Understanding Workers' Compensation EDI Transactions in Pennsylvania

Bureau of Workers Compensation First Report of Injury EDI Transactions In Pennsylvania

General EDI Information EDI is a structured transmission of data between organizations by electronic means. The Bureau of Workers Compensation (BWC) moved from IAIABC EDI Release 1 Claim Standard for First Report of Injury (FROI) claim filings to the IAIABC EDI Release 3 Claims Standard on Sept. 9, 2013.

EDI Claims Tables EDI reporting requirements are defined on the following tables: 1. Required report(s) 2. Data needed on the report(s) Element Requirements Table Event Table Edit Matrix 3. Applied editing

First Report of Injury (FROI) Event Table Claim Event isan incident that requires you to report information to BWC. First Report of Injury (FROI) may contain information on claim administrator, employee, employer and/or accident information. A report of an event is identified or described using a Maintenance Type Code (MTC). Event Table

Partial Display of the FROI Event Table

Maintenance Type Codes (MTCs) The IAIABC defines these as codes defining the specific purpose of individual records within the transaction being submitted. They are used to report claim events and describe the types of FROI transactions being submitted. Any MTCs other than those accepted by Pennsylvania will be rejected as not jurisdictionally valid.

Pennsylvania accepts the following FROI MTCs: 00 Original 01 Cancel 02 Change/Update 04 Denial AQ Acquired Claim AU Acquired/Unallocated UR Upon Request

FROI MTCs Definitions 00 The original/first report transmitted between partners, including the re-transmission of a first report that was rejected due to a critical error. 01 The original first report was sent in error. 02 The claim administrator initiates a Change MTC when it identifies a change in the data element designated on the Element Requirements Table. 04 The entire claim is being denied. AQ Minimal data is sent to report that a new claim administrator has acquired the claim.

FROI MTCs Definitions AU The equivalent of an initial first report (MTC 00) filed by a new claim administrator in response to an AQ transaction that has been rejected because there is no claim match on database, or When an AU is sent in lieu of an AQ based on the Jurisdiction s Event Table, or When the acquiring claim administrator is reopening a claim that was previously canceled. UR Submitted in direct response from the jurisdiction and manually triggered by the claim administrator.

FROI-00 Original Scenario Claimant has NOT lost any time from work Claimant has NOT lost any time from work - - Employee John Doe cut his hand on the job on June 5, at 9:25 a.m. John goes to the local hospital s ER where the hand is treated. He was released and returned to work later that afternoon. John s supervisor reported the injury to the insurer/claim administrator on June 6. On June 10, the insurer chooses to accept liability for all reasonable and necessary medical bills although there wasn t the loss of a full day, shift or turn. To report the injury to BWC, the claim administrator files an Original First Report of Injury (FROI 00) transaction, with a Claim Type Code (DN0074) of M , on June 10. A copy of the report is also mailed to the claimant.

FROI-00 Original Scenario Claimant has lost time from work Claimant has lost time from work - - Employee Jack O Lantern injured his back while unloading freight at his place of employment on May 20 at 1:15 p.m. Jack was taken to the local hospital s ER where they determine he had slipped a disc and could not return to work. Jack would be out of work until at least his next appointment on June 3. Jack s supervisor reported the injury to the insurer/claim administrator on May 22. On May 26, the claim administrator determines the claim is compensable. To report the injury to BWC, the claim administrator files an Original First Report of Injury (FROI 00) transaction on May 26. A copy of the report is also mailed to the claimant.

FROI-04 Denial Scenario Claim Administrator Fully Denies Claim Claim Administrator Fully Denies Claim - - On Aug. 2, employee Theo Seuss reported to his Human Resources Department (HR) that he fell off a ladder on Aug. 1, at 1 p.m. and was unable to work. The employee went to, and was treated by, an approved panel Healthcare Provider. HR reported the injury to the insurer/claim administrator on Aug. 2. On Aug. 5, HR contacted Theo s foreman to ask him to complete an incident report for the alleged injury from Aug. 1. The foreman informed HR that the employee had not worked on Aug. 1. HR immediately informed the claim administrator of this information. On Aug. 5, the claim administrator determines that the claim is NOT compensable because it was NOT a work injury. To report the injury to BWC, the claim administrator files a Denial First Report of Injury (FROI 04) transaction on Aug. 6. A copy of the resulting NCD is also mailed to the claimant.

Event Information A claim administrator must use a SROI 04 to deny a claim if a FROI 00 has already been submitted on a claim. FROI AQ should be filed when you know that the carrier you acquired the claim from has already reported the claim by filing a FROI 00 or equivalent. FROI AU should be filed either when an AQ receives an Acknowledgement of Transaction Rejection (TR) because there is no match or when the adjuster knows the claim was not previously reported to the Bureau.

Element Requirements Table This table defines the event data, by data element name and number (DN), required for a Maintenance Type Code (MTC). The FROI components of this table are: FROI Data Element Requirements Worksheet FROI Conditional Requirements Worksheet Element Requirements Table

FROI Data Element Requirements Worksheet (Partial Display of the FROI Data Element Requirements) REC 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 DN# 0001 0002 0003 0004 0005 0006 0012 0013 0014 0015 0016 0021 0022 0023 0025 0027 0028 0029 0030 0031 0032 0033 0035 0036 0037 DATA ELEMENT NAME Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Code Jurisdiction Claim Number Insurer FEIN Claim Administrator City Claim Administrator State Code Claim Administrator Postal Code Claim Administrator Claim Number (Key Match) Employer FEIN Employer Physical City Employer Physical State Code Employer Physical Postal Code Industry Code Insured Location Identifier Policy Number Identifier Policy Effective Date Policy Expiration Date Date of Injury Time of Injury Accident Site Postal Code Nature of Injury Code Part of Body Injured Code Cause of Injury Code 00 F F F F MC F M M F F M IA IA IA IA NA IA NA NA M IA NA M M M 01 F F F F M F NA NA F F IA NA NA NA NA NA NA NA NA M NA NA NA NA NA 02 F F F F M FY Y Y FY FY Y Y Y Y Y NA Y NA NA Y Y NA Y Y Y 04 F F F F MC F IA IA F F MC IA IA IA IA NA IA NA NA M IA NA IA IA IA AQ F F F F M F IA IA F F IA IA IA IA NA NA IA NA NA M IA NA NA NA NA AU F F F F M F IA IA F F IA IA IA IA IA NA IA NA NA M IA NA IA IA IA UR F F F F M F IA IA F F IA IA IA IA IA NA IA NA NA M IA NA IA IA IA This worksheet describes what elements are required for each FROI MTC. IA is NOT the same as N/A. IA elements should be provided, unless the information is not available.

Requirement Codes F Fatal FC Fatal/Conditional FY Fatal/Yes Change R Restricted RC Restricted/Conditional M Mandatory MC Mandatory/Conditional Y Yes Change YC Yes/Conditional N No E Expected EC Expected/Conditional IA If Applicable/Available NA Not Applicable X - Exclude

FROI Conditional Requirements Worksheet DN# DATA ELEMENT NAME BUSINESS CONDITION(S) TECHNICAL CONDITION(S) 0005 Jurisdiction Claim Number Mandatory except for new claims not already existing in jurisdiction system. Mandatory except for new claims not already existing in jurisdiction system. 0016 Employer FEIN Mandatory except for Denials due to no coverage. Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x. 0042 Employee SSN Refer to Information and Data Reported in Section 2 of the PA Implementation guide. When DN 0270 Employee ID Type Qualifier = S, then mandatory 0056 Initial Date Disability Began Mandatory for a disability continuing the entire day, shift turn, or longer Must be present if DN0074 (Claim Type Code) = I 0154 Employee ID Assigned by Jurisdiction Refer to Information and Data Reported in Section 2 of the PA Implementation guide. When DN 0270 Employee ID Type Qualifier = A, then mandatory 0281 Date Employer Had Knowledge of Date of Disability Mandatory for a disability continuing the entire day, shift turn, or longer and if the injury(s) occured on or after September 9, 2013 Must be present if DN0056 (Initial Date Disability Began) is present and DN0031 (Date of Injury) >=9/9/2013 0165 Employer Mailing City Mandatory except for Denials due to no coverage. Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x. 0167 Employer Mailing Postal Code Mandatory except for Denials due to no coverage. Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x. 0168 Employer Mailing Primary Address Mandatory except for Denials due to no coverage. Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x. This worksheet lists FROI data elements that are conditionally required and describes when they are mandatory.

Data Elements Impacted by Release 3.0 Death Result of Injury Code (DN0146) indicates that a worker s death was the result of the injury. All originating FROI reports involving a death, which have a date of injury AFTER the implementation date, Sept. 9, 2013, should include this data element. For injuries occurring prior to implementation, this should be included in the next required SROI report. Accident Site County/Parrish (DN0118) is the county where the accident/injury occurred. All originating FROI reports that have a date of injury on or after the implementation date should include this data element.

Data Elements Impacted by Release 3.0 - continued Insured FEIN (DN0314) is the Federal Employer Identification Number corresponding to, and uniquely identifying the insured. All originating FROI 00 and FROI 04 reports should include this element. For injuries occurring prior to implementation, this should be included in the next required SROI report. Employer Mailing Address Information Release 3.0 allows jurisdictions to capture both physical and mailing addresses. BWC will require the reporting of the mailing address for employers on all originating FROI transactions with a date of injury on, or after, implementation.

Data Elements Impacted by Release 3.0 - continued Date Employer Had Knowledge of the Date of Disability (DN0281) is the date the employer was notified or became aware of the initial or subsequent period of the employee s disability. All originating FROI reports that have a date of injury on or after implementation MUST include this data element. For injuries occurring prior to implementation, this should be included in the next required SROI report. Employee Date of Birth (DN0052) All originating FROI 00 and FROI 04 reports require this data element.

Data Elements Impacted by Release 3.0 - continued Claim Administrator Mailing Address Information (DN 0012, 0013, 0014) are data elements that represent the city, state and postal code of the claim adjusting office handling the claim. BWC will require this information on all originating FROI transactions. Claim Administrator Claim Number (DN0015) is an identifier for a specific claim within the claim administrator s claim processing system. FROI reports are required to include this data element. For injuries occurring prior to implementation, this should be included in the next required SROI report.

Placeholder Information for Required Fields Social Security numbers (DN0042) and Employer FEINs (DN0016) are required data elements. (The only exception for this data element is for Employer FEIN for FROI 04 transactions with no coverage.) If either of these are not known, contact BWC at 800-482-2383 or 717-772-4447 for a placeholder ID which should be used when submitting the FROI 00.

Edit Matrix Table This table is made up of five worksheets which: Communicate the edits that will be applied to the data being sent to BWC, as well as the standard error messages for those edits when the data is not acceptable, and Describes the proper sequence of submissions, acceptable code values, data used for matching to existing claims and the error messages associated with these edits. Edit Matrix

Five Worksheets in Edit Matrix DN-Error Message contains standard edits and error messages. Value Table lists BWC s acceptable code values. Match Data describes which data elements will be used to determine if the information matches an existing claim or if a new claim must be created. Population Restrictions is a listing of restrictions applied to the data element(s). FROI Sequencing Tables describes how BWC will apply sequencing edits and the order in which specific events are expected to be reported.

DN-Error Message Worksheet (Partial Display of the DN-Error Message listing) Edit Matrix Population Legend: F = Edit applies to the data elements deemed essential for a transmission/transaction to be processed. L = *Not grayed out: Edit applies to the data elements based on the requirements indicated on the Element Requirement Table. *Grayed out: The standard edit will not be applied by the jurisdiction Relaxed requirement edits (err msg 001 Must be >= Initial Date Disability Began 035 Number of Days Worked must be 0-7 018 Population Restrictions Indicator Must be <= Employee Date of Death 036 Relaxed requirement edits: L = Claim: requirement is limited to "conditional" on new claims reported in R3 environment because the data may not (and may never be) available on legacy claims. V = Event: requirement is limited to "conditional" on claims where benefits are being "initiated" or "reinstated" in R3 because the data may not have been collected at the time payments were started in the R1 environment. NI = No migration impact Must be a valid date (CCYYMMDD) 029 Jurisdiction will apply edits? Must be A-Z, 0-9, or spaces 030 Mandatory field not present 001 Must be <= Date of Injury 033 Must be >= Date of Injury 034 Jurisdiction will apply edits?: F = Essential data element; must be edited for successful transaction processing Y = Yes - indicates that all edits marked for the data element will be applied; some may be based on conditions defined in the Element Requirement Table N = No - indicates that none of the standard edits marked for the data elements will be applied All digits must be 0-9 028 Sorted by Error Message & DN DN Must be a valid time 031 Days must be 0-6 019 For Population Restrictions: For Data Elements that have certain population values allowed for specific data elements, a P is indicated in the Population Restrictions Indicator column and the associated data element population restriction is detailed in the Population Restrictions Table. and 108) IAIABC Data Element Name 0000 Entire Batch NI Y 0001 Transaction Set ID NI F F 0002 Maintenance Type Code NI F P F 0003 Maintenance Type Code Date NI F F L L 0004 Jurisdiction Code NI F P F 0005 Jurisdiction Claim Number NI Y P L L 0006 Insurer FEIN NI F F L This worksheet will assist claim administrators in determining the specific cause of an error message.

DN-Error Message Worksheet, continued Shows data elements that have specific data population restrictions and/or accepted values. These are marked with a P and are described in the Population Restrictions worksheet. An L in this worksheet indicates that this edit is being applied by the jurisdiction. If the information provided does not meet the requirement, the listed error number will be returned to the sender. This worksheet also explains the definition of each error number.

Value Table Worksheet (Partial Display of the Value Table) Capture Element Name Acceptable Code Value List - grayed out indicates that a value is 'Not Statutorily Valid' ? Maintenance Type Code (for FROI) Y 00 01 02 04 CO AQ AU UI UR Maintenance Type Code (for SROI) Y 02 04 AB AP CA CB CD CO EP ER FN IP P1 P2 P3 P4 P5 P7 P9 PD PJ PY Maintenance Type Codes (for SROI continued) Initial Treatment Code Y RB RE S1 S2 S3 S4 S5 S6 S7 S8 S9 SD SJ UI UR VE AN BM BW MN QT SA N 0 1 2 3 4 5 Employee Gender Code Y F M U Employee Marital Status Code Y U M S K Employment Status Code Y C 9 8 A B 1 2 3 6 4 5 7 (see hierarchical order in dictionary) Wage Period Code (FROI) N 01 02 04 06 07 Wage Period Code (SROI) Y 01 04 Pre-Existing Disability Code N Y N U Claim Status Code Y O C R X Claim Type Code Y M I N B L Agreement to Compensate Code Y W L The Value Table lists acceptable code values. It identifies if a code value is statutorily valid, not statutorily valid or accepted, but not required, by Pennsylvania. BWC will not accept codes that are not statutorily valid (grayed out).

Population Restrictions Worksheet DN Data Element Name Error Messag e Number 042 Error Message Text Population Restriction 0002 Maintenance Type Code Not Statutorily Valid Valid values limited to 00, 01, FROI 02,FROI 04, AQ, AU, FROI UR SROI 02, SROI 04, AB, AP, CA, CB, FN, IP, P1, P3, P4, P5, P7, P9, PJ, PY, RB, RE, S1, S3, S4, S5, S7, S8, S9, SD, SJ, and SROI UR Value must be PA 0004 Jurisdiction Code 042 Not Statutorily Valid 0005 Jurisdiction Claim Number 042 All digits must be 0-9 Valid values must be numeric 0056 Initial Date Disability Began 042 Not Statutorily Valid When MTC = IP, date must be gtr or eql the Date of Injury (DN0031) Valid values limited to 9, 8, 1 and 2 0058 Employment Status Code 042 Not Statutorily Valid 0063 Wage Period Code (SROI) 042 Not Statutorily Valid Value must be 1 (Weekly) 0074 Claim Type Code 042 Not Statutorily Valid Codes N, B, and L are not valid 0084 Permanent Impairment Percentage Benefit Type Code 042 Not Statutorily Valid Value must be greater than zero and not more than 100% 0085 042 Not Statutorily Valid Codes 040, 242, 410, 540, 541 are not valid 0088 Benefit Period Start Date 042 Not Statutorily Valid When MTC = RB, Benefit Period Start Date must equal Current Date Disability Began (DN0144) Valid values limited to A, B, E, J, L, Q, R, T, U, W, X, Y and 2 0092 Benefit Adjustment Code 042 Not Statutorily Valid 0198 Full Denial Reason Code 042 Not Statutorily Valid Code 1G is not valid 0222 Payment Reason Code 042 Not Statutorily Valid Codes 040, 242, 410, 540, 541 are not valid 0270 0294 Employee ID Type Qualifier Partial Denial Code 042 044 Not Statutorily Valid Not Statutorily Valid Valid values limited to A and S Valid values limited to A This worksheet is a listing of restrictions applied to specific data elements (identified in the DN Error Message Worksheet by a P ).

Transaction Sequencing (Partial Display of the Transaction Sequencing) Apply Seq Edit? Y, N, NA Incoming Maintenance Type Code MTC NAME Element Error Number (DN0116) Suggested Error Text (DN0291) limited to 50 bytes MINIMUM SEQUENCING REQUIREMENTS Business Event Group 1. Establish Claim or New Claim Administrator 1a. Determination not made 1b. Report of Injury 00 N Original None (refer to FROI Match Data/Duplicate Transactions TRANSACTION PROCESSING GUIDELINES in Section 2) 1c. Denial 04 - FROI N Denial None (refer to FROI Match Data/Duplicate Transactions TRANSACTION PROCESSING GUIDELINES in Section 2) 1d. Acquired Claim AQ Y Acquired Claim 063 No previous FROI from prior Clm Admin accepted No previous FROI from prior Clm Admin accepted Previous accepted First Report from prior Claim Administrator Previous accepted First Report from prior Claim Administrator N AU Acquired/Unallocated Business Events 2b and 2c can occur once during the life of the claim. 3 can occur multiple times until benefits are suspended (Event 4). Event 2b or 2c may or may not occur after 2a. Event 2c may or may not occur after 2b. However, once Event 2b or 2c occurs, Event 4 must occur before 5a or 5b can occur. Note: If FROI UR is accepted, jurisdictions must consider the requirements defined for the UR to successfully apply sequencing edits. Business Event Group 2. Initial Payment of Indemnity or equivalent 2a. Non- payment of Indemnity Y 04 - SROI Full Denial SROI 063 Event 1b (FROI) not previously accepted A 00 must have been accepted The Sequencing Table describes how BWC will apply sequencing edits and the order in which events are expected to be reported.

FROI Requirements Written notice to the employee has not changed due to EDI and is still required. A copy of the information provided to BWC must be sent to the claimant in paper form for ALL FROI transactions. To do this, claim administrators can use a form currently generated by their insurer systems or the FROI (LIBC-90) template available in WCAIS. If an insurer chooses to deny a claim on a FROI, they must provide the denial information to the claimant by also sending the resulting denial (LIBC-496).

FROI Requirements - continued The FROI transaction is required to be electronically filed within seven days of an alleged injury that continues for more than a full day, shift or turn. If an injury results in death, the filing must be made within 48 hours. * Please note that although Pennsylvania statute does not require a FROI for medical-only claims, to report claim information to BWC, a FROI 00 must first be filed on a claim.

Resources For further information regarding EDI Release 3 and the PA EDI Claims Implementation Guide: http://www.dli.pa.gov/edi. For information about IAIABC EDI Claims Release 3 Implementation: www.iaiabc.org. Questions or comments: Contact us via the WCAIS Customer Service Center Submit a Question feature (category=EDI).