| <?xml version="1.0" encoding="UTF-8"?> <xs:schema attributeFormDefault="unqualified" elementFormDefault="qualified" targetNamespace="http://www.nemsis.org" xmlns="http://www.nemsis.org" xmlns:xs="http://www.w3.org/2001/XMLSchema"> <xs:sequence> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.01</number> <name>Primary Method of Payment</name> <national>Yes</national> <state>Yes</state> <definition> The primary method of payment or type of insurance associated with this EMS encounter </definition> <v2Number>E07_01</v2Number> <usage>Required</usage> <performanceMeasuresGroup> <performanceMeasure>Airway</performanceMeasure> <performanceMeasure>Cardiac Arrest</performanceMeasure> <performanceMeasure>Pediatric</performanceMeasure> <performanceMeasure>Response</performanceMeasure> <performanceMeasure>STEMI</performanceMeasure> <performanceMeasure>Stroke</performanceMeasure> <performanceMeasure>Trauma</performanceMeasure> </performanceMeasuresGroup> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> <xs:simpleType> </xs:simpleType> </xs:attribute> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:annotation> <xs:documentation>Group Tag to hold Certification information</xs:documentation> </xs:annotation> <xs:complexType> <xs:sequence> <xs:element id="ePayment.PhysicianCertificationStatement" minOccurs="0" name="ePayment.02" type="YesNoUnkValues"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.02</number> <name>Physician Certification Statement</name> <national>No</national> <state>No</state> <definition> Indication of whether a physician certification statement (PCS) is available documenting the medical necessity or the EMS encounter. </definition> <v2Number>E07_02</v2Number> <usage>Optional</usage> <comment> Data Element Name changed from Certificate of Medical Necessity to Physician Certification Statement. The PCS statement and documentation of medical necessity is a requirement of the Centers for Medicare & Medicaid Services. The circumstances are defined in 42 CFR 410.40 (d)(2) and (d)(3). http://www.cms.gov/ <br/><br/>A PCS is required for the following non-emergency transport: <br/>1) Non-Emergency Repetitive Scheduled <br/>2) Non Emergency Non-Repetitive-Scheduled <br/>3) Non Emergency Services - Non Scheduled - Under direct care of a physician </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.DatePhysicianCertificationStatementSigned" minOccurs="0" name="ePayment.03" type="DateTimeType"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.03</number> <name>Date Physician Certification Statement Signed</name> <national>No</national> <state>No</state> <definition> The date the Physician Certification Statement was signed </definition> <usage>Optional</usage> <comment> Added to assist in billing documentation. Associated with ePayment.02: Physician Certification Statement. <br/><br/>DateTime consists of finite-length characters of the form: yyyy '-' mm '-' dd 'T' hh ':' mm ':' ss ('.' s+)? (zzzzzz) <table cellspacing="2"><tr><td> <table border="1px" cellpadding="3px" cellspacing="0"> <tr><td align="center">yyyy</td><td>a four-digit numeral that represents the year</td></tr> <tr><td align="center">'-'</td><td>separators between parts of the date portion</td></tr> <tr><td align="center">mm</td><td>a two-digit numeral that represents the month</td></tr> <tr><td align="center">dd</td><td>a two-digit numeral that represents the day</td></tr> <tr><td align="center">T</td><td>separator that indicates time-of-day follows</td></tr> <tr><td align="center">hh</td><td>a two-digit numeral that represents the hour</td></tr> <tr><td align="center">':'</td><td>a separator between parts of the time-of-day portion</td></tr> <tr><td align="center">mm</td><td>a two-digit numeral that represents the minute</td></tr> <tr><td align="center">ss</td><td>a two-integer-digit numeral that represents the whole seconds</td></tr> <tr><td align="center">'.' s+</td><td>(not required) represents the fractional seconds</td></tr> <tr><td align="center">zzzzzz</td><td>(required) represents the timezone (as described below)</td></tr> </table> </td></tr></table> <br/>Timezones, required, are durations with (integer-valued) hour and minute properties in the form: ('+' | '-') hh ':' mm <table cellspacing="2"><tr><td> <table border="1px" cellpadding="3px" cellspacing="0"> <tr><td align="center">hh</td><td>a two-digit numeral (with leading zeros as required) that represents the hours</td></tr> <tr><td align="center">mm</td><td>a two-digit numeral that represents the minutes</td></tr> <tr><td align="center">'+'</td><td>a nonnegative duration</td></tr> <tr><td align="center">'-'</td><td>a nonpositive duration</td></tr> </table> </td></tr></table> </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ReasonforPhysicianCertificationStatement" maxOccurs="unbounded" minOccurs="0" name="ePayment.04"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.04</number> <name>Reason for Physician Certification Statement</name> <national>No</national> <state>No</state> <definition> The reason for EMS transport noted on the Physician Certification Statement </definition> <usage>Optional</usage> <comment>Added to assist in billing documentation.</comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.HealthcareProviderTypeSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.05" type="HealthcareProviderType"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.05</number> <name> Healthcare Provider Type Signing Physician Certification Statement </name> <national>No</national> <state>No</state> <definition> The type of healthcare provider who signed the Physician Certification Statement </definition> <usage>Optional</usage> <comment> CMS defines the individual signing the PCS as a person who has personal knowledge of the beneficiary's condition at the time the ambulance transport is ordered or the service is furnished. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.LastNameofIndividualSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.06" type="PersonLastName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.06</number> <name> Last Name of Individual Signing Physician Certification Statement </name> <national>No</national> <state>No</state> <definition> The last name of the healthcare provider who signed the Physician Certification Statement. </definition> <usage>Optional</usage> <comment>Added to assist in billing documentation.</comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.FirstNameofIndividualSigningPhysicianCertificationStatement" minOccurs="0" name="ePayment.07" type="PersonFirstName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.07</number> <name> First Name of Individual Signing Physician Certification Statement </name> <national>No</national> <state>No</state> <definition> The first name of the healthcare provider who signed the Physician Certification Statement. </definition> <usage>Optional</usage> <comment>Added to assist in billing documentation.</comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> </xs:sequence> </xs:complexType> </xs:element> <xs:element id="ePayment.PatientResidesinServiceArea" minOccurs="0" name="ePayment.08" type="ResidencyStatusOfThePatient"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.08</number> <name>Patient Resides in Service Area</name> <national>No</national> <state>No</state> <definition> An indication of whether the patient's current residence is within the EMS agency service area. </definition> <usage>Optional</usage> <comment>Added to assist in billing documentation.</comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsuranceGroup" maxOccurs="unbounded" minOccurs="0" name="ePayment.InsuranceGroup"> <xs:annotation> <xs:documentation> Group Tag to hold information about the insurance company </xs:documentation> </xs:annotation> <xs:complexType> <xs:sequence> <xs:element id="ePayment.InsuranceCompanyID" minOccurs="0" name="ePayment.09" type="InsuranceCompanyID"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.09</number> <name>Insurance Company ID</name> <national>No</national> <state>No</state> <definition>The ID Number of the patient's insurance company.</definition> <v2Number>E07_03</v2Number> <usage>Optional</usage> <comment> This element should be used as the Health Plan ID (HPID) field in X12. It is currently under development for X12 and will be a future release. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsuranceCompanyName" minOccurs="0" name="ePayment.10" type="InsuranceCompanyName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.10</number> <name>Insurance Company Name</name> <national>No</national> <state>No</state> <definition>The name of the patient's insurance company.</definition> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsuranceCompanyBillingPriority" minOccurs="0" name="ePayment.11" type="InsuranceCompanyBillingPriority"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.11</number> <name>Insurance Company Billing Priority</name> <national>No</national> <state>No</state> <definition> The billing priority or order for the insurance company. </definition> <v2Number>E07_04</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.12</number> <name>Insurance Company Address</name> <national>No</national> <state>No</state> <definition>The mailing address of the Insurance Company</definition> <v2Number>E07_05</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.InsuranceCompanyCity" minOccurs="0" name="ePayment.13" type="CityGnisCodePayment"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.13</number> <name>Insurance Company City</name> <national>No</national> <state>No</state> <definition> The insurance company's city or township used for mailing purposes. </definition> <v2Number>E07_06</v2Number> <usage>Optional</usage> <comment> The city elements within the ePayment section have been updated to allow free text. This is important for mailing address purposes to submit claims and identify the correct payer. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsuranceCompanyState" minOccurs="0" name="ePayment.14" type="ANSIStateCode"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.14</number> <name>Insurance Company State</name> <national>No</national> <state>No</state> <definition> The insurance company's state, territory, or province, or District of Columbia. </definition> <v2Number>E07_07</v2Number> <usage>Optional</usage> <comment> Based on the ANSI State Code.<br/><br/>GNIS Codes Website: <a>http://geonames.usgs.gov/domestic/download_data.htm</a> </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.15</number> <name>Insurance Company ZIP Code</name> <national>No</national> <state>No</state> <definition>The insurance company's ZIP Code</definition> <v2Number>E07_08</v2Number> <usage>Optional</usage> <comment> ZIP Codes Product Website: <a>https://www.zipcodedownload.com/Products/Product/Z5Commercial/Standard/Overview/</a> <br/>Product: USA - 5-digit ZIP Code Database, Commercial Edition </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsuranceCompanyCountry" minOccurs="0" name="ePayment.16" type="ANSICountryCode"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.16</number> <name>Insurance Company Country</name> <national>No</national> <state>No</state> <definition>The insurance company's country</definition> <usage>Optional</usage> <comment> Based on the ISO Country Code.<br/><br/>ANSI Country Codes (ISO 3166) Website: <a>http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm</a> </comment> <v3Changes>Added to better document international addresses.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsuranceGroupID" minOccurs="0" name="ePayment.17" type="InsuranceGroupID"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.17</number> <name>Insurance Group ID</name> <national>No</national> <state>No</state> <definition>The ID number of the patient's insurance group.</definition> <v2Number>E07_09</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsurancePolicyIDNumber" minOccurs="0" name="ePayment.18" type="InsurancePolicyIDNumber"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.18</number> <name>Insurance Policy ID Number</name> <national>No</national> <state>No</state> <definition>The ID number of the patient's insurance policy</definition> <v2Number>E07_10</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.LastNameoftheInsured" minOccurs="0" name="ePayment.19" type="PersonLastName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.19</number> <name>Last Name of the Insured</name> <national>No</national> <state>No</state> <definition> The last (family) name of the person insured by the insurance company. </definition> <v2Number>E07_11</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.FirstNameoftheInsured" minOccurs="0" name="ePayment.20" type="PersonFirstName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.20</number> <name>First Name of the Insured</name> <national>No</national> <state>No</state> <definition> The first (given) name of the person insured by the insurance company </definition> <v2Number>E07_12</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.MiddleInitialNameoftheInsured" minOccurs="0" name="ePayment.21" type="PersonMiddleName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.21</number> <name>Middle Initial/Name of the Insured</name> <national>No</national> <state>No</state> <definition> The middle name, if any, of the person insured by the insurance company. </definition> <v2Number>E07_13</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.RelationshiptotheInsured" minOccurs="0" name="ePayment.22" type="RelationshipToInsured"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.22</number> <name>Relationship to the Insured</name> <national>No</national> <state>No</state> <definition> The relationship of the patient to the primary insured person </definition> <v2Number>E07_14</v2Number> <usage>Optional</usage> <comment> Descriptors are consistent with X12 Loop 2000C PAT01, Specifies the patient's relationship to the person insured. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.InsuranceGroupName" minOccurs="0" name="ePayment.58" type="InsuranceGroupName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.58</number> <name>Insurance Group Name</name> <national>No</national> <state>No</state> <definition>The name of the patient's insurance group.</definition> <usage>Optional</usage> <comment/> <v3Changes/> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> </xs:sequence> </xs:complexType> </xs:element> <xs:annotation> <xs:documentation> Group Tag to hold information about patient's relative or guardian </xs:documentation> </xs:annotation> <xs:complexType> <xs:sequence> <xs:element id="ePayment.ClosestRelativeGuardianLastName" minOccurs="0" name="ePayment.23" type="PersonLastName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.23</number> <name>Closest Relative/Guardian Last Name</name> <national>No</national> <state>No</state> <definition> The last (family) name of the patient's closest relative or guardian </definition> <v2Number>E07_18</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianFirstName" minOccurs="0" name="ePayment.24" type="PersonFirstName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.24</number> <name>Closest Relative/ Guardian First Name</name> <national>No</national> <state>No</state> <definition> The first (given) name of the patient's closest relative or guardian </definition> <v2Number>E07_19</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianMiddleInitialName" minOccurs="0" name="ePayment.25" type="PersonMiddleName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.25</number> <name>Closest Relative/ Guardian Middle Initial/Name</name> <national>No</national> <state>No</state> <definition> The middle name/initial, if any, of the closest patient's relative or guardian. </definition> <v2Number>E07_20</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.26</number> <name>Closest Relative/ Guardian Street Address</name> <national>No</national> <state>No</state> <definition> The street address of the residence of the patient's closest relative or guardian. </definition> <v2Number>E07_21</v2Number> <usage>Optional</usage> <comment> This element allows for a two line documentation of the address. For out of country addresses the second line should be used to document, city, country, postal code and any other pertinent information. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianCity" minOccurs="0" name="ePayment.27" type="CityGnisCodePayment"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.27</number> <name>Closest Relative/ Guardian City</name> <national>No</national> <state>No</state> <definition> The primary city or township of residence of the patient's closest relative or guardian. </definition> <v2Number>E07_22</v2Number> <usage>Optional</usage> <comment> The city elements within the ePayment section have been updated to allow free text. This is important for mailing address purposes to submit claims and identify the correct payer. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianState" minOccurs="0" name="ePayment.28" type="ANSIStateCode"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.28</number> <name>Closest Relative/ Guardian State</name> <national>No</national> <state>No</state> <definition> The state of residence of the patient's closest relative or guardian. </definition> <v2Number>E07_23</v2Number> <usage>Optional</usage> <comment> Based on ANSI State Code.<br/><br/>GNIS Codes Website: <a>http://geonames.usgs.gov/domestic/download_data.htm</a> </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianZIPCode" minOccurs="0" name="ePayment.29" type="ZIP"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.29</number> <name>Closest Relative/ Guardian ZIP Code</name> <national>No</national> <state>No</state> <definition> The ZIP Code of the residence of the patient's closest relative or guardian. </definition> <v2Number>E07_24</v2Number> <usage>Optional</usage> <comment> ZIP Codes Product Website: <a>https://www.zipcodedownload.com/Products/Product/Z5Commercial/Standard/Overview/</a> <br/>Product: USA - 5-digit ZIP Code Database, Commercial Edition </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianCountry" minOccurs="0" name="ePayment.30" type="ANSICountryCode"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.30</number> <name>Closest Relative/ Guardian Country</name> <national>No</national> <state>No</state> <definition> The country of residence of the patient's closest relative or guardian. </definition> <usage>Optional</usage> <comment> Based on the ISO Country Code.<br/><br/>ANSI Country Codes (ISO 3166) Website: <a>http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm</a> </comment> <v3Changes>Added to improve international compatibility.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianPhoneNumber" maxOccurs="unbounded" minOccurs="0" name="ePayment.31"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.31</number> <name>Closest Relative/ Guardian Phone Number</name> <national>No</national> <state>No</state> <definition> The phone number of the patient's closest relative or guardian </definition> <v2Number>E07_25</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.ClosestRelativeGuardianRelationship" minOccurs="0" name="ePayment.32" type="ClosestRelativeGuardianRelationship"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.32</number> <name>Closest Relative/ Guardian Relationship</name> <national>No</national> <state>No</state> <definition> The relationship of the patient's closest relative or guardian </definition> <v2Number>E07_26</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> </xs:sequence> </xs:complexType> </xs:element> <xs:annotation> <xs:documentation> Group Tag to hold information about patient's employer </xs:documentation> </xs:annotation> <xs:complexType> <xs:sequence> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.33</number> <name>Patient's Employer</name> <national>No</national> <state>No</state> <definition>The patient's employers Name</definition> <v2Number>E07_27</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.34</number> <name>Patient's Employer's Address</name> <national>No</national> <state>No</state> <definition>The street address of the patient's employer</definition> <v2Number>E07_28</v2Number> <usage>Optional</usage> <comment> This element allows for a two line documentation of the address. For out of country addresses the second line should be used to document, city, country, postal code and any other pertinent information. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.PatientsEmployersCity" minOccurs="0" name="ePayment.35" type="CityGnisCodePayment"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.35</number> <name>Patient's Employer's City</name> <national>No</national> <state>No</state> <definition> The city or township of the patient's employer used for mailing purposes. </definition> <v2Number>E07_29</v2Number> <usage>Optional</usage> <comment> The city elements within the ePayment section have been updated to allow free text. This is important for mailing address purposes to submit claims and identify the correct payer. </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.PatientsEmployersState" minOccurs="0" name="ePayment.36" type="ANSIStateCode"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.36</number> <name>Patient's Employer's State</name> <national>No</national> <state>No</state> <definition>The state of the patient's employer</definition> <v2Number>E07_30</v2Number> <usage>Optional</usage> <comment> Based on ANSI State Code.<br/><br/>GNIS Codes Website: <a>http://geonames.usgs.gov/domestic/download_data.htm</a> </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.37</number> <name>Patient's Employer's ZIP Code</name> <national>No</national> <state>No</state> <definition>The ZIP Code of the patient's employer</definition> <v2Number>E07_31</v2Number> <usage>Optional</usage> <comment> ZIP Codes Product Website: <a>https://www.zipcodedownload.com/Products/Product/Z5Commercial/Standard/Overview/</a> <br/>Product: USA - 5-digit ZIP Code Database, Commercial Edition </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.PatientsEmployersCountry" minOccurs="0" name="ePayment.38" type="ANSICountryCode"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.38</number> <name>Patient's Employer's Country</name> <national>No</national> <state>No</state> <definition>The country of the patient's employer</definition> <usage>Optional</usage> <comment> Based on the ISO Country Code.<br/><br/>ANSI Country Codes (ISO 3166) Website: <a>http://www.iso.org/iso/country_codes/iso_3166_code_lists.htm</a> </comment> <v3Changes>Added to improve international compatibility.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.39</number> <name>Patient's Employer's Primary Phone Number</name> <national>No</national> <state>No</state> <definition>The employer's primary phone number.</definition> <v2Number>E07_32</v2Number> <usage>Optional</usage> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> </xs:sequence> </xs:complexType> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.40</number> <name>Response Urgency</name> <national>No</national> <state>No</state> <definition> The urgency in which the EMS agency began to mobilize resources for this EMS encounter. </definition> <v2Number>E07_33</v2Number> <usage>Optional</usage> <comment>This is for billing documentation.</comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.PatientTransportAssessment" maxOccurs="unbounded" minOccurs="0" name="ePayment.41"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.41</number> <name>Patient Transport Assessment</name> <national>No</national> <state>No</state> <definition> Documentation of the patient's transport need based on mobility and/or physical capability. </definition> <usage>Optional</usage> <comment> Added to better justify the medical necessity of the transport. Based on CMS 42 CFR Ch IV (10-1-02 Edition) & 410.40 (d) medical necessity requirement (1) </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.SpecialtyCareTransportCareProvider" maxOccurs="unbounded" minOccurs="0" name="ePayment.42"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.42</number> <name>Specialty Care Transport Care Provider</name> <national>No</national> <state>No</state> <definition> Documentation to show the patient care provided to the patient met the Specialty Care Transport Base Rate requirements. </definition> <usage>Optional</usage> <comment> Added to improve Specialty Care Transport billing justification. In accordance with CMS requirements Specialty Care Transport (SCT): ""Additional training" means the specific additional training that a State requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient during an SCT." </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.AmbulanceTransportReasonCode" maxOccurs="unbounded" minOccurs="0" name="ePayment.44"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.44</number> <name>Ambulance Transport Reason Code</name> <national>No</national> <state>No</state> <definition> The CMS Ambulance Transport Reason Code for the transport. </definition> <usage>Optional</usage> <comment> Added to improve billing with electronic claims using the ASC X12 Standard. The Ambulance Transport Code values are those determined by US Dept of HHS for the "Code indicating the type of ambulance transport". The Accredited Standards Committee X12 organization maintains the standard. See the X12 website http://www.x12.org or United States Health Information Knowledgebase website for more information: https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133080000 </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.RoundTripPurposeDescription" minOccurs="0" name="ePayment.45" type="TripPurposeDesciption"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.45</number> <name>Round Trip Purpose Description</name> <national>No</national> <state>No</state> <definition> Free text description providing the purpose of the round trip EMS transport based on CR109 field for CMS. </definition> <usage>Optional</usage> <comment> Added to improve billing documentation for CMS X12 based transactions. <br/> <br/>Ambulance providers can use this field to provide additional information regarding the circumstances of a round trip transport or for other medical necessity documentation. </comment> <v3Changes> Added to improve billing with electronic claims using X12 </v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.StretcherPurposeDescription" minOccurs="0" name="ePayment.46" type="StretcherPurposeDesciption"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.46</number> <name>Stretcher Purpose Description</name> <national>No</national> <state>No</state> <definition> Free Text Documentation providing the reason for use of a stretcher in the EMS patient transport. </definition> <usage>Optional</usage> <comment> Added to improve billing using CMS X12 transactions based on CR110. Documentation of Stretcher Purpose Description (ePayment.46) is required when needed to justify use of a stretcher. (X12 - Loop 2300 CR110). </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.AmbulanceConditionsIndicator" maxOccurs="unbounded" minOccurs="0" name="ePayment.47"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.47</number> <name>Ambulance Conditions Indicator</name> <national>No</national> <state>No</state> <definition> Documentation of the CRC03 through CRC07 requirements for CMS billing using X12 transactions. </definition> <usage>Optional</usage> <comment> Added to improve billing documentation and justification. </comment> <v3Changes> Added to improve billing with electronic claims using X12. The Codes and Descriptors updated Sept 2013 to meet the X12 5010 standard. </v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.MileagetoClosestHospitalFacility" minOccurs="0" name="ePayment.48" type="Mileage"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.48</number> <name>Mileage to Closest Hospital Facility</name> <national>No</national> <state>No</state> <definition> The mileage to the closest hospital facility from the scene. Documented only if the patient was transported to a facility farther away than the closest hospital. </definition> <usage>Optional</usage> <comment> Added to clarify billing mileage when the patient is not taken to the closest facility. </comment> <v3Changes>Added for improved billing documentation.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.ALSAssessmentPerformedandWarranted" minOccurs="0" name="ePayment.49" type="YesNoValues"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.49</number> <name>ALS Assessment Performed and Warranted</name> <national>No</national> <state>No</state> <definition> Documentation that the patient required an ALS assessment and it was performed. </definition> <usage>Optional</usage> <comment>Added to improve billing justification</comment> <v3Changes>Added to improve billing justification</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.50</number> <name>CMS Service Level</name> <national>Yes</national> <state>Yes</state> <definition>The CMS service level for this EMS encounter.</definition> <v2Number>E07_34</v2Number> <usage>Required</usage> <performanceMeasuresGroup> <performanceMeasure>Airway</performanceMeasure> <performanceMeasure>Pediatric</performanceMeasure> <performanceMeasure>STEMI</performanceMeasure> <performanceMeasure>Stroke</performanceMeasure> <performanceMeasure>Trauma</performanceMeasure> </performanceMeasuresGroup> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> <xs:simpleType> <!-- NV.NotReporting --> </xs:simpleType> </xs:attribute> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.51</number> <name>EMS Condition Code</name> <national>No</national> <state>No</state> <definition> The condition code associated with the CMS EMS negotiated rule-making process. </definition> <v2Number>E07_35</v2Number> <usage>Optional</usage> <performanceMeasuresGroup> <performanceMeasure>Airway</performanceMeasure> <performanceMeasure>Cardiac Arrest</performanceMeasure> <performanceMeasure>Pediatric</performanceMeasure> <performanceMeasure>STEMI</performanceMeasure> <performanceMeasure>Stroke</performanceMeasure> <performanceMeasure>Trauma</performanceMeasure> </performanceMeasuresGroup> <comment> Code list is represented in ICD-10-CM Codes: <br/>Website - <a href="http://uts.nlm.nih.gov" target="_blank">http://uts.nlm.nih.gov</a> <br/>Product - UMLS Metathesaurus </comment> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.CMSTransportationIndicator" maxOccurs="unbounded" minOccurs="0" name="ePayment.52"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.52</number> <name>CMS Transportation Indicator</name> <national>No</national> <state>No</state> <definition> The CMS Ambulance Fee Schedule Transportation and Air Medical Transportation Indicators are used to better describe why it was necessary for the patient to be transported in a particular way or circumstance. </definition> <v2Number>E07_37</v2Number> <usage>Optional</usage> <comment> Name changed from Condition Code Modifier to CMS Transportation Indicator </comment> <v3Changes> Name changed from Condition Code Modifier to CMS Transportation Indicator </v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> <xs:complexType> <xs:simpleContent> </xs:extension> </xs:simpleContent> </xs:complexType> </xs:element> <xs:element id="ePayment.TransportAuthorizationCode" minOccurs="0" name="ePayment.53" type="AuthorizationCode"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.53</number> <name>Transport Authorization Code</name> <national>No</national> <state>No</state> <definition> Prior authorization code provided by the insurance carrier/payer. </definition> <usage>Optional</usage> <v3Changes>Added to improve billing documentation.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.PriorAuthorizationCodePayor" minOccurs="0" name="ePayment.54" type="PersonName"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.54</number> <name>Prior Authorization Code Payer</name> <national>No</national> <state>No</state> <definition> The Payer who has provided the Prior Authorization Code. </definition> <usage>Optional</usage> <comment> Added to document Prior Authorization Codes for an EMS Transport. </comment> <v3Changes>Added to improve billing documentation.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.SupplyItemGroup" maxOccurs="unbounded" minOccurs="0" name="ePayment.SupplyItemGroup"> <xs:annotation> <xs:documentation> Group Tag to hold information about the supply used on the patient by the EMS Crew during the EMS event. </xs:documentation> </xs:annotation> <xs:complexType> <xs:sequence> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.55</number> <name>Supply Item Used Name</name> <national>No</national> <state>No</state> <definition> The name of the supply used on the patient by the EMS Crew during the EMS event. </definition> <usage>Optional</usage> <comment> Added to track EMS supplies for billing. The list of supplies would be created by the EMS Agency. There is no master list of supply items defined. </comment> <v3Changes>Added to track EMS supplies for billing.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> <xs:element id="ePayment.NumberofSupplyItemsUsed" minOccurs="0" name="ePayment.56" type="SupplyCount"> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.56</number> <name>Number of Supply Item(s) Used</name> <national>No</national> <state>No</state> <definition> The number of the specific supply item used on the patient by the EMS Crew during the EMS event. </definition> <usage>Optional</usage> <comment> Associated with ePayment.55 (Supply Item Used Name). Used to better track supply items for billing. </comment> <v3Changes>Added to track EMS supplies for billing.</v3Changes> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> </xs:sequence> </xs:complexType> </xs:element> <xs:annotation> <xs:documentation> <nemsisTacDoc> <number>ePayment.57</number> <name>Payer Type</name> <national>No</national> <state>No</state> <definition>Payer type according to X12 standard.</definition> <usage>Optional</usage> <comment> This element should only be used if Insurance, Medicare, Medicaid, Workers Compensation, or Other Government are selected in ePayment.01 - Primary Method of Payment. </comment> <v3Changes/> </nemsisTacDoc> </xs:documentation> </xs:annotation> </xs:element> </xs:sequence> </xs:complexType> <xs:annotation> <xs:documentation>The name of the patient's insurance group.</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="30"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation>Payer type according to X12 standard.</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="11"> <xs:annotation> <xs:documentation>Other Non-Federal Programs</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="12"> <xs:annotation> <xs:documentation>Preferred Provider Organization (PPO)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="13"> <xs:annotation> <xs:documentation>Point of Service (POS)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="14"> <xs:annotation> <xs:documentation>Exclusive Provider Organization (EPO)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="15"> <xs:annotation> <xs:documentation>Indemnity Insurance</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="16"> <xs:annotation> <xs:documentation> Health Maintenance Organization (HMO) Medicare Risk </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="17"> <xs:annotation> <xs:documentation>Dental Maintenance Organization</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="AM"> <xs:annotation> <xs:documentation>Automobile Medical</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="BL"> <xs:annotation> <xs:documentation>Blue Cross/Blue Shield</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="CH"> <xs:annotation> <xs:documentation>Champus</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="CI"> <xs:annotation> <xs:documentation>Commercial Insurance Co.</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="DS"> <xs:annotation> <xs:documentation>Disability</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="FI"> <xs:annotation> <xs:documentation>Federal Employees Program</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="HM"> <xs:annotation> <xs:documentation>Health Maintenance Organization</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="LM"> <xs:annotation> <xs:documentation>Liability Medical</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="MA"> <xs:annotation> <xs:documentation>Medicare Part A</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="MB"> <xs:annotation> <xs:documentation>Medicare Part B</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="MC"> <xs:annotation> <xs:documentation>Medicaid</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="OF"> <xs:annotation> <xs:documentation>Other Federal Program</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="TV"> <xs:annotation> <xs:documentation>Title V</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="VA"> <xs:annotation> <xs:documentation>Veteran Affairs Plan</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="WC"> <xs:annotation> <xs:documentation>Workers' Compensation Health Claim</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="ZZ"> <xs:annotation> <xs:documentation>Mutually Defined</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> Documentation of the CRC03 through CRC07 requirements for CMS billing using X12 transactions. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="01"> <xs:annotation> <xs:documentation>Patient was admitted to a hospital</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="04"> <xs:annotation> <xs:documentation>Patient was moved by stretcher</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="05"> <xs:annotation> <xs:documentation>Patient was unconscious or in shock</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="06"> <xs:annotation> <xs:documentation>Patient was transported in an emergency situation</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="07"> <xs:annotation> <xs:documentation>Patient had to be physically restrained</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="08"> <xs:annotation> <xs:documentation>Patient had visible hemorrhaging</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="09"> <xs:annotation> <xs:documentation>Ambulance service was medically necessary</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="12"> <xs:annotation> <xs:documentation> Patient is confined to a bed or chair (Use code 12 to indicate patient was bedridden during transport.) </xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The CMS Ambulance Transport Reason Code used in CMS X12 transmissions and CR104. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="A"> <xs:annotation> <xs:documentation> Patient was transported to the nearest facility for care of symptoms, complaints, or both </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="B"> <xs:annotation> <xs:documentation> Patient was transported for the benefit of a preferred physician </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="C"> <xs:annotation> <xs:documentation> Patient was transported for the nearness of family members </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="D"> <xs:annotation> <xs:documentation> Patient was transported for the care of a specialist or for availability of equipment </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="E"> <xs:annotation> <xs:documentation> Patient was transferred to a Rehabilitation Facility </xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> Information about the EMS Transport related to the CMS Ambulance Transport Code and CR103. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="I"> <xs:annotation> <xs:documentation>Initial Trip</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="R"> <xs:annotation> <xs:documentation>Return Trip</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="X"> <xs:annotation> <xs:documentation>Round Trip</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="T"> <xs:annotation> <xs:documentation>Transfer Trip</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> Prior authorization code provided by the insurance carrier/payer. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="50"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The relationship of the patient's closest relative or guardian </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2632001"> <xs:annotation> <xs:documentation>Appointed Guardian</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632003"> <xs:annotation> <xs:documentation>Child/Dependent</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632005"> <xs:annotation> <xs:documentation>Father</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632007"> <xs:annotation> <xs:documentation>Mother</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632009"> <xs:annotation> <xs:documentation>Other (Non-Relative)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632011"> <xs:annotation> <xs:documentation>Other (Relative)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632013"> <xs:annotation> <xs:documentation>Sibling</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632015"> <xs:annotation> <xs:documentation>Spouse</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632017"> <xs:annotation> <xs:documentation>Employee</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632019"> <xs:annotation> <xs:documentation>Life/Domestic Partner</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2632021"> <xs:annotation> <xs:documentation>Unknown</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation>The CMS service level for this EMS encounter.</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2650001"> <xs:annotation> <xs:documentation>ALS, Level 1</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650003"> <xs:annotation> <xs:documentation>ALS, Level 1 Emergency</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650005"> <xs:annotation> <xs:documentation>ALS, Level 2</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650007"> <xs:annotation> <xs:documentation>BLS</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650009"> <xs:annotation> <xs:documentation>BLS, Emergency</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650011"> <xs:annotation> <xs:documentation>Fixed Wing (Airplane)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650013"> <xs:annotation> <xs:documentation>Paramedic Intercept</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650015"> <xs:annotation> <xs:documentation>Specialty Care Transport</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2650017"> <xs:annotation> <xs:documentation>Rotary Wing (Helicopter)</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The CMS Condition Code Air Ambulance Modifier indicating why it was medically necessary to respond with air medical services as opposed to ground medical services. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="C1"> <xs:annotation> <xs:documentation> Interfacility Transport (Requires Higher level of care) </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="C2"> <xs:annotation> <xs:documentation>Interfacility Transport (service not available)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="C3"> <xs:annotation> <xs:documentation> Emergency Trauma Dispatch Condition Code (Major Incident or Mechanism of Injury) </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="C4"> <xs:annotation> <xs:documentation> Medically Necessary Transport (Facility on Divert or Services Unavailable) </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="C5"> <xs:annotation> <xs:documentation>BLS Transport of ALS Patient (ALS not available)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="C6"> <xs:annotation> <xs:documentation> ALS Response (Based on Dispatch Info) to BLS Patient (Condition) </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="C7"> <xs:annotation> <xs:documentation>IV Medications required en route (ALS)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="D1"> <xs:annotation> <xs:documentation> Long Distance-patient's condition requires rapid transportation over a long distance </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="D2"> <xs:annotation> <xs:documentation> Rare Circumstances, Traffic Patterns Precludes Ground Transport </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="D3"> <xs:annotation> <xs:documentation> Time to the closest appropriate hospital due to the patient's condition precludes ground transport; maximize clinical benefits </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="D4"> <xs:annotation> <xs:documentation>Pick up Point not Accessible by Ground Transport</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation>The patient's employers Name.</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="60"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The type of healthcare provider who signed the Physician Certification Statement </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2605001"> <xs:annotation> <xs:documentation>Clinical Nurse Specialist</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2605003"> <xs:annotation> <xs:documentation>Discharge Planner</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2605005"> <xs:annotation> <xs:documentation>Physician (MD or DO)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2605007"> <xs:annotation> <xs:documentation>Physician Assistant</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2605009"> <xs:annotation> <xs:documentation>Registered Nurse</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2605011"> <xs:annotation> <xs:documentation>Registered Nurse Practitioner</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The billing priority or order for the insurance company. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2611001"> <xs:annotation> <xs:documentation>Other</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611003"> <xs:annotation> <xs:documentation>Primary</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611005"> <xs:annotation> <xs:documentation>Secondary</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611007"> <xs:annotation> <xs:documentation>Tertiary</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611009"> <xs:annotation> <xs:documentation>Payer Responsibility Four</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611011"> <xs:annotation> <xs:documentation>Payer Responsibility Five</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611013"> <xs:annotation> <xs:documentation>Payer Responsibility Six</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611015"> <xs:annotation> <xs:documentation>Payer Responsibility Seven</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611017"> <xs:annotation> <xs:documentation>Payer Responsibility Eight</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611019"> <xs:annotation> <xs:documentation>Payer Responsibility Nine</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611021"> <xs:annotation> <xs:documentation>Payer Responsibility Ten</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611023"> <xs:annotation> <xs:documentation>Payer Responsibility Eleven</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2611025"> <xs:annotation> <xs:documentation>Unknown</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation>The ID number of the patient's insurance company</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="60"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation>The name of the patient's insurance company</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="60"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation>The ID number of the patient's insurance group.</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="30"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation>The ID number of the patient's insurance policy</xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="30"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The primary method of payment or type of insurance associated with this EMS encounter </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2601001"> <xs:annotation> <xs:documentation>Insurance</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601003"> <xs:annotation> <xs:documentation>Medicaid</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601005"> <xs:annotation> <xs:documentation>Medicare</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601007"> <xs:annotation> <xs:documentation>Not Billed (for any reason)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601009"> <xs:annotation> <xs:documentation>Other Government</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601011"> <xs:annotation> <xs:documentation>Self Pay</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601013"> <xs:annotation> <xs:documentation>Workers Compensation</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601015"> <xs:annotation> <xs:documentation>Payment by Facility</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601017"> <xs:annotation> <xs:documentation>Contracted Payment</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601019"> <xs:annotation> <xs:documentation>Community Network</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601021"> <xs:annotation> <xs:documentation>No Insurance Identified</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2601023"> <xs:annotation> <xs:documentation>Other Payment Option</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The reason for EMS transport noted on the Physician Certification Statement </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2604001"> <xs:annotation> <xs:documentation>Bed Confined</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604003"> <xs:annotation> <xs:documentation> Cardiac/Hemodynamic monitoring required during transport </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604005"> <xs:annotation> <xs:documentation>Confused, combative, lethargic, comatose</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604007"> <xs:annotation> <xs:documentation>Contractures</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604009"> <xs:annotation> <xs:documentation>Danger to self or others-monitoring</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604011"> <xs:annotation> <xs:documentation>Danger to self or others-seclusion (flight risk)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604013"> <xs:annotation> <xs:documentation>DVT requires elevation of lower extremity</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604015"> <xs:annotation> <xs:documentation>IV medications/fluids required during transport</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604017"> <xs:annotation> <xs:documentation>Moderate to severe pain on movement</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604019"> <xs:annotation> <xs:documentation> Morbid Obesity requires additional personnel/equipment to handle </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604021"> <xs:annotation> <xs:documentation>Non-healing fractures</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604023"> <xs:annotation> <xs:documentation> Orthopedic device (backboard, halo, use of pins in traction, etc.) requiring special handling in transit </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604025"> <xs:annotation> <xs:documentation> Restraints (Physical or Chemical) anticipated or used during transport </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604027"> <xs:annotation> <xs:documentation> Risk of falling off wheelchair or stretcher while in motion (not related to obesity) </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604029"> <xs:annotation> <xs:documentation> Severe Muscular weakness and de-conditioned state precludes any significant physical activity </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604031"> <xs:annotation> <xs:documentation>Special handling en route-Isolation</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604033"> <xs:annotation> <xs:documentation> Third Party assistance/attendant required to apply, administer, or regulate or adjust oxygen en route </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604035"> <xs:annotation> <xs:documentation> Unable to maintain erect sitting position in a chair for time needed to transport, due to moderate muscular weakness and de-conditioning. </xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2604037"> <xs:annotation> <xs:documentation> Unable to sit in chair or wheelchair due to Grade II or greater decubitus ulcers on buttocks. </xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The relationship of the patient to the primary insured person </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2622001"> <xs:annotation> <xs:documentation>Self</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622003"> <xs:annotation> <xs:documentation>Spouse</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622005"> <xs:annotation> <xs:documentation>Child/Dependent</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622009"> <xs:annotation> <xs:documentation>Cadaver Donor</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622011"> <xs:annotation> <xs:documentation>Employee</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622013"> <xs:annotation> <xs:documentation>Life/Domestic Partner</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622015"> <xs:annotation> <xs:documentation>Organ Donor</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622017"> <xs:annotation> <xs:documentation>Unknown</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2622019"> <xs:annotation> <xs:documentation>Other Relationship</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The status of the patient's residency (where they physically reside) within EMS Agencies municipality. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2608001"> <xs:annotation> <xs:documentation>Resident Within EMS Service Area</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2608003"> <xs:annotation> <xs:documentation>Not a Resident Within EMS Service Area</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The urgency in which the EMS agency began to mobilize resources. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2640001"> <xs:annotation> <xs:documentation>Immediate</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2640003"> <xs:annotation> <xs:documentation>Non-Immediate</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> Free Text Documentation providing the reason for use of a stretcher in the EMS patient transport. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="80"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The number of the specific supply item used on the patient by the EMS Crew during the EMS event. </xs:documentation> </xs:annotation> <xs:restriction base="xs:positiveInteger"> <xs:minInclusive value="1"/> <xs:maxInclusive value="100000000"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The name of the supply used on the patient by the EMS Crew during the EMS event. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="80"/> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> Documentation of the patient's transport need based on mobility and/or physical capability. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2641001"> <xs:annotation> <xs:documentation>Unable to sit without assistance</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2641003"> <xs:annotation> <xs:documentation>Unable to stand without assistance</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2641005"> <xs:annotation> <xs:documentation>Unable to walk without assistance</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> Documentation to show the patient care event met the Specialty Care Transport Base Rate requirements. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:enumeration value="2642001"> <xs:annotation> <xs:documentation>Advanced EMT-Paramedic</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642003"> <xs:annotation> <xs:documentation>Nurse</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642005"> <xs:annotation> <xs:documentation>Nurse Practitioner</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642007"> <xs:annotation> <xs:documentation>Physician (MD, DO)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642009"> <xs:annotation> <xs:documentation>Physician Assistant</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642011"> <xs:annotation> <xs:documentation>2009 Emergency Medical Responder (EMR)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642013"> <xs:annotation> <xs:documentation>2009 Emergency Medical Technician (EMT)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642015"> <xs:annotation> <xs:documentation>2009 Advanced Emergency Medical Technician (AEMT)</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642017"> <xs:annotation> <xs:documentation>2009 Paramedic</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642019"> <xs:annotation> <xs:documentation>First Responder</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642021"> <xs:annotation> <xs:documentation>EMT-Basic</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642023"> <xs:annotation> <xs:documentation>EMT-Intermediate</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642025"> <xs:annotation> <xs:documentation>EMT-Paramedic</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642027"> <xs:annotation> <xs:documentation>Other Healthcare Professional</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642029"> <xs:annotation> <xs:documentation>Other Non-Healthcare Professional</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642031"> <xs:annotation> <xs:documentation>Respiratory Therapist</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642033"> <xs:annotation> <xs:documentation>Student</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642035"> <xs:annotation> <xs:documentation>Critical Care Paramedic</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642037"> <xs:annotation> <xs:documentation>Community Paramedicine</xs:documentation> </xs:annotation> </xs:enumeration> <xs:enumeration value="2642039"> <xs:annotation> <xs:documentation>Registered Nurse</xs:documentation> </xs:annotation> </xs:enumeration> </xs:restriction> </xs:simpleType> <xs:annotation> <xs:documentation> The description of the purpose of the round trip EMS transport based on CR109. </xs:documentation> </xs:annotation> <xs:restriction base="xs:string"> <xs:minLength value="2"/> <xs:maxLength value="80"/> </xs:restriction> </xs:simpleType> </xs:schema> |