Maine Workers’ Compensation Board Electronic Filing and Forms Overview

Abbreviations AWW - Average Weekly Wage EDI - Electronic Data Interchange FROI - First Report of Injury (WCB-1) MAE - Monitoring, Audit and Enforcement MOP - Memorandum of Payment (WCB-3) NOC - Notice of Controversy (WCB-9) RTW - Return to Work SOC – Statement of Compensation Paid (WCB-11) WBR – Weekly Benefit Rate MWCB – Maine Workers’ Compensation Board

Form Filing A complete listing of forms may be obtained by contacting the MWCB, 27 State House Station, Augusta, Maine 04333-0027, telephone 1-888-801-9087 or 207-287-3751 or by visiting the MWCB website at www.Maine.Gov/wcb/ All MWCB forms have a four part distribution as follows: COPY 1) Maine Workers Compensation Board COPY 2) Employee COPY 3) Insurer COPY 4) Employer If COPY 1 is now submitted electronically to the MWCB, all other copies must still be sent to the respective recipients. Copies of forms are available on the MWCB website. Chapter 3 §2.1 “Except as specifically provided in 39-A M.R.S.A. § 101 et seq. or in these rules, all forms and correspondence, including, but not limited to petitions, shall be filed in the Central Office of the Workers’ Compensation Board.”

Electronic Form Filing “Electronic Claims” requirements are available at the MWCB website: www.maine.gov/wcb. Claim Administrators must use the IAIABC “Release 3” format. It is critical that employers/insurers and their respective EDI vendors understand the MWCB’s EDI requirements. To avoid violations/penalties, employers/insurers must maintain routine communication with their respective EDI vendors to ensure that any FROIs/NOCs rejected by the MWCB are addressed in a timely manner.

Electronic Form Filing A sender will receive one of the following application acknowledgement codes after submitting an EDI transaction: TA = (Transaction accepted). The transaction was accepted and the First Report of Injury or Subsequent Report of Injury is filed. TE = (Transaction accepted with errors). The error or errors will be identified in the acknowledgement transmission that is sent by the MWCB. All identified errors must be corrected within 14 days after the date the acknowledgement transmission was sent by the MWCB or prior to any subsequent transmission for the same claim, which ever is sooner. TR = (Transaction rejected) The entire transaction has been rejected and the first Report of Injury or subsequent Report of injury is not filed.

First Report of Occupational Injury or Disease (WCB-1) Effective 7/1/05, all claim administrators must submit FROIs to the MWCB via EDI. Do not file FROIs with the MWCB in paper format. Doing so may be perceived as a questionable claims-handling technique. Don’t forget to send a paper copy of the exact information submitted electronically to the injured employee.

First Report of Occupational Injury or Disease (WCB-1) Types of FROI transmissions: 00 = (Original) Used to file an original FROI 01 = (Cancel) Used to cancel an original FROI that was sent in error CO = (Correction) Used to correct a data element or elements when a filing is accepted with errors (“TE”) 02 = (Update/Change) Used to update/change a data element UR = (Upon request) Submitted in response to a request from the MWCB AQ = (Acquired Claim) Used to report that a new claim administrator has acquired the claim

First Report of Occupational Injury or Disease (WCB-1) If there are one or more lost days (hours or wages), the FROI must be sent to the the MWCB within 7 days of the employer’s notice or knowledge. If the length of incapacity is 7 days or less, then the updated FROI must be sent to the MWCB with the Return to Work date (Box 47). If the length of incapacity is more than 7 days, a MOP or NOC must be filed within 14 days of the employer’s notice or knowledge of incapacity.

Wage Statement (WCB-2) When lost time benefits are paid voluntarily, a Wage Statement must be filed within 30 days of the first day of compensability (8th day of incapacity). When lost time benefits are controverted, a Wage Statement must be filed within 30 days of the employer’s notice or knowledge of the incapacity. If the employer completes the Wage Statement, the adjuster should review it for accuracy and ensure the correct AWW is reflected on the MOP.

Schedule of Dependent(s) and Filing Status Statement (WCB-2A) When lost time benefits are paid voluntarily, a Schedule of Dependent(s) and Filing Status Statement must be filed within 30 days of the first day of compensability (8th day of incapacity). When lost time benefits are controverted, a Schedule of Dependent(s) and Filing Status Statement must be filed within 30 days of the employer’s notice or knowledge of the incapacity. If the employee completes the Schedule of Dependent(s) and Filing Status Statement, the adjuster should review it for accuracy and ensure the correct WBR is reflected on the MOP. Did you know that employees who file Married Joint get to include their spouse as a dependent? Example: Married filing jointly with no children is entitled to benefits based on one dependent (their spouse). FYI: The adjuster has the authority to file (based on any known filing status and dependent information) if the employee fails to do so. Upon receipt of the employee’s version of the form, a copy should be forwarded to the Board along with any corresponding corrections (if applicable).

WCB-2 and WCB-2A Recap Wage Statements and Schedule of Dependent(s) and Filing Status Statement forms (WCB-2 and WCB-2A) must be filed for all claims where lost time exceeds seven days (waiting period). Wage Statements and Schedules of Dependent(s) and Filing Status Statement forms (WCB-2 and WCB-2A) must be filed for all controverted lost time claims.

Weekly Benefit Tables Find the AWW within the tables. ZERO ONE TWO THREE FOUR FIVE 561 Single 355.76 367.14 378.06 388.97 399.12 406.38 Married Joint 390.08 397.28 404.24 410.35 413.49 Head of Household 370.05 380.96 391.26 398.47 405.64 411.75 Married Separate 354.58 366.16 377.09 388.00 398.15 405.75 562 Single 356.31 367.71 378.62 389.54 399.72 407.00 Married Joint 390.70 397.90 404.88 410.99 414.21 Head of Household 370.61 381.52 391.89 399.09 406.28 412.39 Married Separate 355.13 366.71 377.65 388.57 398.75 406.38 563 Single 356.86 368.27 379.18 390.10 400.32 407.62 Married Joint 391.32 398.52 405.53 411.63 414.94 Head of Household 371.17 382.09 392.49 399.71 406.92 413.03 Married Separate 355.69 367.26 378.21 389.13 399.35 407.00 Find the AWW within the tables. Select the line that correctly matches the filing status information. Select the column that correctly matches the number of dependents. The “ZERO” column includes only the injured employee.

Memorandum of Payment (WCB-3) A MOP must be filed: Within 14 days of the employer’s notice or knowledge of an undisputed claim for compensation. When a claim for compensation is controverted later than 14 days from the employer’s notice or knowledge of a claim for compensation (“mandatory MOP”) When compensation is paid pursuant to a decision or approved agreement. Box 24 must accurately reflect the date the first indemnity payment was mailed to the claimant for the incapacity reported in Box 23. Box 28 must accurately reflect the first date of incapacity after the 7-day waiting period. If a provisional Memorandum of Payment was filed initially and the actual rate is greater than the provisional rate, an amended Memorandum of Payment or Modification (WCB-4) must be filed to establish the correct average weekly wage and rate. If a provisional Memorandum of Payment was filed initially and the actual rate is less than the provisional rate, a (21-Day) Certificate of Discontinuance or Reduction of Compensation (WCB-8) must be filed to establish the correct average weekly wage and rate.

Discontinuance or Modification of Compensation (WCB-4) A Discontinuance or Modification of Compensation must be filed: When an employee returns to pre-injury earning status with the insured (as a discontinuance). When an employee returns to work part-time for the insured (as a modification). When an employee’s post-injury wages with the insured fluctuate (TP to TT and vice versa). When statutory offsets are applied. When compensation is modified or discontinued pursuant to a decision or approved agreement.

21-day Certificate of Discontinuance (WCB-8) If the employee’s benefits were discontinued or reduced for any reason other than those stated on the previous slide, then a 21-day Certificate of Discontinuance must be filed unless indemnity is being paid pursuant to an order, award, or compensation scheme. DO NOT file this form if indemnity is being paid pursuant to an order, award, or compensation scheme. Benefits may be discontinued or reduced no earlier than 21 days after the form is mailed via certified mail (Box 29) to the claimant. Box 29 must accurately reflect the date the WCB-8 is mailed to the injured employee. Benefits must be paid through the effective date (Box 19) of the discontinuance or (box 25) of the reduction. Form must be sent by certified mail to the employee and to the MWCB.

21-day Certificate of Discontinuance (WCB-8) Certified Mailing Reminder Claim administrators should have this sender’s receipt postmarked to prove when they sent the WCB-8. Postmark Here

Notice of Controversy (WCB-9) Effective 7/1/06, all claim administrators must submit original NOCs to the MWCB via EDI. While claim administrators may post corrections to NOCs via EDI in response to a “TE” error in their transmission reports, any changes to NOCs not specifically related to an EDI “TE” error must be submitted via paper. Do not file NOCs with the MWCB in paper format. Doing so may be perceived as a questionable claims-handling technique. Don’t forget to send a paper copy of the exact information submitted electronically to the injured employee.

Notice of Controversy (Denial) (WCB-9) A NOC must be filed: 1. To dispute indemnity. The NOC must be filed within 14 days of the employer’s notice or knowledge of incapacity If the NOC is not filed within 14 days of the employer’s notice or knowledge of incapacity: A mandatory payment must be issued for total incapacity benefits from the first day of incapacity until the NOC is filed and accrued benefits are paid.. A MOP must be filed To dispute medical bill(s) and/or treatment. The NOC must be filed within 30 days of the receipt of a disputed bill. To dispute jurisdiction. To dispute coverage. To dispute for any other reason as described in the Full or Partial Denial Codes.

Statement of Compensation Paid (WCB-11) The filing requirement for the Statement of Compensation Paid is triggered by indemnity payment(s). If it has been 195 days since the date of injury, then the WCB-11 must be filed if indemnity has been paid. (Interims must be filed within 195 days after the date of injury.) If it has been one year or more since the date of the injury, are payments of any type expected to continue? If yes, an “Interim” WCB-11 must be filed. (Subsequent “Interims” must be filed annually within 15 days of the anniversary date of injury if payments of any type are expected to continue.) If no, then a “Final” WCB-11 must be filed. (“Finals” must be filed when no further payments of any type are anticipated. The amount of Weekly Compensation listed in Box 20 must equal the total of the Amounts Paid reported on all Discontinuances [WCB-4, WCB-4A, and/or WCB-8] previously filed.)

Maine Claims Scenarios - Review Scenario 1 – No Lost Time - medicals accepted FROI not required to be filed. Scenario 2 – No Lost Time - medicals denied File NOC within 30 days of receipt of a medical bill (See Rule 5.7). File FROI (See Rule 8.13).

Maine Claims Scenarios - Review Scenario 3 – Lost Time Return To Work within 7 days-medicals accepted File FROI within 7 days of employer’s notice or knowledge of a lost day (See Section 303, Rule 3.1). File updated FROI within 7 days of RTW (See Rule 8.16). Scenario 4 – Lost Time; Return To Work within 7 days – medicals denied File FROI within 7 days of employer’s notice or knowledge of a lost day. File updated FROI within 7 days of RTW. File NOC within 30 days of receipt of a medical bill.

Maine Claims Scenarios - Review Scenario 5 Lost Time – Greater Than 7 days – Lost Time accepted File FROI within 7 days of employer’s notice or knowledge of a lost day. File MOP within 14 days of employer’s notice or knowledge of incapacity or within 6 calendar days after 1st day of compensability (Box 28 of MOP). File WCB-2 and WCB-2A within 30 days of 1st day of compensability (Box 28 of MOP). File amended MOP (or WCB-4, modification) to establish AWW and WBR. File WCB-4, WCB-4A, or WCB-8 (as applicable) when indemnity is discontinued, reduced or otherwise modified. File (Interim) SOC within 195 days of injury date, and then annually within 15 days of the anniversary date of the injury while payments (of any type) are ongoing. File (Final) SOC when no further payments are anticipated.

Maine Claims Scenarios - Review Scenario 6 – Lost Time greater than 7 days – Lost Time denied File FROI within 7 days of employer’s notice or knowledge of a lost day. File NOC within 14 days of employer’s notice or knowledge of incapacity. If NOC was filed late, you must issue a mandatory payment and file a mandatory MOP (See Rule 1.1). File WCB-2 and WCB-2A within 30 days of employer’s notice or knowledge of incapacity. File amended mandatory MOP to establish AWW and WBR, and to revise the “Amount Paid” (Box 20C), if applicable. File (Interim) SOC within 195 days of injury date, and then annually within 15 days of the anniversary date of the injury while payments (of any type) are ongoing. File (Final) SOC when no further payments are anticipated.

Any questions?

MWCB Contacts Claims Department, Phone (207) 287- @maine.gov MAE Program,