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Header

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;