Introduction to Pennsylvania Electronic Data Interchange (EDI) Bureau of Workers' Compensation

1. Introduction to Pennsylvania Electronic Data Interchange (EDI) Bureau of Workers’ Compensation

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

3. PA EDI Implementation Timeline 3/20/13 Republish EDI Implementation Guide 9/9/13 WCAIS Release 2 and EDI Release 3 Go-live 3/1/13 - 8/8/13 WCAIS application testing with transaction partners 9/9/2013 12/1/12 1/1/13 2/1/13 3/1/13 4/1/13 5/1/13 6/1/13 7/1/13 8/1/13 3/1/13 - 8/8/13 Transaction partners test with their trading partners 12/17/12-2/28/13 Trading partners submit trading partner agreements 3/1/13 - 8/8/13 WCAIS application testing with direct-filing trading partners

4. Implementation Information • The Bureau of Workers’ Compensation (BWC) is implementing the IAIABC Release 3 EDI Claims Standard for BOTH First Report of Injury (FROI) and Subsequent Report of Injury (SROI) claim filings. • Implementation date is Sept. 9, 2013.

5. General EDI Information EDI = Electronic Data Interchange • EDI is a structured transmission of data between organizations by electronic means. • It is computer-system to computer-system communication with no human intervention. • EDI for claims is an electronic way of sending workers’ compensation claim information, which is currently being sent by paper, to BWC. • It will be used to report all claim events. • EDI increases quality and timeliness.

6. What is a Trading Partner? • An entity that has entered into an agreement with another entity to exchange data electronically. • It can be an insurance company, TPA or self-insured employer. • Trading partners will determine the channel they choose to submit their data.

7. Trading Partners must: • Select a transaction partner that they will partner with to submit FROI and SROI EDI transactions, or • File directly with BWC , or • Use the Web portal which will also be available for submission of data. This method requires manual data entry, but will most likely be the preferred option for small insurers or self-insurers who have a small volume of yearly transactions.

8. Submission Options Trading Partners will transmit data to BWC using one of the following channels. The same information will be required for all types of transmissions.

9. What is a Transaction Partner? • An organization that has met BWC’s requirements to accept EDI claim transactions from trading partners. • Transaction partners provide services to submit EDI transactions to jurisdictions. • Trading partners should choose a transaction partner that best suits their needs, if they choose to utilize one.

10. Approved EDI Transaction Partners • EBIX Inc • HealthTech Inc. • Insurance Services Office Inc. • Mitchell Workers’ Compensation Solutions (WCS) Contact information is on the Labor & Industry website at www.dli.state.pa.us; click the Bureau of Workers’ Compensation icon at the bottom right corner of the page, and then click “WCAIS” on the left navigation bar.

11. Trading Partner Agreements • Trading partner agreements are available on the Labor & Industry website and must be submitted to BWC. Go to www.dli.state.pa.us; click the Bureau of Workers’ Compensation icon at the bottom right corner of the page, and then “WCAIS” on the left navigation bar. • BWC requires new documents be filed for everytrading partner so the most current information is on file. • Fax your trading partner agreements and corresponding documents to: 717-783-6365.

12. EDI Direct-Filing Trading Partners • A trading partner can submit EDI Release 3 FROI/SROI transactions by placing their files directly at the Department of Labor & Industry’s SFTP location. • Direct filers must fulfill the direct filer’s criteria and complete all testing requirements successfully.

13. EDI Direct-Filing Trading Partners - continued • At this time, any requests to add EDI transaction partners or direct file/trading partners to the Pennsylvania EDI transaction partner or direct file/trading partners lists received after March 10, 2013, will not be processed until after the "go-live" date for the WCAIS project, Sept. 9, 2013. • This is because testing for EDI transaction partners and direct file/trading partners is currently in progress.

14. EDI Claims Web Portal • Trading partners can submit FROI/SROI transactions directly to BWC by using the WCAIS EDI claims Web portal. • It will have data entry screens which allow trading partners to enter information that would otherwise be required to be submitted using one of the approved transaction partners or by filing directly. • The data elements captured through the Web portal screens will correspond to IAIABC EDI Release 3 claims data elements.

15. EDI Claims Web Portal - continued • Trading partners using the Web portal to submit the EDI transactions will not receive acknowledgements. Instead, they will receive an onscreen confirmation. • Trading partner documents are NOT required to be sent to BWC if you choose to use the EDI claims Web portal. These documents identify the transaction partner a trading partner will be using to submit their EDI transactions and Web portal users will not be doing this.

16. EDI Reporting – FROI’s & SROI’s • Claim Event – an incident that requires you to report information to BWC. • First Report of Injury (FROI) – may contain information on claim administrator, employee, employer and accident information. • Subsequent Report of Injury (SROI) – may contain information on indemnity payments, non-indemnity payments, reason(s) why claim is not being paid, changes, reoccurrences, modifications and suspensions.

17. Maintenance Type Codes (MTC) • MTCs describe the type of FROI or SROI being submitted. • Used to report claim events. • Example of MTCs: FROI-00 Original Report FROI-01 Cancel Report FROI-02 Change FROI-04 Denial SROI-IP Initial Payment SROI-S1 Suspension SROI-RB Reinstatement *Note – For a listing of all accepted PA MTCs, see the PA EDI Claims Implementation Guide and/or the FROI/SROI event tables.

18. Claim Lifecycle Source: IAIABC

19. FROI/SROI Data Obtained • Claim data • Wage data • Benefit data • Payment data • Suspension data • Return-to-work data • Employee data • Employer data • Insurer data • Claim administrator data • Injury data • Accident data

20. Reporting Data • Claim administrators should always submit the most current data on each MTC. • Data may be removed in BWC’s system if a space is sent on the MTC where data had previously been sent. • The cut-off time for processing files will be 11:59 PM Eastern Time. All files located in the “IN” directory will be processed by BWC. Data that arrives after this cut-off time will be processed with the next day’s files.

21. EDI Claims Tables • EDI Reporting requirements are defined on the following tables: 2. Data needed on the report(s) • Required • report(s) 3. Applied editing

22. Event Table tells you: Event Table • The events to report • What triggers the transaction • When the transaction is due • The paper forms that must be sent, and to which parties

23. Element Requirements Table tells you: Element Requirements Table • The information required in a transaction by data element and report type. • The requirement codes, which are: M – Mandatory MC – Mandatory/conditional IA – If applicable/available N/A – Not applicable F – Fatal FY – Fatal yes change X – Exclude Y – Change allowed N – No change

24. Edit Matrix Table contains: • The specific edits applied to reports to determine acceptability by BWC and the standard error messages for those edits when the data is not acceptable. • The proper sequence of submissions, acceptable code values, data used for matching to existing claims and error messages associated with theseedits. Edit Matrix

25. PA EDI Claims Implementation Guide • Provides technical information, procedures and explanations to help claim administrators prepare and navigate future EDI processes. • The guide and EDI tables are available on our website at: http://www.portal.state.pa.us/portal/server.pt?open=514&objID=1183869&mode=2

26. Acknowledgment Record • The acknowledgement record is a transaction returned by the jurisdiction as a result of an EDI report sent. • It contains enough data elements to identify the original report sent and communicates any technical business issues found. • Transactions are either accepted or rejected: TA – Transaction accepted – no errors. TR – Transaction rejected – errors were found and the transaction was NOT accepted. HD – Batch rejected

27. Acknowledgment Record, continued • Submitter is responsible for reviewing all acknowledgement files. • Rejected transactions must be analyzed so the appropriate data can be sent in the next file. • Even accepted transactions must be reviewed to retrieve the appropriate jurisdiction claim number (JCN), which must be used on subsequent transactions.

28. EDI Reporting Overview • Report is submitted to BWC through one of the three options available to trading partners. • BWC identifies the report as either new or duplicate. • BWC runs technical and business edit checks on the report. • BWC accepts or rejects the report (TA or TR). • BWC sends an acknowledgment of the report(s) status back to the sender (Web portal user will instead receive an on-screen confirmation).

29. Statutory Requirements • The First Report of Injury transaction is required to be electronically filed within seven days of the alleged injury. • A transaction to accept or deny a claim must be submitted to BWC no later than 21 days after the employer has notice or knowledge of a claimant’s disability.

30. Statutory Requirements, continued • If benefits are being paid under temporary compensation, a transaction to deny the claim must be received within 90 days of the disability begin date or the claim becomes compensable. * For specific statutory requirements, refer to Section 2.5, Information and Data Reporting, of the PA EDI Claims Implementation Guide.

31. Paper Forms • EDI eliminates most paper reporting to BWC. There are exceptions as required by Pennsylvania law: Statement of Wages, Notices of Temporary Compensation Payable, Notices of Compensation Payable, Notices of Workers’ Compensation Denial, Agreements, Stopping Notices and Notices of Suspension or Modification must be filed with BWC. *For specific form requirements, refer to Section 2.2, BWC Forms Required,of the PA EDI Claims Implementation Guide.

32. Paper Forms, continued • Paper forms, either the existing BWC form or the FROI (LIBC-90) or SROI (LIBC-91) template, MUST be sent to the claimant for ALL transactions. Written notice to the employee has not changed due to EDI and is still required. • The LIBC-91 cannot be used in place of the Notice of Compensation Payable (LIBC-495), Notice of Workers’ Compensation Denial (LIBC-496) or the Notice of Temporary Compensation Payable (LIBC-501). These forms can be submitted to BWC by electronic batch, attaching the form to the individual claim or by mail. • Paper forms will not be coupled with EDI transactions. • Paper forms should be submitted to BWC as close to the EDI transaction date as possible, preferably the same day.

33. Next Steps for Trading Partners • Business staff and IT staff should work together to determine if you are going to file directly, use a transaction partner, or use the PA Web portal. • Understand the EDI reporting requirements and verify that you collect this data. Note: Web data entry application has same edits as flat file. • Review and prepare for testing and implementation. • Complete trading partners agreements and corresponding documents.

34. Next Steps for Trading Partners, continued • If you haven’t already done so, go to our PA EDI Claims Implementation Guide Web page: http://www.portal.state.pa.us/portal/server.pt?open=514&objID=1183869&mode=2 • Our Implementation Guide, claims EDI tables and trading partner forms are all available on this Web page.

35. EDI Release 3 Migration • There will be a three-week transition window, from Aug. 17 to Sept. 8, 2013, for migrating from paper forms and EDI Release 1 FROI’s to EDI Release 3 FROI and SROI’s. • BWC will continue to accept time-sensitive Subsequent Reports of Injury (SROI)paper forms until Sept. 8, 2013. • All documents received during this period will be date stamped to preserve the filing date. Forms sent during this transition period might not be processed by BWC until after our go-live date, Sept. 9, 2013, which may result in delays in viewing claim updates.

36. EDI Release 3 Migration, continued • Release 1 FROI’s will be sent until Aug. 29, 2013. • Claim administrators are requested to delay submission of FROI’s for new claims from Aug. 30 to Sept. 9, 2013 and then submit Release 3 FROI’s after go-live. • The first EDI transaction after go-live, Sept. 9, 2013, must either be a Release 3 FROI, for new claims, or a SROI UR transaction for legacy claims.

37. SROI UR Transaction • Beginning Sept. 9, 2013, claim administrators must send BWC a single SROI UR transaction, as their first transaction, for all open legacy BWC claims. • SROI UR transactions must be filed one time as a catch up to baseline the claim. These transactions may also include the next transaction that otherwise would have been filed. • BWC recommends that these SROI UR transactions be submitted in a single file. • The purpose of the SROI UR transaction will be to set the claim status and reduce potential inconsistencies in the claims data between BWC and claim administrators.

38. PA EDI Migration Timeline 9/9/13 WCAIS Release 2 Go-live 8/17/13 - 9/8/13 Claim administrators BWC LIBC form submission 8/17/13 Start of transition period 9/9/13 – Claim Administrators must submit a Release 3 FROI or SROI UR “catch up” transaction for ALL open claims 8/17/13 - 8/29/13 Claim administrators continue FROI submissions 8/29/13 - 9/8/13 WCAIS application conversion/Legacy system shut down

39. EDI Webinars • Basic training: June 5, 2013, 9 a.m. and repeated at 1 p.m. – This training will provide an overview of EDI Release 3 and basic information on filing options, claims reporting, EDI tables, requirements and EDI reporting. • FROI training: June 18, 2013, 9 a.m. and repeated at 1 p.m. – This training will provide FROI specific information which includes MTCs, tables information, changes from EDI Release 1 to EDI Release 3, requirements and acknowledgments.

40. EDI Webinars, continued • SROI training: July 11, 2013, 9 a.m. and repeated at 1 p.m. – This training will provide SROI specific information including MTCs, tables information, changes from EDI Release 1 to EDI Release 3, requirements and acknowledgments. • Web portal training: July 18, 2013, 9 a.m. and repeated at 1 p.m. – An overview of the EDI claims Web portal that will be available in WCAIS.

41. Resources Resources • Fax your trading partner agreements and corresponding documents to: 717-783-6365. • Send questions regarding EDI Release 3 to: RA-CMDEDI@pa.gov • 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.

42. Questions/Comments Contact us at: RA-CMDEDI@pa.gov.