Bureau of Workers’ Compensation

1. Subsequent Report of Injury EDI Transactions in Pennsylvania 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. The Bureau of Workers’ Compensation (BWC) is implementing the IAIABC EDI Release 3 Claims Standard for Subsequent Report of Injury (SROI) claim filings. • EDI is a structured transmission of data between organizations by electronic means. • Implementation date for EDI Release 3 is Sept. 9, 2013. General EDI Information

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

5. Event Table • Establishes the events accepted by Pennsylvania, and • tells claim administrators when to report an event, based on laws and regulations; as well as which, if any, paper forms are required to be sent to BWC and the claimant. Subsequent Report of Injury (SROI) Event Table

6. Partial Display of SROI Event Table The full table can be viewed on our website at http://www.dli.state.pa.us/wcais.

7. 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 SROI transactions being submitted. • Any MTCs other than those accepted by Pennsylvania will be rejected as not jurisdictionally valid. Maintenance Type Codes (MTCs)

8. 02 – Change • 04 – Denial • AB – Add Concurrent Benefit Type • AP – Acquired/Payment • CA – Change Benefit Amount • CB – Change Benefit Type • FN – Final • IP – Initial Payment • P1 – Partial Suspension, Returned to Work or Medically Determined/Qualified to Return to Work Pennsylvania Accepted SROI MTCs

9. P4 – Partial Suspension, Claimant Death • P7 – Partial Suspension, Benefits Exhausted • PJ – Partial Suspension Pending Appeal or Judicial Review • PD – Partial Denial • PY – Payment Report • RB – Reinstatement of Benefits • RE – Reduced Earnings • S1 – Suspension, Returned to Work, or Medically Determined/Qualified to Return to Work Accepted SROI MTCs, continued

10. S3 – Suspension, Administrative Non-Compliance • S4 – Suspension, Claimant Death • S5 – Suspension, Incarceration • S7 – Suspension, Benefits Exhausted • S8 – Suspension, Jurisdiction Change • SD – Suspension, Directed by Jurisdiction • SJ – Suspended Pending Appeal or Judicial Review • UR – Upon Request Accepted SROI MTCs, continued

11. A claim administrator reduces benefits because an employee has returned to work earning less than their pre-injury wage. The claim administrator chooses to reduce earnings using an agreement. The claim administrator will send a SROI RE with the Award/Order Date (DN0299) populated with the date of the agreement. He will send a copy of a completed Supplemental Agreement (LIBC-337) to the claimant and BWC. (It can be sent to BWC by electronic batch, by upload in the Workers’ Compensation Automation and Integration System, WCAIS, or by mail.) SROI Event Table Scenario

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

13. The Element Requirements Table describes: • MTC Codes associated with one or more of the reportable events defined in the event table, • mandatory conditional (MC) data elements which are mandatory if the condition defined is met, and • business rules that apply to specific data elements when there is an MC indicator. Element Requirements Table

14. (Partial Display of the SROI Requirements) SROI Element Requirements This worksheet lists the specific elements required for each SROI MTC. IA is NOT the same as N/A . IA elements should be provided, unless the information is not available.

15. 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 Requirement Codes

16. Date of Injury (DN0031) – If a claim administrator is uncertain about this date, use the earliest date for which there is some degree of certainty, or the date you receive notice of the accident, whichever is earlier. • Industry Code (DN0025) – This is an important data element for BWC’s statistical reports. Claim administrators should report the correct industry code. If doubt exists, reference the NAICS organization’s website at www.naics.com. Data Reporting

17. SROI Conditional Requirements This worksheet lists data elements that are conditionally required as well as the scenarios that require them.

18. Event Benefits Segment Requirements This worksheet identifies data elements which are required when payments are made on claim.

19. 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 theerror messages associated with these edits. Edit Matrix Table Edit Matrix

20. 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). • SROI Sequencing Tables – describes how BWC will apply sequencing edits and the order in which specific events are expected to be reported. Five Worksheets in Edit Matrix

21. (Partial Display of the DN-Error Message listing) DN – Error Message Worksheet This worksheet will assist claim administrators in determining the specific cause of an error message.

22. 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 explains the definition of each error number. DN – Error Message Worksheet, continued

23. (Partial Display of the Value Table) Value Table Worksheet 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).

24. (Partial Display of the Match Data Elements) Match Data Elements Worksheet This worksheet describes the data elements used to determine whether the information matches an existing claim or if a new claim should be created.

25. These data elements can only be changed on a SROI 02 (Change) transaction. • Only one primary or secondary match data element can be changed on the same SROI 02 transaction. • Additional match data elements are used as confirmation that a claim is a duplicate. Match Data Elements Worksheet, continued

26. 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”).

27. (Partial Display of the Transaction Sequencing) Transaction Sequencing The Sequencing Table describes how BWC will apply sequencing edits and the order in which events are expected to be reported.

28. This diagram, included in the PA Implementation guide, illustrates the expected sequence of EDI transactions per the BWC business scenario requirements. PA EDI Transaction Sequencing

29. 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 p.m. 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 file date. Reporting Data

30. Today’s Process Tomorrow’s Process Forms Received by BWC Today vs. Tomorrow’s EDI R3 Process

31. Today’s Process Tomorrow’s Process Forms Received by BWC Today vs. Tomorrow’s EDI R3 Process, continued

32. EDI will be used to report ALL claim events, however, the following forms continue to be required to be sent, by upload or mail, to BWC: Claim Reporting

33. Written notice to the employee has not changed due to EDI. Paper forms must be sent to the claimant for ALL transactions, whether they are forms currently generated by insurer systems, the SROI Template (LIBC-91)* available in WCAIS or LIBC forms downloaded from the department’s website. • 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. Claim Reporting, continued

34. The LIBC-502, Notice Stopping Temporary Compensation, can be submitted electronically thru WCAIS or it will be available for download from the department’s website, to be completed offline. If the LIBC-502 is not submitted thru WCAIS, it can be submitted to BWC by electronic batch, attaching the form to the individual claim by upload or mailed. • The LICB-494 (both A and C), Statement of Wages, will be available for download from the department’s website, to be completed offline, and then either submitted to BWC by electronic batch, attaching the form to the individual claim by upload or mailed. Claim Reporting, continued

35. The LIBC-751, Notification of Suspension or Modification can be prepared and printed in WCAIS or downloaded and completed offline. Once the form is notarized and signed, it can be submitted to BWC by electronic batch, attaching the form to the individual claim by upload or by mail. • Agreements, which can be the current form in insurer systems or a form downloaded from the department’s website, can be submitted to BWC by electronic batch, attaching the form to the individual claim by upload or by mail. Claim Reporting, continued

36. If a claim administrator chooses to use an agreement to initiate payment or to change, stop or reinstate benefits paid on a claim, in addition to the appropriate EDI transaction, an agreement must be uploaded or mailed to BWC, as required by Pennsylvania Law. • This should be done as close to the transaction date as possible, preferably the same day. Claim Reporting, continued

37. The presence of an agreement should be indicated by populating the Award/Order Date (DN0299) with the date the parties entered into the agreement in their EDI transaction. • If a claim administrator chooses to use a Notification of Suspension or Modification (LIBC-751) to modify or suspend benefits, the signed, dated and notarized form MUST be filed within seven days of the modification/suspension date, per the Workers’ Compensation Act. Claim Reporting, continued

38. When a claim administrator begins paying on a claim, the claim administrator is required to report those payments on a SROI IP (Initial Payment) transaction. • When submitting the transaction, the claim administrator should populate the Agreement to Compensate Code (DN0075) with a “W” to indicate they are not accepting liability for the claim. Reporting Temporary Compensation on the Initial Payment (SROI IP)

39. When paying a claim under temporary compensation, a claim administrator has 90 days to determine whether or not to accept liability. • To accept liability, a claim administrator should file a SROI 02 (Change) to update the Agreement to Compensate Code to an “L.” • To deny a claim, a claim administrator must file a Notice Stopping Temporary Compensation (LIBC-502) electronically through WCAIS and submit a SROI 04 (Denial) transaction. Complying with the 90-Day Rule for Temporary Indemnity Claims

40. If at the end of the 90-day period the claim administrator has neither accepted or denied liability for a claim, the claim will automatically convert to a fully compensable claim and insurer will be held liable for payment. • Once a claim is accepted with liability, the claim administrator will be prevented from submitting a SROI 04 Denial. Complying with the 90-Day Rule for Temporary Indemnity Claims, continued

41. When paying a claim for only medical bills under temporary compensation, a claim administrator has 90 days to determine whether or not to accept liability. • The SROI PY (Payment) transaction must indicate the claim administrator is not accepting liability by setting the Agreement to Compensate Code to “W.” • To accept liability, the claim administrator should file a SROI 02 (Change) transaction to update the Agreement to Compensate Code from “W” to “L.” Complying with the 90-Day Rule for Temporary Medical-Only Claims

42. To deny liability, the claim administrator should file a Notice Stopping Temporary Compensation (LIBC-502) electronically through WCAIS and submit a SROI 04 (Denial) transaction. • If at the end of the 90-day period the claim administrator has neither accepted or denied the claim, it will automatically convert to a compensable medical-only claim and insurer will be held liable for medical payment. Complying with the 90-Day Rule for Temporary Medical-Only Claims, continued

43. The filing of a suspension while the Agreement to Compensate Code is set to “W” will be prohibited. • The Act requires a FROI be filed within seven days of the loss of a full day, turn or shift. However, in EDI Release 3, a FROI 00 (Original) must be filed first to initiate a claim. Once it’s on file, a SROI PY (Payment) transaction with the Claim Type Code (DN0074) marked with “M” can be submitted to report the initial payment of medical expenses. Complying with the 90-Day Rule for Temporary Medical-Only Claims, continued

44. Partial Denials can be used to deny liability for indemnity benefits but continue the payment of medical bills only if an IP (Initial Payment) transaction is on file with the Agreement to Compensate Code set to “W.” • If the claim administrator accepts liability for medical expenses, the Agreement to Compensate Code must be set to “L.” • If an agreement is entered by the parties, the Award/Order Date (DN0299) should be populated with the date the parties entered into the agreement in their EDI transaction. Partial Denials (PD)

45. When an initial payment is made to a claimant, the claim administrator should file a SROI IP (Initial Payment) transaction with the Agreement to Compensate Code set to “L” to indicate that they have accepted liability for the claim. • If the claim administrator is sending the claimant a Notice of Compensation Payable (LIBC-495), the SROI IP is filed without populating the Award/Order Date (DN0299). Reporting Agreement to Compensate on the Initial Payment (SROI IP)

46. The FROI 00 (Original) should be filed within 48 hours of every injury resulting in death. • To temporarily accept liability for a fatality, file a SROI IP (Initial Payment) with the Agreement to Compensate Code set to “W.” • To accept liability, file a SROI IP with the Agreement to Compensate Code set to “L.” Reporting Fatalities

47. If an agreement is entered by the parties, the Award/Order Date (DN0299) should be populated with the date the parties entered into the agreement in their EDI transaction. • When the claim administrator has knowledge that information associated with one or more data elements marked with a Y or FY in the Elements Requirement Table has changed, SROI 02 (Change) transaction must be filed. Reporting Fatalities, continued

48. If a spouse remarries, the payment of a dowry is due; this requires a SROI PY (Payment Report). • If a spouse dies and there are no dependents, a SROI S4 (Suspension, Claimant Death) transaction must be filed. • A change in the benefit amount paid to a dependent requires a SROI CA (Change in Benefit Amount) transaction. Reporting Fatalities, continued

49. If a spouse remarries and there are no other dependents on the claim, a SROI S7 (Suspension, Benefits Suspended) transaction is required to suspend the claim. If there are other dependents, a SROI CA is required to change the benefit amounts for the remaining dependents. • In the event the employee dies as a result of an injury and payments begin, a SROI CB (Change in Benefits) transaction must be filed and the Death Result of Injury Code should be populated. Reporting Fatalities, continued

50. A Return to Work (SROI S1) transaction must be filed when a claimant returns to work with no loss in earnings. • An Administrative Non-Compliance (SROI S3) transaction must be filed if a claimant fails to return form LIBC-760 (Employee Verification of Employment, Self-Employment or Change in Physical Condition) to the claim administrator and benefits are suspended. • A Claimant Death (SROI S4) transaction must be filed if a claimant has died and benefits are no longer due. A Death Certificate or Coroner’s Report must also be filed with BWC. Suspending Benefits