PAYMENT PROCESSING OVERVIEW



Claim Payment Process

Overview

The Awarded Offeror (contractor) does not prepare checks. Checks or Automated Clearing House (ACH) payments are paid by the Pennsylvania Treasury Department after authorizations for payments are received from the contractor. As explained in Appendix L – Legal Defense Services, this process does not apply to authorizations for legal defense services, which have a separate payment process. To meet statutory deadlines for payments, the payment processing times and schedules must be met. This process is not negotiable.

There are at least three separate interface files (depending on the payment type) and one file is communicated by electronic mail. After the interface file is sent, a report of the information provided on the interface must be provided to OA and Comptroller Operations along with explanation of reimbursement (EOR) forms for medical and expense payments. Examples of the current reports and EOR’s are included with this Appendix.

The interface files are validated and released to the Treasury Department for payment by check or ACH payment (ACH only upon approval by OA). The Treasury Department retains and exercises its pre-audit authority under all circumstances; therefore, additional documentation on certain payments may be requested prior to releasing the payment.

If errors to the authorized payments are discovered after the file has been interfaced, but before the Treasury Department has mailed the payment, authorizations may be voided (or deleted or rejected. Only voids are possible; payment amounts cannot be changed.

File Details

There are at least four files that are used to transfer authorized payment data to the Commonwealth. Delivery of payment authorization files occurs by FTP transfer to the Commonwealth’s Public FTP Server, using credentials provided by the Commonwealth. Files will be in an XML format provided by the Commonwealth, and named according to Commonwealth specifications. Files must be encrypted. Exact file formats and specifications will be provided by OA upon execution of the contract. Fields that will need to be included are at least those from the information provided on the sample reports below. The current file specifications are provided with this appendix for informational purposes, but these shall not be considered to be final requirements.

Initial Indemnity Payment (Advancement) File. The initial indemnity payments are paid through a Treasury Department advancement account that is processed by Comptroller Operations. No interface is required. Initial indemnity payments must be authorized so that payment is made within the statutory timeframe of 21 days. The authorizations must be provided in readable/writable PDF format by an e-mail attachment each Tuesday and Thursday morning. Although this process is ordinarily used for first checks, it is also available on a limited basis for use for processing checks when timing is critical. However, it is not used for initial payments when the workers’ compensation check is turned over to the agency for claimants receiving Heart and Lung or Act 632/534 supplemental benefits.

Indemnity Treasury Check Payment File. After the first indemnity payment is made, the claim is put on a regular payment schedule. The interface of biweekly payments is sent every other week in accordance with a schedule; a copy of the current schedule is provided with this Appendix. More than one file may be requested on the identified file transfer dates with data split between files by payment type. This file also contains payments made on behalf of claimants to attorneys, guardians, or court ordered payees. It is important to note that this process is not used for the special benefits of Heart and Lung or Act 632/534 as explained below.

Indemnity Transfer Voucher Payment File. The transfer voucher interface includes all reimbursements that will be sent to the Bureau of Commonwealth Payroll Operations (BCPO) for reimbursement of the salary paid under Heart and Lung and Act 632/534. If a payment is being made to an attorney or other payee, that payment must be included on the indemnity treasury check payment file. This file is sent every other week in accordance with the same schedule mentioned above and provided with this Appendix.

Medical/Other Payments. The medical/other payment interface contains all payments to providers for medical care as well as for allocated expenses (with the exception of legal defense fees). Payment authorization must be interfaced daily to ensure timely payment. More than one file may be requested each day with data split between files by payment type. Payment is typically made ten business days from the receipt of the interface file. A copy of the current payment schedule is provided with this Appendix.

Processing Information

Indemnity Deletions. After the Indemnity Treasury Check Payment File interface is sent by the contractor and before the checks are mailed by the Treasury Department, there is a window when checks can be deleted/voided and not sent. The contractor must provide to OA the deletion information in a Microsoft Excel attachment to an e-mail on Tuesday and Wednesday mornings of the week the checks are scheduled to be mailed. Only deletions (also known as voids or redlines) are possible; payment amounts cannot be changed. A copy of the deletion report is provided with this Appendix.

Supporting Reports. Reports and copies of the EOR’s must be provided by the contractor to OA and Comptroller Operations at the same time the interface file is transferred. These must be provided in a readable/writable PDF format. Samples of the current reports are provided within this Appendix.

Explanation of Reimbursement (EOR). The contractor must mail the EOR to the provider within 10 business days of transmission of the interface file to ensure receipt within two days of the date the check is issued by the Treasury Department.

Direct Deposit. Direct deposit is currently offered to claimants who consent and whose claims meet one or more of the following conditions: claims open at least one year; claims with catastrophic injuries; or claims receiving survivor benefits. The contractor shall gather and securely maintain all bank routing numbers, account numbers, and checking or savings data. Such data must be included in the Indemnity Treasury Check Payment interface file. The contractor must also file the required LIBC form with the Bureau of Workers’ Compensation. Direct deposit options may be expanded during this contract to include more claimants and vendors; details about the expansion of direct deposit will be provided upon award of the contract.

Vendor Record Synchronization. The contractor may be requested to utilize Commonwealth vendor numbers for payments to claimants, attorneys, providers, or other payees when more than six payments are made to such payee each year. Payee records from the contractor will be interfaced to the Commonwealth to obtain vendor numbers and ensure synchronization of data. The vendor identification number shall be required to be provided with the interface. Details about this process will be provided upon award of the contract.

1099 Requirements. An IRS form W-9 shall be obtained for all non-claimant payments. If a payment is made to a name other than the IRS recognized name as shown on the W-9, a copy of the W-9 associated with the other name shall be provided. To the extent possible the payee name and address data remains fixed for a payee from payment to payment. Changes to payee information, for both indemnity and medical payments after an initial payment is processed, shall be limited to material changes to the payee name/address data. For payments where a vendor identification number is utilized, the Office of the Budget, Bureau of Comptroller Operations Office will maintain all payee, address, and W-9 data. The Internal Revenue Services assesses a $30, $60 or $100 fine for each 1099 form that is reported where the name/SS number or FID combination does not agree with their records. Any fines assessed against the Commonwealth for such infractions which are the fault of the contractor will be paid by the contractor.

Testing Requirements

Commonwealth testing standards require Unit Testing along with end-to-end Integration testing by the Office of Administration, Bureau of Integrated Enterprise Systems to ensure all functionality and interfaces work properly. A formal signoff by OA on full system testing is required to assure a quality implementation. The contractor shall allow enough time to complete this testing and include this timeline in a full project plan that shall be submitted with the proposal. At a minimum the contractor shall plan on all testing to be completed with formal signoff on system interfaces and functionality 30 days in advance of the implementation date. Shall testing not be completed by this date due to contractor delays, daily negotiations to solve the problems will begin between OA and the contractor’s project manager. Upon completion of successful system testing OA will provide formal notification that system functionality and interface testing is complete and the system is acceptable (reference Appendix E – Service Level Agreements).

Indemnity Payment Processing Schedule

This schedule provides the timing of events related to indemnity check and transfer payment processing. The date for a particular action may be adjusted at the discretion of Comptroller Operations staff. Highlighted fields indicate adjustments due to holidays occurring during the pay cycle. The exact schedule will be provided upon award of the contract.

|2009-10 PAYMENT SCHEDULE |

|OA WORKERS' COMPENSATION PROGRAM |

|INDEMNITY - 811 |

| | | | | |

|PROCESSING |FILE CLEARED |DELETION REQUEST FROM CSI AND OA TO COMPTROLLER|CHECKS |CHECK |

| |TO TREASURY |BY 9 A.M. |MAILED |PAYDATE |

|SATURDAY |MONDAY |WEDNESDAY |THURSDAY |MONDAY |

|24-Oct-09 |26-Oct-09 |4-Nov-09 |5-Nov-09 |9-Nov-09 |

|7-Nov-09 |9-Nov-09 |18-Nov-09 |19-Nov-09 |23-Nov-09 |

|21-Nov-09 |23-Nov-09 |2-Dec-09 |3-Dec-09 |7-Dec-09 |

|5-Dec-09 |7-Dec-09 |16-Dec-09 |17-Dec-09 |21-Dec-09 |

|19-Dec-09 |21-Dec-09 |29-Dec-09 |30-Dec-09 |4-Jan-10 |

|2-Jan-10 |4-Jan-10 |12-Jan-10 |13-Jan-10 |15-Jan-10 |

|14-Jan-10 |15-Jan-10 |27-Jan-10 |28-Jan-10 |1-Feb-10 |

|30-Jan-10 |1-Feb-10 |9-Feb-10 |10-Feb-10 |12-Feb-10 |

|11-Feb-10 |12-Feb-10 |24-Feb-10 |25-Feb-10 |1-Mar-10 |

|27-Feb-10 |1-Mar-10 |10-Mar-10 |11-Mar-10 |15-Mar-10 |

|13-Mar-10 |15-Mar-10 |24-Mar-10 |25-Mar-10 |29-Mar-10 |

|27-Mar-10 |29-Mar-10 |7-Apr-10 |8-Apr-10 |12-Apr-10 |

|10-Apr-10 |12-Apr-10 |21-Apr-10 |22-Apr-10 |26-Apr-10 |

|24-Apr-10 |26-Apr-10 |5-May-10 |6-May-10 |10-May-10 |

|8-May-10 |10-May-10 |19-May-10 |20-May-10 |24-May-10 |

|22-May-10 |24-May-10 |2-Jun-10 |3-Jun-10 |7-Jun-10 |

|5-Jun-10 |7-Jun-10 |16-Jun-10 |17-Jun-10 |21-Jun-10 |

|19-Jun-10 |21-Jun-10 |29-Jun-10 |30-Jun-10 |2-Jul-10 |

|1-Jul-10 |2-Jul-10 |14-Jul-10 |15-Jul-10 |19-Jul-10 |

|17-Jul-10 |19-Jul-10 |28-Jul-10 |29-Jul-10 |2-Aug-10 |

|31-Jul-10 |2-Aug-10 |11-Aug-10 |12-Aug-10 |16-Aug-10 |

|14-Aug-10 |16-Aug-10 |25-Aug-10 |26-Aug-10 |30-Aug-10 |

|28-Aug-10 |30-Aug-10 |8-Sep-10 |9-Sep-10 |13-Sep-10 |

|11-Sep-10 |13-Sep-10 |22-Sep-10 |23-Sep-10 |27-Sep-10 |

|25-Sep-10 |27-Sep-10 |5-Oct-10 |6-Oct-10 |8-Oct-10 |

|7-Oct-10 |8-Oct-10 |10-Oct-10 |21-Oct-10 |25-Oct-10 |

|23-Oct-10 |25-Oct-10 |3-Nov-10 |4-Nov-10 |8-Nov-10 |

|6-Nov-10 |8-Nov-10 |17-Nov-10 |18-Nov-10 |22-Nov-10 |

|20-Nov-10 |22-Nov-10 |1-Dec-10 |2-Dec-10 |6-Dec-10 |

|4-Dec-10 |6-Dec-10 |15-Dec-10 |16-Dec-10 |20-Dec-10 |

|2009-2010 HOLIDAYS |

|Thursday, January 01, 2009 | |New Year's Day |

|Monday, January 19, 2009 | |Dr. Martin Luther King, Jr. Day |

|Monday, February 16, 2009 | |Presidents' Day |

|Monday, May 25, 2009 | |Memorial Day |

|Friday, July 03, 2009 | |Independence Day |

|Monday, September 07, 2009 | |Labor Day |

|Monday, October 12, 2009 | |Columbus Day |

|Wednesday, November 11, 2009 | |Veterans Day |

|Thursday, November 26, 2009 | |Thanksgiving Day |

|Friday, November 27, 2009 | |Day after Thanksgiving |

|Friday December 25, 2009 | |Christmas Day |

|January 1, 2010 | |New Years Day |

|Monday, January 18, 2010 | |Dr. Martin Luther King, Jr. Day |

| | | |

|Monday, February 15, 2010 | |Presidents' Day |

|Monday, May 31, 2010 | |Memorial Day |

|Monday, July 05, 2010 | |Independence Day |

|Monday, September 06, 2010 | |Labor Day |

|Monday, October 11, 2010 | |Columbus Day |

|Thursday, November 11, 2010 | |Veterans Day |

|Thursday, November 25, 2010 | |Thanksgiving Day |

|Friday, November 26, 2010 | |Day after Thanksgiving |

|Friday, December 24, 2010 |  |Christmas Day |

| | | |

Medical Payment Processing Schedule

This schedule provides the timing of events related to medical payment processing. The date for a particular action may be adjusted at the discretion of Comptroller Operations staff. Highlighted fields indicate adjustments due to holidays occurring during the pay cycle. The exact schedule will be provided upon award of the contract

|OA WORKER'S COMPENSATION PROGRAM |

|2011 PAYMENT SCHEDULE-MEDICAL |

| | | | | |

|FILE DATE |FI|PAY DATE | |FILE DATE |

| |LE| | | |

| |RE| | | |

| |CE| | | |

| |IV| | | |

| |ED| | | |

|FILE DATE |FILE RECEIVED |PAY DATE |

|PREPARED BY: COMPSERVICES, INC. |OFFICE OF ADMINISTRATION | PAGE NO: 1 | |

|DATE PREPARED: |8/12/2011 | |CYCLE NO: 1122400 |

| |INDEMNITY PAYMENT AUTHORIZATION REPORT - TREASURY CHECK PAYMENTS | |

|CLAIM DEPARTMENT: 002 AUDITOR GENERAL | | | | |

|ITEM | CLAIM | INJURY | PAYMENT | VOUCHER PAY |

| NO |PAYEE NAME AND ADDRESS |

Sample Indemnity Transfer Voucher Payments Report

___________________________________________________________________________________________________

Sample Medical and Other Payments Report

Sample Indemnity Deletion Report

____________________________________________________________________________________________________________________

|Date 7/26/11 |Commonwealth of Pennsylvania | |Cycle11196 |

|For Run: |7/15/2011 | Indemnity Deletion Report | | |

| | | | | |

|Group: |Commonwealth of Pennsylvania | |EOMB#: |1111111 |

|Employer: |CORRECTIONS | SS# . . . . : 123-45-6789 | |

|Claimant: |Doe, Michael |DOI . . . . : X/XX/2006 | |

|Claim#: 111-111-0000000 | | |

|Pat Acct#: 12345RWC |Review date : |9/1X/XX/2006 |

| |Bill Recvd : |8/1X/XX/2006 |

|Prov ID#: 01234567 - 000 License#: | | |

| |Print date : |9/XX/XX/2007 |

|JANE WORKERS DC |Recon date : | |

|555 MAIN STREET |Voucher date: |9/1X/XX/2011 Vch#: 0987654 |

|ANYWHERE, PA 11111 |Diagnosis : | |

| |1. 723.3 |CerVicobrachial syndrome |

|Dates of Svc: X/XX/2011 -X/XX/2011 | | |

| | | |

|Service Modifiers POS |Diag Cd |Billed |MRA Reduct |CM Reduct |Oth1 Reduc |PPO Reduct |Payment |

| | | | | | | | |

|Date of Service: X/XX/2011 - |X/XX/2011 | | | | | | |

|98941 11 |1 |55.00 |.00 | .00 |.00 | .00 |55.00 |

|Description: Chiropractic manipulative | |Units: |1.00 |Billed Code: 98941 |

| Billed Charges: |55.00 | | | | | |

| Reductions: | | .00 | .00 | .00 | .00 | |

| Total Payment: | | | | | |55.00 |

|CompServices, Inc | |

|PO Box 535370 | |

|Pittsburgh, PA 15253-5370 | |

|(888) 871-3606 | |

|This bill has been adjudicated according to the PA Fee Schedule. |If you have any questions please direct |

|them to: CSI, Inc. | |

| P.O. Box 3460 | |

| Pittsburgh, PA 15230-3460 | |

| (800) 297-2726 | |

| | |

| | |

|Healthcare Providers are prohibited from billing for, or otherwise attempting to recover from the |

|employee, the difference between the Provider's charge and the amount paid on this bill. |

|******** Within two business days of receiving this explanation of reimbursement, the check will be |

|provided directly from the Commonwealth of Pennsylvania, Treasury. You can identify the corresponding |

|check with the Vch# at the top of this form to the invoice number that will be located on the check |

|remittance advice. ******** |

Interface File Mapping Details

These mapping details are provided for informational purposes. They are subject to modifications, and the final format details will be provided upon award of the contract.

|Record Type |Field Name |Field |Required |Data Type |Description |Comment |

| | |Length | | | | |

|  |InterfaceType |Max. 20 |Required |STRING |Interface identifier (i.e. Request-396) |"Request-396" |

|  |SourceSystem |  |  |  |  |  |

|  | Name |Max. 50 |Required |STRING |File Name - Must be same on each file, |OA-811, OA-812 or OA-814 as appropriate |

| | | | | |used for validating authenticity | |

|  | DocumentID |Max. 16 |Required |STRING |Unique document number in Source System |Required for the WC - 13 character field - Format 081FFFYYDDDSS. |

| | | | | | |FFF = 811 for Treasury Check Payment file, 812 for Medical/Other |

| | | | | | |Payments, or 814 for Transfer Voucher Payment File, YYDDD is the |

| | | | | | |Julian date equilavent to the date the file is created/sent, SS is |

| | | | | | |a 2 digit sequence number to allow multiple files for a given |

| | | | | | |payment group to be submitted on the same day |

|  | Time |6 |Required |TIME |HHMMSS |Time Document Created |

|  |Target System |  |  |  |  |  |

|  | Name |Max. 50 |Required |STRING |Name of Target System |"SAP" |

|  | DocumentID |Max. 16 |Optional |STRING |Unique document number in Source System |Not Needed |

|  | Date |8 |Optional |DATE |MMDDYYYY |Date Document Created |

|  | Time |6 |Optional |TIME |HHMMSS |Time Document Created |

|HEADER |HD_REC (1 for each file) |  |  |  |  |  |

|HD |CRE_DT |8 |Required |DATE |MMDDYYYY |File Creation Date |

|HD |CRE_TM |6 |Required |TIME |HHMMSS |File Creation Time |

|HD |CP_NM |Max. 40 |Required |STRING |Contact Person Name |File Contact Person for Problems |

|HD |CP_TEL |Max. 10 |Required |STRING |Contact Person Telephone Number |Contact Person Telephone Number |

|HD |EMAIL |Max. 25 |Optional |STRING |Contact Person Email |Required for WC - Contact Person Email |

|HD |FILE_NM |Max. 40 |Required |STRING | Agency and Program Name |"OA WORKERS COMP" |

|HD |REC_CNT |8 |Optional |STRING |Includes all data records plus header |Required for WC. |

| | | | | | |Leading zeros "00000156" (will include all data records plus |

| | | | | | |header). Control total |

|HD |HD_AMT |16 |Optional |DECIMAL |File Total Amount (2 explicit decimal; |Required for WC. |

| | | | | |explicit sign in first position; ie |Pattern value: "[\+|\-] |

| | | | | |+000000000000.00) |\d\d\d\d\d\d\d\d\d\d\d\d\.\d\d" |

|HD |TRS_PO |Max. 19 |Required |STRING |A Number Which Will be Applied In SAP |Digits 1-2 = Business Area; Digit 3 = BA Interface number; Digits |

| | | | | |Text Field. Will be known to Comptroller|4-5 = YY; Digit 6-8 = Julian Date; Digit 9-10 = Sequential Number |

| | | | | |office and will be on hard copies sent to|of Interfaces that Day. EX. 8110326701. Used as a batch control |

| | | | | |Comptroller offices. This will also be |number for Treasury. 811 file will start with 811 and 812 file will|

| | | | | |unique number for tracking this interface|start with 812 as shown in 811 example above. |

| | | | | |in Treasury systems | |

|Document Header |DH_REC |  |  |  |  |  |

|DH |DOC_T |2 |Required |STRING |Document Type |"ZI" |

|DH |DOC_NO |Max. 16 |Optional |STRING |Document Number |Not needed |

|DH |REC_T |2 |Optional |STRING |Record Type (DH) |Not needed |

|DH |TR_CD |Max. 6 |Optional |STRING |Transaction Code (FB60) |Not needed |

|DH |DH_AMT |16 |Required |DECIMAL |Invoice Total Amount (2 explicit decimal;|Pattern value: "[\+|\-] |

| | | | | |explicit sign in first position; ie |\d\d\d\d\d\d\d\d\d\d\d\d\.\d\d" |

| | | | | |+000000000000.00) | |

|DH |LN_CNT |3 |Optional |INTEGER |Number of linesof detail for invoice |Number of Detail line items (DT Records) for the invoice (DH |

| | | | | | |Record) |

| | | | | | |Min. value = 001 Max. value = 999 |

|DH |REF_DOC |Max. 16 |Optional |STRING |Invoice Reference Number; left justify; |Required for WC - 15 character vendor invoice number |

| | | | | |blank fill | |

|DH |DH-LIQ |16 |Optional |DECIMAL |Invoice Liquidation Amount (2 explicit |Not needed |

| | | | | |decimal; explicit sign in first position;| |

| | | | | |ie +000000000000.00) | |

|DH |PAY_DT |8 |Optional |DATE |Requested Payment Date - MMDDYYYY |If used, Enter in Baseline Date & input P066 in Payment Terms. If |

| | | | | | |blank, system assigned based on document date |

|DH |V_NO |Max. 10 |Required |STRING |SAP Headquarter Vendor Number |600000 = 1099 Eligible |

| | | | | | |600001 = Non-1099 Eligible |

|DH |ALT_V |10 |Optional |STRING |SAP Alternate Payee Vendor Number |Not needed |

|DH |PAY_M |2 |Required |STRING |Method of payment (check, ACH, etc) |Required-01 for check, 02 for ACH. |

| | | | | | |814 file - always 01 |

|DH |BNK_PRTNR |4 |Optional |STRING |N/A for One Time Vendors |Not needed |

|DH |SUP_PAY_M |2 |Required |STRING |Identifies how payment is distributed |"01" - Treasury Mails check |

| | | | | |(mailed by Treasury, returned to | |

| | | | | |Comptroller, etc) | |

|DH |PAY_BLK |1 |Optional |STRING |Identifies the reason why a payment does |Always "A" |

| | | | | |not go to Treasury | |

|DH |NOTES |Max. 79 |Required |STRING |Addendum data, printed on Remittance |Will print on Check Transmittal to help identify payment |

| | | | | |Advice. Claimants Name or any other |For 811 & 812 Sherri Keiter-Reed provided vendor with requirements |

| | | | | |information to be put on Remittance |for what is to be placed in this text field |

| | | | | |Advice by Treasury |814 - Always "Transfer Payment" |

|Vendor Detail |DV_REC |  |  |  |  |  |

|DV |DOC_T |Max. 2 |Optional |STRING |Document Type |Not needed |

|DV |DOC_NO |Max. 16 |Optional |STRING |Document Number |Not needed |

|DV |REC_T |Max. 2 |Optional |STRING |Always "DV" |Not needed |

|DV |VEND_NO |Max. 10 |Required |STRING |600000 - 1099 Eligible Vendor |Required-If not one of these records, fail record |

| | | | | |600001 - Non-1099 Eligible Vendor | |

|DV |V_NAME1 |Max. 35 |Required |STRING |First SAP Name Field |Vendor NAME (ALL CAPS) |

| | | | | | |If payee is an individual, person's first name is placed in this |

| | | | | | |field. If payee is a company, company name is placed in this field |

|DV |V_NAME2 |Max. 35 |Optional |STRING |Second SAP Name Field |Optional - Vendor NAME - 2nd Line (ALL CAPS) |

| | | | | | |If payee is individual, person's last name is placed in this field.|

| | | | | | |Else, blank |

|DV |ST |Max. 35 |Optional |STRING |First SAP Street Field |Either STREET or PO BOX required, but both fields can't be |

| | | | | | |populated. (ALL CAPS) |

|DV |ST2 |Max. 35 |Optional |STRING |Second Street Address |Optional - NAME 4 to be populated as a 2nd Street address. Sent to|

| | | | | | |Treasury as Street 2. (ALL CAPS) |

|DV |PO |Max. 19 |Optional |STRING |PO BOX |Either STREET or PO BOX required, but both fields can't be |

| | | | | | |populated. (ALL CAPS) |

|DV |CITY |Max. 18 |Required |STRING |City |Required (ALL CAPS) |

|DV |REG |Max. 2 |Required |STRING |State |Required (ALL CAPS) |

|DV |ZIP |Max. 9 |Required |STRING |Zip Code |Required-Hyphen will be inserted at SAP level for 9 digit code |

|DV |CNTY |Max. 4 |Required |STRING |  |Optional for US. |

|DV |TX_CD1 |Max. 9 |Optional |STRING |USA: Social Security number |Optional: Either Tax Code 1 or Tax Code 2 Required. Must be 9 |

| | | | | | |digits in length |

|DV |TX_CD2 |Max. 9 |Optional |STRING |USA: Corporate ID number |Optional: Either Tax Code 1 or Tax Code 2 Required. Must be 9 |

| | | | | | |digits in length. |

|DV |BNK_KY |Max. 9 |Optional |STRING |ABA Rounting number |Ignore if Payment is Check; Required if Payment method is ACH. Must|

| | | | | | |be 9 digits in length. |

|DV |BNK_ACT |Max. 17 |Optional |STRING |Bank Account Number |Ignore if Payment is Check; Required if Payment method is ACH. |

|DV |ACT_TYP |Max. 2 |Optional |STRING |Optional: 01 for checking accounts, 02 |Ignore if Payment is Check; Required if Payment method is ACH. |

| | | | | |for savings accounts | |

|DV |OPT_INFO |Max. 21 |Optional |STRING |Additional Refenece Data |Not needed |

|DV |WC_CLMNT_NAME |35 |Optional |STRING |Claimant's name |Required for 811 and 814 file |

|DV |WC_CLAIM_NO |13 |Optional |STRING |Claim Number to which the payment applies|Required for 811 and 814 file |

|DV |WC_CLMNT_TAX_CD |9 |Optional |STRING |Claimant Social Security Number |Required for 811 and 814 files |

|DV |WC_INJURY_DT |8 |Optional |DATE |MMDDYYYY |Required for 811 and 814 files |

|DV |WC_BEGIN_DIS_DT |8 |Optional |DATE |MMDDYYYY |Required for 811 and 814 files - Date disability began, Not |

| | | | | | |necessarily the injury date |

|DV |WC_SVC_FROM_DT |8 |Optional |DATE |MMDDYYYY |Required for 811 and 814 files |

|DV |WC_SVC_TO_DT |8 |Optional |DATE |MMDDYYYY |Required for 811 and 814 files |

|DV |WC_COMP_TYPE |2 |Optional |STRING |Type of compensation being paid |Required for 811 file - 01 = DL/IL, 02 = Heart & Lung, 03 = Act |

| | | | | | |632/534, 04 = No spec. Benefits, 05 = NBH (no longer H&L), 06 = NBA|

| | | | | | |(no longer Act 532/534, 07 = Salary in lieu |

|DV |WC_PAY_TYPE |2 |Optional |STRING |Type payee |Required for 811 file - 01 = DL/IL, 02 = Heart & Lung, 03 = Act |

| | | | | | |632/534, 04 = No spec. Benefits, 05 = NBH (no longer H&L), 06 = NBA|

| | | | | | |(no longer Act 532/534, 07 = Salary in lieu |

|Document Detail |DT_REC (May Have Multiple for Each Doc|  |  |  |  |  |

| |Header) | | | | | |

|DT |DOC_T |2 |Optional |STRING |Document Type |Not needed |

|DT |DOC_NO |Max. 16 |Optional |STRING |Document Number |Required for WC - 15 characters vendor invoice number |

|DT |REC_T |2 |Optional |STRING |Always "DT" |Not needed |

|DT |LN_ITM |3 |Required |INTEGER |Sequential Line Number starting with 001 |Min. value = 001 Max. value = 999 |

|DT |FUND |10 |Optional |STRING |SAP Fund |Required on all WC files. Constant value which will be provided to |

| | | | | | |vendor by the Commonwealth once SAP Fund has been determined |

|DT |WBS |Max. 24 |Optional |STRING |SAP WBS Element |Not needed |

|DT |DT_AMT |16 |Required |DECIMAL |Line Item Amount (2 explicit decimal; |Pattern value: "[\+|\-] |

| | | | | |explicit sign in first position; ie |\d\d\d\d\d\d\d\d\d\d\d\d\.\d\d" |

| | | | | |+000000000000.00) |Claim Amount |

|DT |VEND |Max. 10 |Optional |STRING |  |Not needed |

|DT |DUE_ON |8 |Optional |DATE |MMDDYYYY |Not needed |

|DT |ITM_TXT |50 |Optional |STRING | |Not needed |

|DT |REF_NO |10 |Optional |STRING |SAP Earmarked Fund document number used |Not needed |

| | | | | |when liquidating an encumbrance | |

|DT |REF_LN |3 |Optional |INTEGER |Line Item of Earmarked Fund to be charged|Not needed |

| | | | | |and liquidated. Leading zero filled | |

|DT |DT_LIQ |16 |Optional |DECIMAL |Line Item Liquidation Amount (2 explicit |Not needed |

| | | | | |decimal; explicit sign in first position;| |

| | | | | |ie +000000000000.00) | |

|DT |GAAP_CD |1 |Optional |STRING |  |Not needed |

|DT |SRV_BEG |8 |Required |DATE |MMDDYYYY |Value date used for GAAP purposes. First day of service period or |

| | | | | | |good receipt date. |

| | | | | | |For all WC files - Service Begin Date |

|DT |ASSGNT |Max. 18 |Optional |STRING |SAP Assignment Field |Not needed |

|DT |REF_KY1 |Max. 12 |Optional |STRING |SAP Reference Key 1 field |Not needed |

|DT |REF_KY2 |Max. 12 |Optional |STRING |SAP Reference Key 2 field |Not needed |

|DT |REF_KY3 |Max. 20 |Optional |STRING | |Not needed |

|DT |TYP_CD |Max. 2 |Optional |STRING | |Not needed |

|DT |STC_CD |1 |Optional |STRING |Set to complete indicator for EM funds |Not needed |

-----------------------

W8142R COMMONWEALTH OF PENNSYLVANIA

|PREPARED BY: COMPSERVICES, INC. |OFFICE OF ADMINISTRATION | PAGE NO: 1 | |

|DATE PREPARED: |9/07/2011 | | CYCLE NO: 1125001 |

| | |INDEMNITY PAYMENT AUTHORIZATION REPORT - ADVANCEMENT ACCOUNT PAYMENTS | |

|CLAIM DEPARTMENT: 021 PUBLIC WELFARE | | | | |

|ITEM |CLAIM |INJURY | PAYMENT | VOUCHER PAY |

| NO |PAYEE NAME AND ADDRESS |TYPE |DATE |

|PREPARED BY: COMPSERVICES, INC. |WORK COMP MEDICAL/LEGAL CLAIMS |PAGE NO: |1 |

|DATE PREPARED: |7/12/2011 |APPROVED PAYEE LISTING | | |

| |CYCLE NO: 1119300 | | |

|ITEM | | |IRS |SVC END |INVOICE |VOUCHER |EFT |

| NO |VENDOR ID |PAYEE NAME AND ADDRESS |STATUS |DATE |AMOUNT |NUMBER | |

|0001 |012345678 |NO NAME MEDICAL CENTER |NO |6/03/2011 |54.00 |1777777 | |

| | |6789 LOST STREET | | | | | |

| | |LOST TOWN, PA 100010000 | | | | | |

|0002 |012345678 |NO NAME MEDICAL CENTER |NO |6/21/2011 |54.00 |1777778 | |

| | |6789 LOST STREET | | | | | |

| | |LOST TOWN, PA 100010000 | | | | | |

|0003 |876543210 |DOE RAY DC |YES |6/27/2011 |168.91 |1777779 | |

| | |456 ROCKY ROAD | | | | | |

| | |MOUNTAIN, PA 199995555 | | | | | |

|0004 |876543210 |DOE RAY DC |YES |6/23/2011 |55.00 |1777780 | |

| | |456 ROCKY ROAD | | | | | |

| | |MOUNTAIN, PA 199995555 | | | | | |

|W8144R |COMMONWEALTH OF PENNSYLVANIA | |

|PREPARED BY: COMPSERVICES, INC. |OFFICE OF ADMINISTRATION |PAGE NO: |1 |

|DATE PREPARED: |3/25/2011 | |CYCLE NO: 1108400 |

| |INDEMNITY PAYMENT AUTHORIZATION REPORT - TRANSFER VOUCHER PAYMENTS | |

|CLAIM DEPARTMENT: 011 CORRECTIONS | | | | |

|ITEM | CLAIM |INJURY | PAYMENT | VOUCHER PAY |

NO |PAYEE NAME AND ADDRESS |TYPE |DATE |CLAIM NUMBER |AMOUNT |PERIOD COVERED |NUMBER |TYPE EFT

| |0001 |MARY LYNN DOE |H&L |9/25/2008 |0000000000000 |1,256.82 |3/12/2011- 3/25/2011 |2101726 |01 | | |123 EAST 4TH STREET | | | | | | | | | |WATER, PA 11110000 | | | | | | | | | |*****7197 |PV1: TT

| | | | | | | | |0002 |SALLY SUE |H&L |1/12/2010 |0000000000000 |1,017.80 |3/12/2011- 3/25/2011 |2101813 | 01 | | |666 MADISON DRIVE | | | | | | | | | |LAKE, PA 155550000 | | | | | | | | | |*****6911 |PV1: TT |

| | | | | | | |0003 |JOHN R CREEK |H&L |9/27/2010 |0000000000000 |1,473.30 |3/12/2011- 3/25/2011 |2101901 | 01 | | |111 EAST 9TH STREET | | | | | | | | | |OCEAN, PA 177770000 | | | | | | | | | |*****7968 |PV1: TT | | | | | | | | | | | | | | | | | | |

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