 `PayToProvCity` varchar(30) default NULL,

 `PayToProvState` char(2) default NULL,

 `PayToProvZip` varchar(15) default NULL,

 /*Pay-to Payer*/

 `PayToPayerIDType` char(2) default NULL,

 `PayToPayerID` varchar(80) default NULL,

 `PayToPayerTaxID` varchar(12) default NULL,

 `PayToPayerLast` varchar(60) default NULL,

 `PayToPayerFirst` varchar(35) default NULL,

 `PayToPayerMiddle` varchar(25) default NULL,

 `PayToPayerSuffix` varchar(10) default NULL,

 `PayToPayerAddress` varchar(55) default NULL,

 `PayToPayerAddress2` varchar(55) default NULL,

 `PayToPayerCity` varchar(30) default NULL,

 `PayToPayerState` char(2) default NULL,

 `PayToPayerZip` varchar(15) default NULL,

 `PayToPayerOtherIDQual` char(2) default NULL,

 `PayToPayerOtherID` varchar(30) default NULL,

 /*Subscriber*/

 `SubscriberLast` varchar(60) default NULL,

 `SubscriberFirst` varchar(35) default NULL,

 `SubscriberMiddle` varchar(25) default NULL,

 `SubscriberSuffix` varchar(10) default NULL,

 `SubscriberIDType` char(2) default NULL,

 `SubscriberID` varchar(80) default NULL,

 `SubscriberAddress` varchar(55) default NULL,

 `SubscriberAddress2` varchar(55) default NULL,

 `SubscriberCity` varchar(30) default NULL,

 `SubscriberState` char(2) default NULL,

 `SubscriberZip` varchar(15) default NULL,

 `SubscriberCountry` varchar(3) default NULL,

 `SubscriberLocation` varchar(30) default NULL,

 `SubscriberSubdivision` varchar(3) default NULL,

 `SubscriberDOB` varchar(10) default NULL,

 `SubscriberSex` char(1) default NULL,

 `SubscriberEthnicity` varchar(75) default NULL,

 `SubscriberMaritalStatus` char(1) default NULL,

 `SubscriberCollectionMethod` varchar(30) default NULL,

 `SubscriberSSN` varchar(12) default NULL,

 `SubscriberAgencyClaimNo` varchar(50) default NULL,

 `SubscriberMemberID` varchar(50) default NULL,

 `SubscriberPersonalID` varchar(50) default NULL,

 `SubscriberContact` varchar(60) default NULL,

 `SubscriberTel` varchar(15) default NULL,

 `SubscriberTelExt` varchar(10) default NULL,

 /*Destination Payer*/

 `PayerName` varchar(60) default NULL,

 `PayerIDType` char(2) default NULL,

 `PayerID` varchar(30) default NULL,

 `PayerAddress` varchar(55) default NULL,

 `PayerAddress2` varchar(55) default NULL,

 `PayerCity` varchar(30) default NULL,

 `PayerState` char(2) default NULL,

 `PayerZip` varchar(15) default NULL,

 `PayerResponsibility` char(1) default NULL,        

 `PayerOtherIDQual1` varchar(3) default NULL,

 `PayerOtherID1` varchar(50) default NULL,

 `PayerOtherIDQual2` varchar(3) default NULL,

 `PayerOtherID2` varchar(50) default NULL,

 `PayerOtherIDQual3` varchar(3) default NULL,

 `PayerOtherID3` varchar(50) default NULL,

 `GroupNo` varchar(50) default NULL,

 `GroupName` varchar(60) default NULL,

 `InsuranceType` char(2) default NULL,

 `FilingIndicator` char(2) default NULL,

 `COBIndicator` char(1) default NULL,

 /*Responsible*/

 `ResponsibleLast` varchar(60) default NULL,

 `ResponsibleFirst` varchar(35) default NULL,

 `ResponsibleMiddle` varchar(25) default NULL,

 `ResponsibleSuffix` varchar(10) default NULL,

 `ResponsibleAddress` varchar(55) default NULL,

 `ResponsibleAddress2` varchar(55) default NULL,

 `ResponsibleCity` varchar(30) default NULL,

 `ResponsibleState` char(2) default NULL,

 `ResponsibleZip` varchar(15) default NULL,

 `ResponsibleIDType` char(2) default NULL,

 `ResponsibleID` varchar(80) default NULL,

 /*Patient*/

 `PatientLast` varchar(60) default NULL,

 `PatientFirst` varchar(35) default NULL,

 `PatientMiddle` varchar(25) default NULL,

 `PatientSuffix` varchar(10) default NULL,

 `PatientAddress` varchar(55) default NULL,

 `PatientAddress2` varchar(55) default NULL,

 `PatientCity` varchar(30) default NULL,

 `PatientState` char(2) default NULL,

 `PatientZip` varchar(15) default NULL,

 `PatientCountry` varchar(3) default NULL,

 `PatientLocation` varchar(30) default NULL,

 `PatientSubdivision` varchar(3) default NULL,

 `PatientIDType` char(2) default NULL,

 `PatientID` varchar(80) default NULL,

 `PatientSSN` varchar(12) default NULL,

 `PatientMemberID` varchar(50) default NULL,

 `PatientPersonalID` varchar(50) default NULL,

 `PatientInsurancePolicy` varchar(50) default NULL,

 `PatientDOB` varchar(50) default NULL,

 `PatientSex` char(1) default NULL,

 `PatientEthnicity` varchar(75) default NULL,

 `PatientMaritalStatus` char(1) default NULL,

 `PatientCollectionMethod` varchar(30) default NULL,

 `PatientRelationship` char(2) default NULL,

 `PatientPaid` varchar(10) default NULL,

 `PregnancyIndicator` char(1) default NULL,

 /*Rendering Provider*/

 `RendProvIDType` char(2) default NULL,

 `RendProvID` varchar(80) default NULL,

 `RendProvNPI` varchar(12) default NULL,

 `RendProvTaxID` varchar(12) default NULL,

 `RendProvLast` varchar(60) default NULL,

 `RendProvFirst` varchar(35) default NULL,

 `RendProvMiddle` varchar(25) default NULL,

 `RendProvSuffix` varchar(10) default NULL,

 `RendProvSpecialty` varchar(10) default NULL,

 `RendProvOtherIDQual1` varchar(3) default NULL,

 `RendProvOtherID1` varchar(50) default NULL,

 `RendProvOtherIDQual2` varchar(3) default NULL,

 `RendProvOtherID2` varchar(50) default NULL,

 `RendProvOtherIDQual3` varchar(3) default NULL,

 `RendProvOtherID3` varchar(50) default NULL,

 /*Attending Provider*/

 `AttendProvLast` varchar(60) default NULL,

 `AttendProvFirst` varchar(35) default NULL,

 `AttendProvMiddle` varchar(25) default NULL,

 `AttendProvSuffix` varchar(10) default NULL,

 `AttendProvIDType` char(2) default NULL,

 `AttendProvID` varchar(80) default NULL,

 `AttendProvTaxID` varchar(12) default NULL,

 `AttendProvNPI` varchar(12) default NULL,

 `AttendProvOtherIDQual1` varchar(100) default NULL,

 `AttendProvOtherID1` varchar(100) default NULL,

 `AttendProvSpecialty` varchar(10) default NULL,

 /*Operating Provider*/

 `OperatingProvLast` varchar(60) default NULL,

 `OperatingProvFirst` varchar(35) default NULL,

 `OperatingProvMiddle` varchar(25) default NULL,

 `OperatingProvSuffix` varchar(10) default NULL,

 `OperatingProvIDType` char(2) default NULL,

 `OperatingProvID` varchar(80) default NULL,

 `OperatingProvNPI` varchar(12) default NULL,

 `OperatingProvTaxID` varchar(12) default NULL,

 `OperatingProvOtherIDQual1` varchar(100) default NULL,

 `OperatingProvOtherID1` varchar(100) default NULL,

 `OperatingProvSpecialty` varchar(10) default NULL,

 /*Other Provider*/

 `OtherProvLast` varchar(60) default NULL,

 `OtherProvFirst` varchar(35) default NULL,

 `OtherProvMiddle` varchar(25) default NULL,

 `OtherProvSuffix` varchar(10) default NULL,

 `OtherProvIDType` varchar(100) default NULL,

 `OtherProvID` varchar(100) default NULL,

 `OtherProvTaxID` varchar(12) default NULL,

 `OtherProvNPI` varchar(12) default NULL,

 `OtherProvOtherIDQual1` varchar(100) default NULL,

 `OtherProvOtherID1` varchar(100) default NULL,

 `OtherProvSpecialty` varchar(100) default NULL,

 /*Facility*/

 `FacilityType` char(2) default NULL,

 `FacilityIDType` char(2) default NULL,

 `FacilityID` varchar(80) default NULL,

 `FacilityNPI` varchar(12) default NULL,

 `FacilityTaxID` varchar(12) default NULL,

 `FacilityOtherIDQual1` varchar(100) default NULL,

 `FacilityOtherID1` varchar(100) default NULL,

 `FacilityName` varchar(80) default NULL,

 `FacilityAddress` varchar(55) default NULL,

 `FacilityAddress2` varchar(55) default NULL,

 `FacilityCity` varchar(30) default NULL,

 `FacilitySpecialty` varchar(100) default NULL,

 `FacilityState` char(2) default NULL,

 `FacilityZip` varchar(15) default NULL,

 /*Referring Provider*/

 `RefProvLast` varchar(60) default NULL,

 `RefProvFirst` varchar(35) default NULL,

 `RefProvMiddle` varchar(25) default NULL,

 `RefProvSuffix` varchar(10) default NULL,

 `RefProvIDType` char(2) default NULL,

 `RefProvID` varchar(80) default NULL,

 `RefProvTaxID` varchar(12) default NULL,

 `RefProvNPI` varchar(12) default NULL,

 `RefProvOtherIDQual1` varchar(100) default NULL,

 `RefProvOtherID1` varchar(100) default NULL,

 `RefProvSpecialty` varchar(10) default NULL,

 /*Supervising Provider*/

 `SupervProvLast` varchar(60) default NULL,

 `SupervProvFirst` varchar(35) default NULL,

 `SupervProvMiddle` varchar(25) default NULL,

 `SupervProvSuffix` varchar(10) default NULL,

 `SupervProvIDType` char(2) default NULL,

 `SupervProvID` varchar(80) default NULL,

 `SupervProvTaxID` varchar(12) default NULL,

 `SupervProvNPI` varchar(12) default NULL,

 `SupervProvOtherIDQual1` varchar(3) default NULL,

 `SupervProvOtherID1` varchar(50) default NULL,

 `SupervProvSpecialty` varchar(10) default NULL,

 /*Assistant Surgeon*/

 `AssistSurgLast` varchar(60) default NULL,

 `AssistSurgFirst` varchar(35) default NULL,

 `AssistSurgMiddle` varchar(25) default NULL,

 `AssistSurgSuffix` varchar(10) default NULL,

 `AssistSurgIDType` char(2) default NULL,

 `AssistSurgID` varchar(80) default NULL,

 `AssistSurgTaxID` varchar(12) default NULL,

 `AssistSurgNPI` varchar(12) default NULL,

 `AssistSurgOtherIDQual1` varchar(3) default NULL,

 `AssistSurgOtherID1` varchar(50) default NULL,

 `AssistSurgSpecialty` varchar(10) default NULL,

 /*Ambulance Pick-up Location*/

 `PickUpAddress` varchar(55) default NULL,

 `PickUpAddress2` varchar(55) default NULL,

 `PickUpCity` varchar(30) default NULL,

 `PickUpState` char(2) default NULL,

 `PickUpZip` varchar(15) default NULL,

 /*Ambulance Drop-off Location*/

 `DropOffName` varchar(80) default NULL,

 `DropOffAddress` varchar(55) default NULL,

 `DropOffAddress2` varchar(55) default NULL,

 `DropOffCity` varchar(30) default NULL,

 `DropOffState` char(2) default NULL,

 `DropOffZip` varchar(15) default NULL,        

 /*COB Payer 1*/

 `OtherInsuredLast` varchar(60) default NULL,

 `OtherInsuredFirst` varchar(35) default NULL,

 `OtherInsuredMiddle` varchar(25) default NULL,

 `OtherInsuredSuffix` varchar(10) default NULL,

 `OtherInsuredIDQual` char(2) default NULL,

 `OtherInsuredID` varchar(10) default NULL,

 `OtherInsuredAddress` varchar(55) default NULL,

 `OtherInsuredAddress2` varchar(55) default NULL,

 `OtherInsuredCity` varchar(30) default NULL,

 `OtherInsuredState` char(2) default NULL,

 `OtherInsuredZip` varchar(15) default NULL,

 `OtherInsuredCountry` varchar(3) default NULL,

 `OtherInsuredSubdivision` varchar(3) default NULL,

 `OtherInsuredPolicy` varchar(50) default NULL,

 `OtherInsuredDOB` varchar(10) default NULL,

 `OtherInsuredSex` char(1) default NULL,

 `OtherInsuredRelationship` char(2) default NULL,

 `OtherInsuredOtherIDQual1` char(3) default NULL,

 `OtherInsuredOtherID1` varchar(50) default NULL,

 `OtherInsuredOtherIDQual2` char(3) default NULL,

 `OtherInsuredOtherID2` varchar(50) default NULL,

 `OtherInsuredOtherIDQual3` char(3) default NULL,

 `OtherInsuredOtherID3` varchar(50) default NULL,

 `OtherPayerResponsibility` varchar(100) default NULL,

 `OtherPayerName` varchar(35) default NULL,

 `OtherPayerIDQual` char(2) default NULL,

 `OtherPayerID` varchar(80) default NULL,

 `OtherPayerAddress1` varchar(55) default NULL,

 `OtherPayerAddress2` varchar(55) default NULL,

 `OtherPayerCity` varchar(30) default NULL,

 `OtherPayerState` char(2) default NULL,

 `OtherPayerZip` varchar(15) default NULL,

 `OtherPayerPaid` varchar(10) default NULL,

 `OtherPayerGroupName` varchar(100) default NULL,

 `OtherPayerGroupNo` varchar(100) default NULL,

 `OtherPayerInsuranceType` char(2) default NULL,

 `OtherPayerFilingIndicator` char(2) default NULL,

 `OtherPayerAdjustmentReasonGroup` varchar(100) default NULL,

 `OtherPayerAdjustmentReason` varchar(100) default NULL,

 `OtherPayerAdjustmentAmount` varchar(100) default NULL,

 `OtherPayerPaidDate` varchar(15) default NULL,

 `OtherPayerInfoRelease` varchar(100) default NULL,

 `OtherPayerBenefitAssign` varchar(100) default NULL,

 `OtherPayerDocControlNo` varchar(100) default NULL,

 `OtherPayerPriorAuth` varchar(100) default NULL,

 `OtherPayerOtherIDQual1` char(3) default NULL,

 `OtherPayerOtherID1` varchar(50) default NULL,

 `OtherPayerOtherIDQual2` char(3) default NULL,

 `OtherPayerOtherID2` varchar(50) default NULL,

 /*COB Payer 2*/

 `OtherInsured2Last` varchar(60) default NULL,

 `OtherInsured2First` varchar(35) default NULL,

 `OtherInsured2Middle` varchar(25) default NULL,

 `OtherInsured2Suffix` varchar(10) default NULL,

 `OtherInsured2IDQual` char(2) default NULL,

 `OtherInsured2ID` varchar(10) default NULL,

 `OtherInsured2Address` varchar(55) default NULL,

 `OtherInsured2Address2` varchar(55) default NULL,

 `OtherInsured2City` varchar(30) default NULL,

 `OtherInsured2State` char(2) default NULL,

 `OtherInsured2Zip` varchar(15) default NULL,

 `OtherInsured2Country` varchar(3) default NULL,

 `OtherInsured2Subdivision` varchar(3) default NULL,

 `OtherInsured2Policy` varchar(50) default NULL,

 `OtherInsured2DOB` varchar(10) default NULL,

 `OtherInsured2Sex` char(1) default NULL,

 `OtherInsured2Relationship` char(2) default NULL,

 `OtherInsured2OtherIDQual1` char(3) default NULL,

 `OtherInsured2OtherID1` varchar(50) default NULL,

 `OtherInsured2OtherIDQual2` char(3) default NULL,

 `OtherInsured2OtherID2` varchar(50) default NULL,

 `OtherInsured2OtherIDQual3` char(3) default NULL,

 `OtherInsured2OtherID3` varchar(50) default NULL,

 `OtherPayer2Responsibility` varchar(100) default NULL,

 `OtherPayer2Name` varchar(35) default NULL,

 `OtherPayer2IDQual` char(2) default NULL,

 `OtherPayer2ID` varchar(80) default NULL,

 `OtherPayer2Address1` varchar(55) default NULL,

 `OtherPayer2Address2` varchar(55) default NULL,

 `OtherPayer2City` varchar(30) default NULL,

 `OtherPayer2State` char(2) default NULL,

 `OtherPayer2Zip` varchar(15) default NULL,

 `OtherPayer2Paid` varchar(10) default NULL,

 `OtherPayer2GroupName` varchar(100) default NULL,

 `OtherPayer2GroupNo` varchar(100) default NULL,

 `OtherPayer2InsuranceType` char(2) default NULL,

 `OtherPayer2FilingIndicator` char(2) default NULL,

 `OtherPayer2AdjustmentReasonGroup` varchar(100) default NULL,

 `OtherPayer2AdjustmentReason` varchar(100) default NULL,

 `OtherPayer2AdjustmentAmount` varchar(100) default NULL,

 `OtherPayer2PaidDate` varchar(15) default NULL,

 `OtherPayer2InfoRelease` varchar(100) default NULL,

 `OtherPayer2BenefitAssign` varchar(100) default NULL,

 `OtherPayer2DocControlNo` varchar(100) default NULL,

 `OtherPayer2PriorAuth` varchar(100) default NULL,

 `OtherPayer2OtherIDQual1` char(3) default NULL,

 `OtherPayer2OtherID1` varchar(50) default NULL,

 `OtherPayer2OtherIDQual2` char(3) default NULL,

 `OtherPayer2OtherID2` varchar(50) default NULL,

 /*Claim Data*/

 `ClaimNo` varchar(50) NOT NULL,

 `Amount` decimal(10,2) default NULL,

 `EstimatedAmountDue` decimal(10,2) default NULL,

 `PatientEstimatedAmountDue` decimal(10,2) default NULL,

 `PlaceOfService` char(2) default NULL,

 `ClaimFrequency` char(1) default NULL,

 `SubmitReason` char(1) default NULL,

 `ProviderSignature` char(1) default NULL,

 `ProviderAcceptsAssignment` char(1) default NULL,

 `BenefitAssignment` char(1) default NULL,

 `InfoReleaseCode` char(1) default NULL,

 `PatientSignatureCode` char(1) default NULL,

 `RelatedCauses` char(2) default NULL,

 `RelatedCauses2` char(2) default NULL,

 `RelatedCausesState` char(2) default NULL,

 `SpecialProgramCode` char(3) default NULL,

 `ProviderParticipation` char(1) default NULL,

 `EOBIndicator` char(1) default NULL,

 `DelayReasonCode` char(2) default NULL,

 `ServiceDateFrom` varchar(15) default NULL,

 `ServiceDateTo` varchar(15) default NULL,

 `OnsetDate` varchar(15) default NULL,

 `SimilarSymptomsDate` varchar(10) default NULL,

 `DisabilityBegin` varchar(10) default NULL,

 `DisabilityEnd` varchar(10) default NULL,

 `HospitalizationBegin` varchar(20) default NULL,

 `HospitalizationEnd` varchar(10) default NULL,

 `AccidentDate` varchar(20) default NULL,

 `LastMenstrualPeriod` varchar(15) default NULL,        

 `RepricerReceivedDate` varchar(15) default NULL,

 `AdmissionDate` varchar(15) default NULL,

 `AdmissionHour` varchar(10) default NULL,

 `AdmissionType` char(1) default NULL,

 `AdmissionSource` char(1) default NULL,

 `DischargeHour` varchar(10) default NULL,

 `PatientStatus` char(2) default NULL,

 `CoveredDays` varchar(4) default NULL,

 `NonCoveredDays` varchar(4) default NULL,

 `COBDays` varchar(4) default NULL,

 `LifeTimeReserveDays` varchar(4) default NULL,

 `PriorAuthorization` varchar(50) default NULL,

 `ClearingHouseID` varchar(100) default NULL,

 `MedicalRecordNumber` varchar(50) default NULL,

 `MothersMedicalRecordNumber` varchar(50) default NULL,

 `ServiceAuthorizationException` varchar(50) default NULL,

 `ReferralNumber` varchar(50) default NULL,

 `PayerClaimControlNumber` varchar(50) default NULL,        

 `RepricedClaimNumber` varchar(50) default NULL,

 `AdjustedRepricedClaimNumber` varchar(50) default NULL,

 `AutoAccidentState` varchar(50) default NULL,

 `OrigRefNo` varchar(50) default NULL,

 `ClaimType` char(1) default NULL,

 `TypeOfBill` varchar(20) default NULL,

 `Remark1` varchar(90) default NULL,

 `Remark2` varchar(90) default NULL,

 `Remark3` varchar(90) default NULL,

 `Remark4` varchar(90) default NULL,

 `K3_1` varchar(80) default NULL,

 `K3_2` varchar(80) default NULL,

 `K3_3` varchar(80) default NULL,

 `K3_4` varchar(80) default NULL,

 `K3_5` varchar(80) default NULL,

 `K3_6` varchar(80) default NULL,

 `K3_7` varchar(80) default NULL,

 `K3_8` varchar(80) default NULL,

 `K3_9` varchar(80) default NULL,

 `K3_10` varchar(80) default NULL,

 `OutsideLab` char(1) default NULL,

 `LabCharge` varchar(10) default NULL,

 `Test_Prod` char(1) default NULL,

 `ReportTypeCode1` varchar(100) default NULL,

 `ReportTransmissionCode1` varchar(100) default NULL,

 `AttachmentControlNumber1` varchar(100) default NULL,

 /*Dental Claims*/

 `Predetermination` varchar(100) default NULL,

 `OrthodonticTotal` varchar(100) default NULL,

 `OrthodonticRemaining` varchar(100) default NULL,

 `OrthodonticYesNo` varchar(100) default NULL,

 `ToothStatus` varchar(100) default NULL,

 `AppliancePlacementDate` varchar(100) default NULL,

 /*Diagnosis Information*/

 `AdmitDiagnosis` varchar(10) default NULL,

 `ECode` varchar(100) default NULL,

 `ECode2` varchar(100) default NULL,

 `ECode3` varchar(100) default NULL,

 `ECode4` varchar(100) default NULL,

 `ECode5` varchar(100) default NULL,

 `ECode6` varchar(100) default NULL,

 `ECode7` varchar(100) default NULL,

 `ECode8` varchar(100) default NULL,

 #`ECode9` varchar(100) default NULL,

 #`ECode10` varchar(100) default NULL,

 #`ECode11` varchar(100) default NULL,

 #`ECode12` varchar(100) default NULL,

 `ReasonForVisit` varchar(100) default NULL,

 `ReasonForVisit2` varchar(100) default NULL,

 `ReasonForVisit3` varchar(100) default NULL,

 `PrincipalDiagnosis` varchar(10) default NULL,

 `Diag2` varchar(10) default NULL,

 `Diag3` varchar(10) default NULL,

 `Diag4` varchar(10) default NULL,

 `Diag5` varchar(10) default NULL,

 `Diag6` varchar(10) default NULL,

 `Diag7` varchar(10) default NULL,

 `Diag8` varchar(10) default NULL,

 `Diag9` varchar(10) default NULL,

 `Diag10` varchar(10) default NULL,

 `Diag11` varchar(10) default NULL,

 `Diag12` varchar(10) default NULL,

 `Diag13` varchar(10) default NULL,

 `Diag14` varchar(10) default NULL,

 `Diag15` varchar(10) default NULL,

 `Diag16` varchar(10) default NULL,

 `Diag17` varchar(10) default NULL,

 `Diag18` varchar(10) default NULL,

 `Diag19` varchar(10) default NULL,

 `Diag20` varchar(10) default NULL,

 `Diag21` varchar(10) default NULL,

 `Diag22` varchar(10) default NULL,

 `Diag23` varchar(10) default NULL,

 `Diag24` varchar(10) default NULL,

 `Diag25` varchar(10) default NULL,

 `DRG` varchar(15) default NULL,

 /*Procedure Information*/

 `PrincipalProcedure` varchar(10) default NULL,

 `PrincipalProcedureDate` datetime default NULL,

 `Proc2` varchar(50) default NULL,

 `Proc2Date` datetime default NULL,

 `Proc3` varchar(10) default NULL,

 `Proc3Date` datetime default NULL,

 `Proc4` varchar(10) default NULL,

 `Proc4Date` datetime default NULL,

 `Proc5` varchar(10) default NULL,

 `Proc5Date` datetime default NULL,

 `Proc6` varchar(10) default NULL,

 `Proc6Date` datetime default NULL,

 `Proc7` varchar(10) default NULL,

 `Proc7Date` datetime default NULL,

 `Proc8` varchar(10) default NULL,

 `Proc8Date` datetime default NULL,

 `Proc9` varchar(10) default NULL,

 `Proc9Date` datetime default NULL,

 `Proc10` varchar(10) default NULL,

 `Proc10Date` datetime default NULL,

 `Proc11` varchar(10) default NULL,

 `Proc11Date` datetime default NULL,

 `Proc12` varchar(10) default NULL,

 `Proc12Date` datetime default NULL,

 `Proc13` varchar(10) default NULL,

 `Proc13Date` datetime default NULL,

 `Proc14` varchar(10) default NULL,

 `Proc14Date` datetime default NULL,

 `Proc15` varchar(10) default NULL,

 `Proc15Date` datetime default NULL,

 `Proc16` varchar(10) default NULL,

 `Proc16Date` datetime default NULL,

 `Proc17` varchar(10) default NULL,

 `Proc17Date` datetime default NULL,

 `Proc18` varchar(10) default NULL,

 `Proc18Date` datetime default NULL,

 `Proc19` varchar(10) default NULL,

 `Proc19Date` datetime default NULL,

 `Proc20` varchar(10) default NULL,

 `Proc20Date` datetime default NULL,

 `Proc21` varchar(10) default NULL,

 `Proc21Date` datetime default NULL,

 `Proc22` varchar(10) default NULL,

 `Proc22Date` datetime default NULL,

 `Proc23` varchar(10) default NULL,

 `Proc23Date` datetime default NULL,

 `Proc24` varchar(10) default NULL,

 `Proc24Date` datetime default NULL,

 `Proc25` varchar(10) default NULL,

 `Proc25Date` datetime default NULL,

 /*Value Codes*/

 `ValueCode1` char(3) default NULL,

 `ValueAmount1` varchar(10) default NULL,

 `ValueCode2` char(3) default NULL,

 `ValueAmount2` varchar(10) default NULL,

 `ValueCode3` char(3) default NULL,

 `ValueAmount3` varchar(10) default NULL,

 `ValueCode4` char(3) default NULL,

 `ValueAmount4` varchar(10) default NULL,

 `ValueCode5` char(3) default NULL,

 `ValueAmount5` varchar(10) default NULL,

 `ValueCode6` char(3) default NULL,

 `ValueAmount6` varchar(10) default NULL,

 `ValueCode7` varchar(10) default NULL,

 `ValueAmount7` varchar(10) default NULL,

 `ValueCode8` char(3) default NULL,

 `ValueAmount8` varchar(10) default NULL,

 `ValueCode9` char(3) default NULL,

 `ValueAmount9` varchar(10) default NULL,

 `ValueCode10` char(3) default NULL,

 `ValueAmount10` varchar(10) default NULL,

 `ValueCode11` char(3) default NULL,

 `ValueAmount11` varchar(10) default NULL,

 `ValueCode12` char(3) default NULL,

 `ValueAmount12` varchar(10) default NULL,

 #`ValueCode13` char(3) default NULL,

 #`ValueAmount13` varchar(10) default NULL,

 #`ValueCode14` char(3) default NULL,

 #`ValueAmount14` varchar(10) default NULL,

 #`ValueCode15` char(3) default NULL,

 #`ValueAmount15` varchar(10) default NULL,

 #`ValueCode16` char(3) default NULL,

 #`ValueAmount16` varchar(10) default NULL,

 #`ValueCode17` varchar(10) default NULL,

 #`ValueAmount17` varchar(10) default NULL,

 #`ValueCode18` char(3) default NULL,

 #`ValueAmount18` varchar(10) default NULL,

 #`ValueCode19` char(3) default NULL,

 #`ValueAmount19` varchar(10) default NULL,

 #`ValueCode20` char(3) default NULL,

 #`ValueAmount20` varchar(10) default NULL,

 #`ValueCode21` char(3) default NULL,

 #`ValueAmount21` varchar(10) default NULL,

 #`ValueCode22` char(3) default NULL,

 #`ValueAmount22` varchar(10) default NULL,

 #`ValueCode23` char(3) default NULL,

 #`ValueAmount23` varchar(10) default NULL,

 #`ValueCode24` char(3) default NULL,

 #`ValueAmount24` varchar(10) default NULL,

 /*Condition Codes*/

 `ConditionCode1` varchar(30) default NULL,

 `ConditionCode2` varchar(30) default NULL,

 `ConditionCode3` varchar(30) default NULL,

 `ConditionCode4` varchar(30) default NULL,

 `ConditionCode5` varchar(30) default NULL,

 `ConditionCode6` varchar(30) default NULL,

 `ConditionCode7` varchar(30) default NULL,

 `ConditionCode8` varchar(30) default NULL,

 `ConditionCode9` varchar(30) default NULL,

 `ConditionCode10` varchar(30) default NULL,

 #`ConditionCode11` varchar(30) default NULL,

 #`ConditionCode12` varchar(30) default NULL,

 #`ConditionCode13` varchar(30) default NULL,

 #`ConditionCode14` varchar(30) default NULL,

 #`ConditionCode15` varchar(30) default NULL,

 #`ConditionCode16` varchar(30) default NULL,

 #`ConditionCode17` varchar(30) default NULL,

 #`ConditionCode18` varchar(30) default NULL,

 #`ConditionCode19` varchar(30) default NULL,

 #`ConditionCode20` varchar(30) default NULL,

 #`ConditionCode21` varchar(30) default NULL,

 #`ConditionCode22` varchar(30) default NULL,

 #`ConditionCode23` varchar(30) default NULL,

 #`ConditionCode24` varchar(30) default NULL,

 /*Occurrence Codes*/

 `OccurranceCode1` char(3) default NULL,

 `OccurranceDate1` varchar(10) default NULL,

 `OccurranceCode2` char(3) default NULL,

 `OccurranceDate2` varchar(10) default NULL,

 `OccurranceCode3` char(3) default NULL,

 `OccurranceDate3` varchar(10) default NULL,

 `OccurranceCode4` char(3) default NULL,

 `OccurranceDate4` varchar(10) default NULL,

 `OccurranceCode5` char(3) default NULL,

 `OccurranceDate5` varchar(10) default NULL,

 `OccurranceCode6` char(3) default NULL,

 `OccurranceDate6` varchar(10) default NULL,

 `OccurranceCode7` char(3) default NULL,

 `OccurranceDate7` varchar(10) default NULL,

 `OccurranceCode8` char(3) default NULL,

 `OccurranceDate8` varchar(10) default NULL,        

 #`OccurranceCode9` char(3) default NULL,

 #`OccurranceDate9` varchar(10) default NULL,

 #`OccurranceCode10` char(3) default NULL,

 #`OccurranceDate10` varchar(10) default NULL,        

 #`OccurranceCode11` char(3) default NULL,

 #`OccurranceDate11` varchar(10) default NULL,

 #`OccurranceCode12` char(3) default NULL,

 #`OccurranceDate12` varchar(10) default NULL,

 #`OccurranceCode13` char(3) default NULL,

 #`OccurranceDate13` varchar(10) default NULL,

 #`OccurranceCode14` char(3) default NULL,

 #`OccurranceDate14` varchar(10) default NULL,

 #`OccurranceCode15` char(3) default NULL,

 #`OccurranceDate15` varchar(10) default NULL,

 #`OccurranceCode16` char(3) default NULL,

 #`OccurranceDate16` varchar(10) default NULL,

 #`OccurranceCode17` char(3) default NULL,

 #`OccurranceDate17` varchar(10) default NULL,

 #`OccurranceCode18` char(3) default NULL,

 #`OccurranceDate18` varchar(10) default NULL,        

 #`OccurranceCode19` char(3) default NULL,

 #`OccurranceDate19` varchar(10) default NULL,

 #`OccurranceCode20` char(3) default NULL,

 #`OccurranceDate20` varchar(10) default NULL,

 #`OccurranceCode21` char(3) default NULL,

 #`OccurranceDate21` varchar(10) default NULL,

 #`OccurranceCode22` char(3) default NULL,

 #`OccurranceDate22` varchar(10) default NULL,

 #`OccurranceCode23` char(3) default NULL,

 #`OccurranceDate23` varchar(10) default NULL,

 #`OccurranceCode24` char(3) default NULL,

 #`OccurranceDate24` varchar(10) default NULL,

 `OccurranceSpanCode1` char(3) default NULL,

 `OccurranceSpanFrom1` varchar(10) default NULL,

 `OccurranceSpanTo1` varchar(10) default NULL,

 `OccurranceSpanCode2` char(3) default NULL,

 `OccurranceSpanFrom2` varchar(10) default NULL,

 `OccurranceSpanTo2` varchar(10) default NULL,

 `OccurranceSpanCode3` char(3) default NULL,

 `OccurranceSpanFrom3` varchar(10) default NULL,

 `OccurranceSpanTo3` varchar(10) default NULL,

 `OccurranceSpanCode4` char(3) default NULL,

 `OccurranceSpanFrom4` varchar(10) default NULL,

 `OccurranceSpanTo4` varchar(10) default 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*/

 `RepricingMethodology` varchar(3) NULL,

 `RepricedAmount` decimal(10,2) NULL,

 `SavingsAmount` decimal(10,2) NULL,

 `RepricerID` varchar(30) NULL,

 `RepricingRate` varchar(9) NULL,

 `APG_Code` varchar(30) NULL,

 `APG_Amount` decimal(10,2) 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,

 PRIMARY KEY  (`ID`)

) ENGINE=InnoDB DEFAULT CHARSET=latin1;

 

Detail

CREATE TABLE `edi_ClaimDetail`(

 `ID` int(11) NOT NULL auto_increment,

 `ClaimID` int(11) NOT NULL,

 `LineNumber` decimal(18, 0) NULL,

 `LineID` varchar(50) NULL,

 `ServiceDateFrom` datetime NULL,

 `ServiceDateTo` date NULL,

 `AssessmentDate` date NULL,

 `FacilityCode` char(2) NULL,

 `RevenueCode` varchar(48) NULL,

 `ProcedureCode` varchar(48) NULL,

 `Amount` decimal(10,2) NULL,

 `Unit` varchar(50) NULL,

 `Quantity` float NULL,

 `UnitRate` decimal(10,2) NULL,

 `NonCovered` decimal(10,2) NULL,

 `Paid` decimal(10,2) 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` decimal(10,2) NULL,

 `FacilityTax` decimal(10,2) NULL,

 `SalesTax` decimal(10,2) NULL,

 `ApprovedAmount` decimal(10,2) 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` decimal(10,2) NULL,

 `SavingsAmount` decimal(10,2) NULL,

 `RepricerID` varchar(30) NULL,

 `RepricingRate` varchar(9) NULL,

 `APG_Code` varchar(30) NULL,

 `APG_Amount` decimal(10,2) 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` decimal(10,2) NULL,

 `DrugUnitCode` char(2) NULL,

 `DrugUnits` double 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` decimal(10,2) NULL,

 `OtherPayer1PaidProcedure` varchar(30) NULL,

 `OtherPayer1PaidRevenueCode` varchar(30) NULL,

 `OtherPayer1PaidQuantity` bigint NULL,

 `OtherPayer1BundledLine` int NULL,

 `OtherPayer1AdjustmentReasonGroup1` char(2) NULL,

 `OtherPayer1AdjustmentReason1` varchar(5) NULL,

 `OtherPayer1AdjustmentAmount1` decimal(10,2) NULL,

 `OtherPayer1AdjustmentQuantity1` bigint NULL,

 `OtherPayer1AdjustmentReasonGroup2` char(2) NULL,

 `OtherPayer1AdjustmentReason2` varchar(5) NULL,

 `OtherPayer1AdjustmentAmount2` decimal(10,2) NULL,

 `OtherPayer1AdjustmentQuantity2` bigint NULL,

 `OtherPayer1AdjustmentReasonGroup3` char(2) NULL,

 `OtherPayer1AdjustmentReason3` varchar(5) NULL,

 `OtherPayer1AdjustmentAmount3` decimal(10,2) NULL,

 `OtherPayer1AdjustmentQuantity3` bigint NULL,

 `OtherPayer1AdjustmentReasonGroup4` char(2) NULL,

 `OtherPayer1AdjustmentReason4` varchar(5) NULL,

 `OtherPayer1AdjustmentAmount4` decimal(10,2) NULL,

 `OtherPayer1AdjustmentQuantity4` bigint NULL,

 #`OtherPayer1AdjustmentReasonGroup5Plus` varchar(77) NULL,

 #`OtherPayer1AdjustmentReason5Plus` varchar(155) NULL,

 #`OtherPayer1AdjustmentAmount5Plus` varchar(493) NULL,

 #`OtherPayer1AdjustmentQuantity5Plus` varchar(415) NULL,

 `OtherPayer1PaidDate` varchar(15) default NULL,

 /*COB 2 */

 `OtherPayer2ID` varchar(30) NULL,

 `OtherPayer2Paid` decimal(10,2) NULL,

 `OtherPayer2PaidProcedure` varchar(30) NULL,

 `OtherPayer2PaidRevenueCode` varchar(30) NULL,

 `OtherPayer2PaidQuantity` bigint NULL,

 `OtherPayer2BundledLine` int NULL,

 `OtherPayer2AdjustmentReasonGroup1` char(2) NULL,

 `OtherPayer2AdjustmentReason1` varchar(5) NULL,

 `OtherPayer2AdjustmentAmount1` decimal(10,2) NULL,

 `OtherPayer2AdjustmentQuantity1` bigint NULL,

 `OtherPayer2AdjustmentReasonGroup2` char(2) NULL,

 `OtherPayer2AdjustmentReason2` varchar(5) NULL,

 `OtherPayer2AdjustmentAmount2` decimal(10,2) NULL,

 `OtherPayer2AdjustmentQuantity2` bigint NULL,

 `OtherPayer2AdjustmentReasonGroup3` char(2) NULL,

 `OtherPayer2AdjustmentReason3` varchar(5) NULL,

 `OtherPayer2AdjustmentAmount3` decimal(10,2) NULL,

 `OtherPayer2AdjustmentQuantity3` bigint NULL,

 `OtherPayer2AdjustmentReasonGroup4` char(2) NULL,

 `OtherPayer2AdjustmentReason4` varchar(5) NULL,

 `OtherPayer2AdjustmentAmount4` decimal(10,2) NULL,

 `OtherPayer2AdjustmentQuantity4` bigint NULL,

 #`OtherPayer2AdjustmentReasonGroup5Plus` varchar(77) NULL,

 #`OtherPayer2AdjustmentReason5Plus` varchar(155) NULL,

 #`OtherPayer2AdjustmentAmount5Plus` varchar(493) NULL,

 #`OtherPayer2AdjustmentQuantity5Plus` varchar(415) NULL,

 `OtherPayer2PaidDate` date NULL,

 PRIMARY KEY  (`ID`)

) ENGINE=InnoDB DEFAULT CHARSET=latin1;