1. Bureau of Workers’ Compensation

2. Speaker Introduction Tammy Laughman, manager EDI Unit – Claims Management Division Bureau of Workers’ Compensation Email: RA-CMDEDI@pa.govRA-CMDEDI@pa.gov

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

4. 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 Edit Matrix Event Table 3. Applied editing

5. First Report of Injury (FROI) Event Table Claim Event – is an 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

6. Partial Display of the FROI Event Table

7. 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.

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

9. 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.

10. 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.

11. FROI-00 Original Scenario 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.

12. FROI-00 Original Scenario 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. Claimant has lost time from work -

13. FROI-04 Denial Scenario 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 report is also mailed to the claimant. Claim Administrator Fully Denies Claim -

14. 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 when an AQ receives an Acknowledgement of Transaction Rejection (TR) because there is no match.

15. 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

16. FROI Data Element Requirements Worksheet (Partial Display of the FROI Data Element Requirements) 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. RECDN#DATA ELEMENT NAME00010204AQAUUR 1480001Transaction Set IDFFFFFFF 1480002Maintenance Type CodeFFFFFFF 1480003Maintenance Type Code DateFFFFFFF 1480004Jurisdiction CodeFFFFFFF 1480005Jurisdiction Claim NumberMCMM MMM 1480006Insurer FEINFFFYFFFF 1480012Claim Administrator CityMNAYIA 1480013Claim Administrator State CodeMNAYIA 1480014Claim Administrator Postal CodeFFFYFFFF 1480015Claim Administrator Claim Number (Key Match)FFFYFFFF 1480016Employer FEINMIAYMCIA 1480021Employer Physical CityIANAYIA 1480022Employer Physical State CodeIANAYIA 1480023Employer Physical Postal CodeIANAYIA 1480025Industry CodeIANAYIANAIA 1480027Insured Location IdentifierNA 1480028Policy Number IdentifierIANAYIA 1480029Policy Effective DateNA 1480030Policy Expiration DateNA 1480031Date of InjuryMMYMMMM 1480032Time of InjuryIANAYIA 1480033Accident Site Postal CodeNA 1480035Nature of Injury CodeMNAYIANAIA 1480036Part of Body Injured CodeMNAYIANAIA 1480037Cause of Injury CodeMNAYIANAIA

17. 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

18. FROI Conditional Requirements Worksheet This worksheet lists FROI data elements that are conditionally required and describes when they are mandatory. DN#DATA ELEMENT NAMEBUSINESS CONDITION(S)TECHNICAL CONDITION(S) 0005Jurisdiction Claim Number Mandatory except for new claims not already existing in jurisdiction system. 0016Employer FEINMandatory except for Denials due to no coverage. Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x. 0042Employee 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 0056Initial Date Disability Began Mandatory for a disability continuing the entire day, shift turn, or longer Must be present if DN0074 (Claim Type Code) = I 0154Employee 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 0165Employer Mailing CityMandatory except for Denials due to no coverage. Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x. 0167Employer Mailing Postal CodeMandatory except for Denials due to no coverage. Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x. 0168Employer Mailing Primary AddressMandatory except for Denials due to no coverage.Mandatory, except if FROI 04 and Full Denial Reason Code (DN0198) = 3x.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. Edit Matrix Table 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 This table is made up of five worksheets which:

25. 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.

26. DN-Error Message Worksheet (Partial Display of the DN-Error Message listing) This worksheet will assist claim administrators in determining the specific cause of an error message. Sorted by Error Message & DN 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: 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 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 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. Relaxed requirement edits (err msg 001 and 108) Jurisdiction will apply edits? Population Restrictions Indicator Mandatory field not present Number of Days Worked must be 0-7 Days must be 0-6 All digits must be 0-9 Must be a valid date (CCYYMMDD) Must be A-Z, 0-9, or spaces Must be a valid time Must be <= Date of InjuryMust be >= Date of Injury Must be >= Initial Date Disability Began Must be <= Employee Date of Death DNIAIABC Data Element Name 001018019028029030031033034035036 0000Entire BatchNIY 0001Transaction Set IDNIF F 0002Maintenance Type CodeNIFPF 0003Maintenance Type Code DateNIF F L L 0004Jurisdiction CodeNIFPF 0005Jurisdiction Claim NumberNIYPL L 0006Insurer FEINNIF F L

27. 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.

28. Value Table Worksheet (Partial Display of the Value Table) 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). Element Name Capture ? Acceptable Code Value List - grayed out indicates that a value is 'Not Statutorily Valid' Maintenance Type Code (for FROI) Y00010204COAQAUUIUR Maintenance Type Code (for SROI) Y0204ABAPCACBCDCOEPERFNIPP1P2P3P4P5P7P9PDPJPY Maintenance Type Codes (for SROI continued) YRBRES1S2S3S4S5S6S7S8S9SDSJUIURVEANBMBWMNQTSA Initial Treatment Code N012345 Employee Gender Code YFMU Employee Marital Status Code YUMSK Employment Status Code YC98AB1236457(see hierarchical order in dictionary) Wage Period Code (FROI) N0102040607 Wage Period Code (SROI) Y0104 Pre-Existing Disability Code NYNU Claim Status Code YOCRX Claim Type Code YMINBL Agreement to Compensate Code YWL

29. Population Restrictions Worksheet This worksheet is a listing of restrictions applied to specific data elements (identified in the DN Error Message Worksheet by a “P”). DNData Element Name Error Messag e Number Error Message TextPopulation Restriction 0002Maintenance Type Code042Not 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 0004Jurisdiction Code042Not Statutorily ValidValue must be PA 0005Jurisdiction Claim Number042All digits must be 0-9Valid values must be numeric 0056Initial Date Disability Began042Not Statutorily Valid When MTC = IP, date must be gtr or eql the Date of Injury (DN0031) 0058Employment Status Code042Not Statutorily ValidValid values limited to 9, 8, 1 and 2 0063Wage Period Code (SROI)042Not Statutorily ValidValue must be 1 (Weekly) 0074Claim Type Code042Not Statutorily ValidCodes N, B, and L are not valid 0084 Permanent Impairment Percentage 042Not Statutorily ValidValue must be greater than zero and not more than 100% 0085Benefit Type Code042Not Statutorily ValidCodes 040, 242, 410, 540, 541 are not valid 0088Benefit Period Start Date042Not Statutorily Valid When MTC = RB, Benefit Period Start Date must equal Current Date Disability Began (DN0144) 0092Benefit Adjustment Code042Not Statutorily ValidValid values limited to A, B, E, J, L, Q, R, T, U, W, X, Y and 2 0198Full Denial Reason Code042Not Statutorily ValidCode 1G is not valid 0222Payment Reason Code042Not Statutorily ValidCodes 040, 242, 410, 540, 541 are not valid 0270Employee ID Type Qualifier042Not Statutorily ValidValid values limited to A and S 0294Partial Denial Code044Not Statutorily ValidValid values limited to A

30. Transaction Sequencing (Partial Display of the Transaction Sequencing) The Sequencing Table describes how BWC will apply sequencing edits and the order in which events are expected to be reported. 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 N00Original None (refer to FROI Match Data/Duplicate Transactions TRANSACTION PROCESSING GUIDELINES in Section 2) 1c. Denial N04 - FROIDenial None (refer to FROI Match Data/Duplicate Transactions TRANSACTION PROCESSING GUIDELINES in Section 2) 1d. Acquired Claim YAQAcquired Claim063 No previous FROI from prior Clm Admin accepted Previous accepted First Report from prior Claim Administrator NAUAcquired/Unallocated No previous FROI from prior Clm Admin accepted Previous accepted First Report from prior Claim Administrator 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 Y04 - SROIFull Denial SROI063Event 1b (FROI) not previously accepted A 00 must have been accepted

31. 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 a denial (LIBC-496).

32. 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.

33. Resources For further information regarding EDI Release 3 and the PA EDI Claims Implementation Guide: http://www.dli.state.pa.us/wcais. For information about IAIABC EDI Claims Release 3 Implementation: www.iaiabc.org. Questions or comments: RA-CMDEDI@pa.gov.

34. Questions ?