3 Additional DWC StaffKaren Kubie - DWC Claims EDI Lead Business AnalystKim Wiley – DWC EDI IT Project ManagerJanice Youngblood – DWC EDI IT Consultant/ProgrammerMargaret Forsman - DWC Claims EDI Business Analyst
4 Additional DWC StaffTonya Granger - DWC Lead EDI POC Analyst & Claims AnalystDebra Lee – DWC EDI Claims AnalystLaura Cotner - DWC EDI Claims and POC Analyst
5 Rule Chapter 69L of the Florida Administrative Code is the EDI Rule for Proof of Coverage and Claims (non-medical)
6 EDI Rule 69L-56,F.A.C. was effective January 7, 2007. It requires all insurers to implement the IAIABC Claims EDI Release 3 electronic format.
7 EDI Rule 69L-56 F.A.C.This EDI Implementation applies to all required form filings for all Dates of Injuries, and not just those injuries that occur after the Insurer’s EDI Implementation date. This includes legacy claims.
9 On a National level, in 1990 the IAIABC spearheaded a program to utilize the concept of EDI for Workers’ Compensation data.
10 What is the IAIABC?The International Association of Industrial Accident Boards and Commissions.A 93-year-old organization of jurisdictional workers’ compensation administrators and others interested in WC.
11 What is EDI?Electronic Data Interchange is the electronic exchange of data between business trading partners (i.e., claim administrators to state agencies), in a standardized format.This does not include reporting byInjured Workers!EDI
12 Bringing Together the Important Participants Developing an Electronic StandardBringing Together the Important ParticipantsJurisdictionsCarriersVendorsTPA’s
13 Developing a National Standard through the IAIABC EDI Development Committees was a “consensus development” process that required “give” and “take” from all participants.
14 The end result is a national standard format for the reporting of workers’ compensation data electronically.
15 IAIABC EDI Project Background 1990: IAIABC membership adopted IAIABC Committee’s proposal to develop standards for communicating data electronically between providers, payers, and state administrators via EDI.1993: Claims Release 12000: Claims Release 2 (Iowa)2005: Claims Release 3Culmination of 4 yrs of work – list how many people have been involved – level of care & detail
16 Where can you find the IAIABC R3 Implementation Guide & Codes?
17 The Release 3 Claims Implementation Guide can be purchased for $95 from the IAIABC’s website: or it is free if your company is an IAIABC EDI Member. The latest R Guide is dated January 1, 2008
18 The Release 3 Claims Implementation Guide contains the transaction record layouts, data dictionary, business and technical rules, national scenarios, etc.
22 STANDARD USAGE FOR ALL PRODUCTS Error Message DictionaryGlossaryCountry CodesState CodesIndustry Codes (NAICS 2002 or 2007)Nature of Injury CodesCause of Injury CodesPart of Body CodesPermanent Impairment Body Part Codes
25 GlossaryThe purpose of the Glossary is to acquaint the reader with easy-to-understand definitions of workers' compensation terms that are not defined in the R3 Dictionary as Data Elements.
26 GlossaryThe Glossary defines terms that are common to FROI/SROI, MED, and POC EDI reporting.Not all of the terms are directly related to one of the IAIABC EDI reporting products, but they are commonly used in the business and data reporting environment.
30 ACRONYMSEDI Committee participants frequently use acronyms in their discussions, and newcomers (and veterans, too!) can easily lose their place in what is going on if they don’t understand what the acronyms stand for.
31 ACRONYM Examples: FTP File Transfer Protocol FEIN Federal Employer Identification NumberFROIFirst Report of InjuryGUIGraphical User InterfaceHTTPHyper Text Transfer ProtocolSROISubsequent Report of InjuryURLUniform Resource Locator
34 Release 3 Combined Business & Technical Data Dictionary
35 The Release 3 Data Dictionary Section 6 in the Implementation Guide
36 Release 3 Data Dictionary Identifies the Data Number (DN)Gives the Definition of the Data ElementGives the Last Revision Date of the Data Element
37 Release 3 Data Dictionary Gives the Format (i.e. 2 A/N = two characters alpha/numeric)Lists the Valid Values for the DNGives DP (Data Population) Rule to Help Identify the Correct Use of the Data Element
43 FL Supplement Overview: Tracks all monthly additions or corrections to the requirement tables.
44 FL’s Claims EDI Webpage If you haven’t already, begin reviewing FL’s requirement tables (including updated supplement) immediately to determine: When each transaction must be sent (Event Table) Data Elements required for each transaction / MTC (Element Requirement Table)
45 FL’s Claims EDI Webpage (Cont’d)…Review FL’s requirement tables (including updated supplement) immediately to determine:Edits that will reject the record (Edit Matrix)
46 FL’s Claims EDI Webpage The FL Claims EDI Webpage contains helpful resource documents including:FL EDI Migration StrategiesMTC Filing InstructionsFL R3 Business ScenariosFL Quick Code Reference GuideTraining Questions & AnswersMTC to Form CrosswalkCrosswalks of paper DWC Claims Forms to EDI Data Elements
52 Release 3 FROI Transaction Originally, the EDI First Report of Injury Record was identified by a Transaction Set ID of '148' and had a specific Record Layout.In Release 3, the 148 record must be paired with a companion record - R21, FROI Companion Record to complete the First Report of Injury transaction.
53 Release 3 FROI Transaction This means the Release 3 FROI transaction requires 2 records to communicate the First Report event, the “148” & “R21” records.
60 POP QUIZIf the Accident Description Narrative segments are 50 characters each, and this Accident Description is 161 characters…
61 …how many segments must be sent to report the entire Accident Description Narrative?
62 ANSWER = d (4 segments) DN Data Element Name Data Beg End 0038 Accident/Injury Description NarrativeAS HELEN WAS LEAVING HER WORK SITE (BLDG 500) SHE16011650WAS WAITING FOR HER HUSBAND TO PICK HER UP ON THE16511700STEPS OF THE BLDG. AS SHE LEANED AGAINST THE RAIL17011750ING & FELL.17511800
65 Release 3 SROI Transaction Originally, the EDI Subsequent Report of Injury Record was identified by a Transaction Set ID of ‘A49' and had a specific Record Layout.In Release 3, the A49 must be pairedwith a companion record - R22, SROI Companion Record, to complete the SROI transaction.
66 Release 3 SROI Transaction This means the Release 3 SROI transaction requires 2 records to communicate the Subsequent Report event, the “A49” & “R22” records.
75 Maintenance Type CodeA code that defines the specific purpose of each transaction being transmitted.
76 Maintenance Type CodeDWC Forms required to be filed with the Division are replaced by EDI filings identified by MTC codes.
77 Maintenance Type CodeMost MTC codes equate to a specific DWC Form that will no longer be required to be filed with DWC. However the DWC Form may still be required to be sent to other parties (e.g., DWC-1, DWC-4).
82 Initial Payment Equivalents: EP – Employer Paid Salary in Lieu of Comp FL SROI MTC’s:Initial Payment Equivalents:IP - Initial PaymentPY – PaymentEP – Employer Paid Salary in Lieu of CompAP - Acquired First Payment
83 FL SROI MTC’s: Initial Payment Equivalents (cont’d): CD – Compensable Death-No Known Dependents/PayeesVE - Volunteer
84 Denials: FL SROI Report MTC’s: 04 – Full Denial PD – Partial Denial (Indemnity Only & other required partial denials).
85 Additions/Changes FL SROI MTC’s: AB – Add Concurrent Benefit CA – Change in Benefit AmountCB – Change in Benefit Type
86 Reinstatements FL SROI MTC’s: ER – Employer Reinstatement RB – Reinstatement of BenefitsER – Employer Reinstatement
87 Full Suspensions (of all Indemnity) FL SROI MTC’s:Full Suspensions (of all Indemnity)S1 – RTW or Released to RTWS2 - Medical Non-ComplianceS3 – Administrative Non-Compliance
88 Full Suspensions (of all Indemnity) FL SROI MTC’s:Full Suspensions (of all Indemnity)S4 – Claimant DeathS5 - IncarcerationS6 – Claimant’s Whereabouts Unknown
89 Full Suspensions (of all Indemnity) FL SROI MTC’s:Full Suspensions (of all Indemnity)S7 – Benefits ExhaustedS8 – Jurisdiction ChangeYou should recognize these from the DWC-4 Form
90 Partial Suspension (of a concurrent benefit) FL SROI MTC’s:Partial Suspension (of a concurrent benefit)P7 – Benefits ExhaustedFL’s only concurrent benefit type is PT and PT Supplemental Benefits. If one benefit is suspended but the other benefit continues, a Partial Suspension is filed.
91 Periodic Reports FL SROI MTC’s: SA – Sub Annual For EDI R3, the Annual Claim Cost Report has been replaced with a Sub Annual report, due every 6 months from the Date of Injury until the claim is closed.
92 FL SROI MTC’s:Periodic Reports(cont’d)…FN – Final
100 codes that represent the type of non-indemnity benefits being paid. 311321370OBT’s arecodes that represent the type of non-indemnity benefits being paid.
101 Other Benefit Type Codes (required by FL) 300 – Total Funeral Expenses310 – Total Penalties311 – Total Employee Penalties320 – Total Interest321 – Total Employee Interest370 – Total Other Medical
102 Other Benefit Type Codes (required by FL) 380 – Total Voc Rehab Evaluation390 – Total Voc Rehab Education400 – Total Other Voc Rehab430 – Total Unallocated Prior Indemnity Benefits (acquired claims)475 – Total Medical Travel Expenses
103 300400475FL has reduced the amount of OBT Codes required to be reported for R3, because the majority of medical information is already being reported to the Division via another electronic format.
104 Other Benefit Type Codes (not required by FL) FL no longer requires the reporting of Physician (Medical), Hospital, or Pharmacy/Durable Medical Paid To Date on the EDI Claim Cost “Periodic” report.
106 What Is The Claims EDI Mandate All About ? How Does It Affect FL WC Insurers?
107 Rule 69L-56 Rule Section Overview 69L Forms and Instructions69L Definitions
108 69L-56.100 Proof of Coverage (POC) Electronic Reporting Requirements 69L Technical Requirements for POC EDI Transmissions69L Policy Cancellation or Non-renewal Requirements69L Time Periods for Filing Electronic Policy Information
109 69L-56. 300. Claims EDI Reporting. Requirements and 69L Claims EDI Reporting Requirements and Implementation Schedules69L Electronic First Report of Injury or Illness69L Electronic Notice of Denial and Rescinded Denial69L Electronic Periodic Claim Cost Reports
110 69L-56. 304 Electronic Notice of Action or. Change, Including 69L Electronic Notice of Action or Change, Including Change in Claims Administration, Required by the Insurer’s Primary Implementation Schedule69L Electronic Notice of Action or Change, Suspensions, and Reinstatement of Indemnity Benefits Required by the Insurer’s Secondary Implementation Schedule
111 69L-56.307 Electronic Cancellation of Claim 69L Technical Requirements for Claims EDI Transmissions69L Claims EDI Test to Production Status Requirements
112 69L-56. 330. Electronic Formats for. Reporting the Employee’s 8th 69L Electronic Formats for Reporting the Employee’s 8th Day of Disability and the ClaimAdministrator’s Knowledge of 8th Day of Disability (This section will eventually be repealed after all current R1 trading partners implement R3)69L Insurer Responsibilities Where Third Party Services are Utilized
113 The following DWC paper forms currently being filed with the Division will be replaced by electronic transactions:DWC-1 First Report Of Injury or IllnessDWC-12 Notice of DenialDWC-13 Claim Cost ReportDWC-4 Notice of Action/ChangeDWC-49 Aggregate Claims Administration Change Report
114 EDI filing requirements (i. e EDI filing requirements (i.e., when a claim administrator must file these EDI transactions with DWC) are in Rule 69L-56, F.A.C.Paper form copies required to be sent to other parties will still be required per Rule 69L-3, F.A.C.
115 How Will MTC’s and Insurers Be “Phased In” for Implementing EDI R3?
116 EDI Claims R3 Implementation The Division has established by rule two implementation schedules for “phasing in” all of the MTC’s required for R3 reporting:The Primary Implementation Schedule includes MTC’s for reporting the electronic equivalent of the DWC-1, 12, 13 & 49 & some DWC-4 data.The Secondary Implementation Schedule includes MTC’s that equate to most DWC-4’s.
117 EDI Claims R3 Implementation Again, implementation of EDI R3 applies to all MTC’s required by rule for all Dates of Injuries, not just for dates of injuries occurring after the Insurer’s R3 production implementation date.Legacy claims are included in the mandate.
118 EDI Claims R3 Implementation Paper forms previously filed do NOT need to be re-submitted electronically.
119 EDI Claims R3 Implementation The Division has divided insurers/self-insurers into three ‘test to production’ periods (tiers), based on Insurer Code #.Insurer Code #’s and currentR1 Trading Partners will implement first.Insurer Code #’s will implement next.Insurer Code #’s and will implement last.
120 EDI Claims R3 Implementation If there are multiple subsidiary insurer entities within an insurer’s corporate structure / organization, the insurer’s compliance date for the Primary Implementation Schedule will be based on the lowest numeric value assigned to any of the subsidiary insurer entities in the group.
121 For Example (Old Reliable Group): Old Reliable Ins Co. = # 145 Old Reliable P&C Co. = # 328Old Reliable of Illinois = # 733All insurers in the Old Reliable Group are required to file electronically in the firstgroup of the Primary ImplementationSchedule. They must begin testingon
122 EDI Claims R3 Implementation Third Party Administrators (TPAs) are not included in this list because they are not ‘Insurers’.However, a TPA must be ready to comply with the EDI filing requirements as soon as their first Insurer client is required to comply.
123 EDI Claims R3 Implementation Third Party Administrators (TPAs) are not required to implement all of their insurer clients at the same time, but….
124 EDI Claims R3 Implementation …the 30 day initial late filing penalty waiver in rule 69L (d), is only applicable to the “claim administrator” as a whole at the time it first implements R3 EDI filings.
125 EDI Claims R3 Implementation Therefore, if a claim administrator implements R3 EDI for different clients at different times, the subsequent clients will not be granted a separate 30 day late filing penalty waiver.
126 Claims EDI Primary Implementation Schedule Phase In: The first group (Insurer Code #s ) begantesting November 1, 2007, and are being phased in to production beginningFirst Group Must Begin Testing:First Group Phased In Production:
127 Claims EDI Primary Implementation Schedule Phase In: The second group (Insurer Code #s ) must begin testing February 1, 2008, and be in production no later than the last day of the3rd month after the testing period begins.Second Group Must Begin Testing:Second Group Must Be In Production:
128 Claims EDI Primary Implementation Schedule Phase In: The third group (Insurer Code #s and ) must begin testing May 1, 2008, and be in production no later than the last day of the 3rd month after the testing period begins.Third Group Must Begin Testing:Third Group Must Be In Production:
129 What ‘Forms’ Will Be Required To Be Electronically Submitted In The Claims EDI Release 3 Primary Implementation Schedule?
130 The Claims EDI R3 Primary Implementation Schedule will include the electronic form equivalents for: First Report of Injury (DWC-1)Notice of Denial (DWC-12)Claim Cost Report (DWC-13)Aggregate Claims Administration Change Report (DWC-4 or DWC-49)Notice of Action/Change (certain fields) (DWC-4)
131 What MTC’s Will Be Required in the Claims EDI Release 3 Primary Implementation Schedule?
132 Claims EDI R3 Required MTC’s First Report of Injury (FROI): The following Maintenance Type Codes (MTC’s) are required to be implemented during the Primary Implementation Schedule for theFirst Report of Injury (FROI):MTC’s 00, 01, 02, 04, AQ, & AU(Definitions of MTC’s are in the IAIABC R3 Implementation Guide/Data Dictionary).
133 Claims EDI R3 Required MTC’s The following Maintenance Type Codes (MTC’s) are required to be implemented for the Primary Implementation Schedule for theSubsequent Report (SROI):MTC’s IP, EP, AP, PY, PD, CD, VE, 02, 04, SA & FN
134 FL requires both the FROI and SROI combination filing to constitute the electronic form equivalent of a DWC-1 reporting initial payment or ‘equivalent’ information.
135 Claims EDI R3 Required MTC’s SROI Maintenance Type Codes (MTC’s) required by FL to be filed with a FROI MTC (00 or AU) to report the initial payment or equivalent are:IP, EP, PY, PD, CD, VE, & AP
136 Some data elements from the DWC-4 will be required to be sent during the Primary Implementation Schedule, because of the design of the record layout.
137 These required DWC-4 data elements are identified in the EDI Rule 69L , F.A.C., and some examples follow….
138 Example DWC-4 Changes Required in Primary Implementation Claim Administrator Postal Code not due to change in claims administrationIndustry CodeManual Classification CodeEmployee SSNEmployee First/Last Name, Last Name Suffix, Middle Name/InitialDate of Injury
139 Claims EDI R3 Secondary Implementation Schedule Phase In: The insurer should begin testing the remainder of DWC-4 related MTC’s no later than 9 months after the its compliance date associated with the Primary Implementation Schedule, and be in production status no later than 1 quarter after the required testing start date.
140 Claims EDI R3 Secondary Implementation Schedule Phase In: 1st Group’s (Insurer Code #s ) Primary Implementation Schedule compliance date =First Group Must Begin Testing for the Secondary Implementation Schedule:First Group Must Be in Production for the Secondary Implementation Schedule:
141 Claims EDI Secondary Implementation Schedule Phase In: 2nd Group’s (Insurer Code # ) Primary Implementation Schedule compliance date =Second Group Must Begin Testing for the Secondary Implementation Schedule:Second Group Must Be in Production for the Secondary Implementation Schedule:
142 Claims EDI Secondary Implementation Schedule Phase In: 3rd Group’s (Insurer Code #s and ) Primary Implementation Schedule compliance date =Third Group Must Begin Testing for the Secondary Implementation Schedule:Third Group Must Be in Production for the Secondary Implementation Schedule:
143 Claim Administrator’s can voluntarily send MTC’s required in the Secondary Implementation Schedule (most DWC-4’s) during the Primary Implementation Schedule.
144 What MTC’s Will Be Required in the Claims EDI Release 3 Secondary Implementation Schedule?
145 Claims EDI MTC’s Required Subsequent Report (SROI): The following Maintenance Type Codes (MTC’s) are required to be implemented for the Secondary Implementation Schedule for theSubsequent Report (SROI):02, P7, S1-S8, CA, CB, AB, RB, & ER
152 Not all MTC filing. requirements set out in Rule. 69L-56, F. A. C Not all MTC filing requirements set out in Rule 69L-56, F.A.C., can be equated to a DWC Form. See rule and “FL Claims EDI Event Table” (also “MTC Filing Instructions”) for a complete accounting of MTC’s required by FL.
154 How Will EDI Errors Be Communicated to Claim Administrators?
155 The Division will acknowledge every EDI R3 transaction received with the standard EDI Acknowledgement format: ‘AKC’.AKC Report
156 Transmissions received on or before 9:00 p. m. , E. S. T Transmissions received on or before 9:00 p.m., E.S.T., will be processed by DWC the same day the transmission was sent.It will be acknowledged the next calendar day (morning).
157 Transmissions received after 9:00 p. m Transmissions received after 9:00 p.m. EST will be processed by DWC the following calendar day.It will be acknowledged the day after the transmission is processed.
158 FL processes transmissions 7 days a week, including holidays.
159 The ‘AKC’ acknowledgement will identify how many transactions passed edits (TA -Transaction Accepted); how many failed edits (TR -Transaction Rejected); and the specific error(s) that caused the transaction to reject.
160 FL does not use the TE – “Transaction Accepted with Errors” Acknowledgement Code.
161 If a transaction is improperly rejected by the Division, the entire batch will be re-processed and re-acknowledged using the ‘ARC’ Acknowledgement format (see the technical training PowerPoint for more details on the Acknowledgement Process)
162 The Claim Administrator will receive credit for the date the transaction was originally received by the Division.
163 FL provides EDI Claim Administrators the capability of viewing all FROI’s & SROI’s received, via the on-line Claims EDI Data Warehouse.
164 The on-line Claims EDI Data Warehouse will assist claim administrators in resolving EDI errors faster, and may also assist in resolving issues with the Centralized Performance System (CPS).Claims EDI Warehouse
165 More detailed information regarding the on-line Claims EDI Data Warehouse will be provided later in the training.Claims EDI Warehouse
171 Claim Business Events Claim Event Flow in FL 1. Establish Claim with 2. Initial Paymentor Equivalent9. Lump Sum Payment(s)7. Suspend10. Periodic Reports3. Changes to Benefits/Amnts5. Reinstate11. Changes(Non-Indemnity)Benefits6. Change4. Suspension of all Benefits12. Cancel8. Claim Closure
172 An Event is a business circumstance that occurs in the life of a WC Claim which requires the reporting of EDI information to DWC. These circumstances reflect FL’s requirements, including:First Report of Injury eventsSubsequent Report eventsPeriodic events
173 FL identifies all of the transactions (MTC’s) that are required for reporting specific business events on itsEvent Table.
174 Interpreting the FL Event Table Example: Florida requires the submission of a FROI MTC 00for First Reports of Injury or Illness based on the insurer’s mandate date …
175 Interpreting the FL Event Table … when disability is immediate & continuous & lost time is greater than seven (7) days.
176 Interpreting the FL Event Table The filing must receive a TA within 21 calendar days after the claim administrator’s knowledge of the injury.
177 Interpreting the FL Event Table A DWC-1 or IA-1 (ACORD 4) form must also be sent to the employee & employer
178 Periodic (Claim Cost) Reports In addition to reporting “typical” business claim Events, FL requires the claim administrator to report the “cost status” of the claim viaPeriodic (Claim Cost) Reports
185 Event Table FL Periodic Reports SA Sub-Annual – Submitted every 6 months after the DOI, as defined on FL’s Event Table.FN Final – Submitted when Claim Administrator determines no further benefits will be paid.
186 Event TableIn addition to the Event Table, FL describes its business events in the ‘MTC Filing Instructions’. This document assists claim administrators understand what MTC’s to use in reporting required business events to FL.MTCFilingInstructions
193 FL SCENARIO ASSUMPTIONS General scenario assumptions are included in the scenarios to assist in understanding the sample data that is presented.
194 FL SCENARIO ASSUMPTIONS The FL Scenarios were enhanced from the IAIABC scenarios in the R3 Implementation Guide.All the 2001 dates were moved forward to 2007 (the next year where all dates fell on the same day of the week).
195 FL SCENARIO ASSUMPTIONS Calculated Weekly Compensation Amount is the Comp. Rate, and is 66 2/3% of the Average Wage.The statutory comp rate max is not accurate per FL law.
196 FL SCENARIO ASSUMPTIONS Scenarios are presented in uppercase text. However, data may be sent to FL in mixed case format.Payment of indemnity benefits is based upon a 5 day work weekThe Industry Code must be a 2002 or 2007 NAICS code.
197 FL SCENARIO ASSUMPTIONS FL Scenarios contain required sample data elements pertinent to the scenario. These data are identified as “M” (Mandatory) or “MC” (Mandatory/Conditional) on the FL Element Requirement Table.
198 FL SCENARIO ASSUMPTIONS Additional data elements may be present in the scenario if they are identified as “IA” (If Applicable/Available) on the Element Requirement Table (e.g., Middle Initial and Suffix).
199 FL SCENARIO ASSUMPTIONS Although Claim Administrators may send additional data elements marked “NA” (Not Applicable), such data will not be edited or loaded by FL, and therefore not presented in the scenarios.
206 FL SCENARIOSA FROI must be paired with the applicable SROI that is reporting the initial payment or equivalent, unless the FROI is reporting a Full Denial (MTC 04), Cancel (MTC 01), Change (MTC 02) or Acquired Claim (MTC AQ).
210 Indemnity Benefits other than TP or IB or settlement will be paid, an NEW CLAIM: Lost Time CaseWhere Disability is Immediate and ContinuousIf the Initial Payment of Indemnity Benefits will be made by the Claim Administrator, andIndemnity Benefits other than TP or IB or settlement will be paid, anElectronic First Report of Injury or Illness is due.
211 Due: 21 Days after Claim Administrator’s Knowledge of the Injury NEW CLAIM: Lost Time CaseWhere Disability is Immediate and ContinuousSend: FROI 00 with SROI IPDue: 21 Days after Claim Administrator’s Knowledge of the InjuryNote: Also provide FORM DWC-1 or IA-1 to the employee & employer.
212 To avoid late filing penalties for an Electronic First Report of Injury or Illness, the EDI DWC-1 should be triggered immediately upon the CA’s disposition of the claim (payment or denial), to allow time for correction of potential errors and resubmission, and for subsequent receipt/acceptance by the Division within the filing due dates specified in Rule 69L-56, F.A.C.
213 FROI “00” Scenario Narrative Employee fell from ladder at employer’s warehouse on 6/15/07.Employee broke his leg.Foreman witnessed the accident.Employee treated and released from the Emergency Room.
214 FROI “00” Scenario Narrative Employee earned $15.00 an hour working 40 hours a week.Employer reported injury to insurer on 6/17/07.
215 FROI MTC “00” SCENARIOClaim Administrator reported the loss to DWC on 6/29/07.
216 FROI MTC “00” SCENARIO Insurer is identified. Claim Administrator details are provided (remainder are on R21).
217 FROI MTC “00” SCENARIO Employer/Insured information is reported. The Employer’s name is on the R21The rest of the Employer’s address is on the R21NAICS Code
218 FROI MTC “00” SCENARIOIf applicable, Policy Number should be reported, but Effective Date & Expiration Date are not required.
219 FROI MTC “00” SCENARIO Details of the accident are included. Employee broke leg falling from a ladder.
220 FROI MTC “00” SCENARIOEmployer reported injury to claim administrator on 6/17/07.
221 FROI MTC “00” SCENARIO Details about injured employee are sent. The rest of the Employee’s name and address is on the R21
222 FROI MTC “00” SCENARIODate the initial disability began & other FROI fields must be reported on the SROI.Manual “Risk” Class Code is only on the FROI.
223 FROI MTC “00” SCENARIOEmployee earned $15.00 an hour and worked 5 days a week.Employee has not returned to work.
224 FROI MTC “00” SCENARIOFROI Companion Record - R21
225 FROI MTC “00” SCENARIOClaim Administrator Claim Number is repeated in the R21. It links the R21 companion to the related 148.
226 FROI MTC “00” SCENARIO Claim Administrator FEIN is sent. Claim Administrator Name is sent,and rest of the Claim Admin Address.456 Main St
227 FROI MTC “00” SCENARIO ID qualifier = S. Positions 232 to 246 contain a Social Security Number.
228 FROI MTC “00” SCENARIORemainder of Employee name, address fields and phone are here in the R21 record.
229 FROI MTC “00” SCENARIO Type of Loss Code is reported on the SROI. Employee has not returned to work.
230 FROI MTC “00” SCENARIOInsured FEIN and Insured Name are reported.
231 FROI MTC “00” SCENARIOInsurer Name and Insurer Type Code are reported.
232 FROI MTC “00” SCENARIODetails of accident site:
237 FROI MTC “00” SCENARIOAccident description exceeds 50 characters; two segments are needed to send entire narrative description.
238 Variable Segment Population Rules for FROI ACCIDENT/INJURY DESCRIPTION NARRATIVES SEGMENT:No more than 10 (50 byte narrative text) segments per claim, and the number of segments sent must equal the “Number” of Accident/Injury Description Narratives segment counter.
239 FROI MTC “00” SCENARIOForeman Jones was the only witness.
240 Variable Segment Population Rules for FROI WITNESSES SEGMENT:No more than 5 witnesses per claim, and the number of segments sent must equal the “Number” of Witnesses segment counter.
243 MTC “IP” (Initial Payment) The claim administrator has issued its first payment of indemnity benefits (not a lump sum payment/settlement.)The Initial Payment transaction implies that indemnity benefits are ongoing until suspended.
244 SROI IP Scenario Narrative On 6/29/07, the Claim Administrator issued the first indemnity check.Check covered TTD benefits from 6/23/07 through 6/29/07 (Day 8-14).
245 SROI MTC “IP” SCENARIOInitial Payment transaction is sent to the Division on 6/29/07.
246 SROI MTC “IP” SCENARIOInitial Date Disability Began is the day after DOI because Employer paid for DOI.Employee was a 5 day per week worker.
247 SROI MTC “IP” SCENARIOClaim Admin Claim Number must be sent on every record.
248 SROI MTC “IP” SCENARIONo Jurisdiction Claim number required because IP SROI is filed with 00 FROI.
249 SROI MTC “IP” SCENARIOClaim Type indicates Lost Time case.
250 SROI MTC “IP” SCENARIONo variable segments; A49 ends at position 208.
251 SROI MTC “IP” SCENARIOClaim Administrator Claim Number is repeated in R22. It links the R22 companion to the related A49.
260 SROI MTC “IP” SCENARIOOne Benefits segment and one Payment segment are required on this claim.
261 SROI MTC “IP” SCENARIOTemporary Total was the only benefit paid. MTC is also in Ben segment for IP.
262 SROI MTC “IP” SCENARIOGross & Net Weekly Amount = $400/week (comp rate), effective on the DOI.
263 SROI MTC “IP” SCENARIO Initial payment reflected benefits were paid from June 23 through June 29, (Day 8-14) for 1 week in the amount of $400.
264 SROI MTC “IP” SCENARIOBen Payment Issue Date is the date payment left the CA’s control, e.g., mailed ( ), not necessarily the system check issue date.
265 SROI MTC “IP” SCENARIOFL requires the reporting of the exact amount of the Claim Administrator’s initial payment of indemnity benefits on MTC IP; therefore, the Payment segment must also be sent on the SROI, in accordance with the Element Requirement table.
266 SROI MTC “IP” SCENARIO MTC IP requires a Payments segment. Payment Reason Code = Benefit Type Code.
267 SROI MTC “IP” SCENARIOPayment information related to the Initial Payment is captured in the Payments segment.
268 SROI MTC “IP” SCENARIOPayment Issue Date = Benefit Payment Issue Date in Benefits Segment.
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