Presentation on theme: "Claims EDI R3 Data Warehouse Featured Functionality"— Presentation transcript:
1 Claims EDI R3 Data Warehouse Featured Functionality
2 The DWC Claims EDI Data Warehouse reflects the raw data exactly as sent by the claim administrator, with a few formatting exceptions (e.g. dates displayed in readable format).It does not imply that the EDI filing was accepted and loaded to DWC’s accident database.
3 Maintaining Trading Partner Accounts The EDI Team establishes the initial data warehouse administrator account for each Trading Partner.Afterwards, this designated “Account Administrator” is be responsible for the maintenance of their company’s account.
4 Maintaining Trading Partner Accounts Access to a Trading Partner’s warehouse account should be removed when an employee no longer works for your company.Please do not delete the user from the warehouse …Do Not Delete
5 Instead, follow the instructions on the following slides… Maintaining Trading Partner Accounts… An account should only be deleted if it was established in error. Deleting the user will also delete the user’s name as the ‘last note author’ in the warehouse.Instead, follow the instructions on the following slides…
6 From the Main Menu click on Maintain My Company’s Log In Accounts.
7 Find the user you wish to revoke and click on their user id.
8 Place a check mark in the revoked box and a date and time revoked will be automatically added.
9 Click Save and Close. The user will no longer have access; however, their notes will remain as the last note author.
10 POP QUIZ:If a transaction receives a TR, and I don’t understand why, what do I do next?...
11 ANSWER:… Login to the Data Warehouse and look up the filing.
20 What do you do if you do not understand the error? Note the Element # (0185) and Error # (064)
21 Go to your copy of the Edit Matrix. Most recent version is posted on DWC’s Claims EDI webpage at
22 Click on the ‘Population Restrictions’ tab in the spreadsheet.
23 Find the DN # and Error # from the Error tab in the warehouse, in the 3rd column of the Population Rest.
24 Read the details of the error in the 5th column.
25 This error indicates that although Insurer Type Code ‘S’ was sent to indicate a self-insured employer, DWC can not match the Insurer FEIN sent to the FEIN of an authorized self insurer.
26 In this example, since the rejection was for an EDI DWC-1, the Claim Admin. must quickly determine the correct self insured FEIN number (or Insurer Type Code) and resubmit both the FROI 00 and SROI IP to achieve a “TA” within the timeframes required by rule.
27 Search by Element/Error Code New Feature:Search by Element/Error Code
28 The new ‘Search by Element/Error Code’ feature was added in response to a suggestion from a Trading Partner.
29 Search by Element/Error Code This feature allows you to research how many claims have rejected (or received TA-FL) for a particular DN/Error combination.We recommend your query include a reasonable date range to avoid locking up the system.
35 The error, “BOTH FROI & SROI MUST PASS EDITS TO ACCEPT FILING” means: When submitting an original First Report (MTC 00), you are required to submit a corresponding SROI initial payment or equivalent, soIf either transactions fails edits, both transactions will automatically fail for this reason.
36 In this example the SROI failed, so the FROI was not accepted. All 001 Error requirements/conditions are documented in the Element Requirement Table. Note DN 0196.
37 Go to your copy of the Element Requirement Table. Most recent version is posted on the Claims EDI webpage at
38 Click on SROI Elements Tab…and find DN 0196. The requirement code = MC, which means you must look at the SROI Conditions Tab
40 Reminder: How to research errors? Error 001 – Element Requirement Table (including Conditions Tab) Error 057 – Edit Matrix: Pop Rest and Duplicate Tab Error 063 – Edit Matrix: Pop Rest, Sequencing and Duplicate Tab Error Edit Matrix: Pop Rest and Match Data, and Duplicate Tabs All Other Error #’s: Pop Restrictions Tab
41 Some Errors for Error # 063 are found in the Sequencing Tab of the Edit Matrix.
42 Most Errors for Error # 057, and some for #063 and 117 are found in the Duplicate Processing Tab of the Edit Matrix.
43 Recap:‘TR’ Acknowledgement Code means your “transaction rejected” and must be resent.A TR can not be fixed with an 02 Change.At this time, please do not write notes or ask questions related to TR records via the warehouse; instead
44 Reminder:Do not alter any factual data or Benefit/Payment information in an attempt to pass an edit.Thoroughly research the problem and either correct the inaccurate data and re-send the transaction, or the EDI team if you suspect our program/edit is at fault.
45 Recap:If inaccurate data results in a CPS penalty, the Claim Administrator must send MTC 02 (or other appropriate MTC) to correct the data.After the MTC is accepted, notify the CPS specialist to re-evaluate the penalty.
46 This email copies all team members. If you already investigated an error and still do not understand it, please send an to rather than individual EDI team members.This copies all team members.CLAIMS EDI
47 When sending emails, please: Create a subject line specific to the error; do not include SSN’s;Provide the JCN or your Claim number;Provide the MTC and Received Date; &Clarify which error in which table you do not understand.Note: We can not address questions relative to problems in your company’s or vendor’s software.
48 The Claims EDI Team receives approximately 50+ s per day; therefore, if you have not received an answer or some acknowledgement of your ed question within 2 business days, please resubmit.
49 Responding to Reconciliation (Non-Fatal) Errors TA-FL’s
50 Reconciliation (Non-Fatal) Errors FL’s program also contains edits that identify data considered to be “suspect”, but which does not warrant rejecting the filing.These edits generate “Reconciliation Errors”.
51 Reconciliation (Non-Fatal) Errors ‘Reconciliation Errors’ are assigned an Acknowledgement Code of ‘TA’ on the AKC;But displayed as ‘TA-FL’ in the data warehouse.FL does not use ACK Code ‘TE’ – Transaction Accepted with Errors.
52 Reconciliation (Non-Fatal) Errors FL also does not accept MTC ‘CO’ – Correction to repair/respond to non-fatal errors.Instead, non-fatal ‘TA-FL’ errors are addressed via the data warehouse in conjunction with MTC 02 - Change (or other applicable MTC/response).
53 Reconciliation (Non-Fatal) Errors DWC sends notification (next day) to the Claim Admin. re: the posting of all non-fatal errors in the data warehouse.Claim Admin. should rectify the error on or before 21 days after the date the error was posted to the data warehouse (see Rule 69L (1)(i), F.A.C.)
54 Reconciliation (Non-Fatal) Errors TA-FL errors will not be identified on the ACK or in the warehouse if the transaction is rejected (TR).Only one Ack code can be returned on the AKC.Therefore, you may receive a TA-FL error after rectifying a TR.
55 Reconciliation (Non-Fatal) Errors How do I quickly find all my TA-FL error messages to see what needs to be addressed?TA-FL
56 Responding to Reconciliation Errors On the Search page you can select the Processing Result to display only OPEN TA-FL errors.
57 Alternatively, you can retrieve all OPEN TA-FL’s for a specified time period) by selecting ‘Open Reconciliation Errors Listing’ under ‘Notification Listings’.
58 Reconciliation (Non-Fatal) Errors There is also a NEW FEATURE in the warehouse that allows you to generate a listing of all TA-FL errors by type and the specific claims that received those errors -‘Claims EDI (TA-FL) Errors Detail Report’…
59 The Claims EDI (TA-FL) Errors Detail Report was added in response to a suggestion from a Trading Partner.
60 From the Main Menu, first select ‘Report Cards and Statistical Reports’
62 Fill in your search criteria (Date range, office location )
63 You will receive a ‘Claims EDI (TA-FL) Errors Detail Report’ You will receive a ‘Claims EDI (TA-FL) Errors Detail Report’. Results are presented in EE Name order (alpha) and then by TA-FL # (ascending).
64 Summaries of TA-FL errors by count, form type, and error # are provided at the end of the report:
65 Now let’s return to looking up TA-FL’s via the Search screen…
66 Responding to Reconciliation Errors On the Search Results screen you can see that there are internal reconciliation errors that are open.
67 Responding to Reconciliation Errors If the last note author is blank or is your DWC EDI Liaison, then the Claim Admin knows they must address the error, if it is still open.
68 Responding to Reconciliation Errors If the last note author is the Claim Admin, then your DWC EDI Liaison will review the response and determine if the error can be closed.
69 Responding to Reconciliation Errors Reconciliation Errors are in Yellow
70 Responding to Reconciliation Errors Claim Admin’s should check the error for which they are typing a response.If there is more than 1 error, you must Select each error and respond separately.
71 Responding to Reconciliation Errors Claim Admin’s must type a response to the selected error message to advise how the error will be rectified.
72 Responding to Reconciliation Errors The DWC EDI Liaison will type a response back to the Claim Admin.DWC responseClaim Admin response
73 Responding to Reconciliation Errors The Claim Admin can check the “Intend to send 02 transaction to correct” box, to indicate an 02 will be sent.Claim Admin response
74 Responding to Reconciliation Errors When the error has been rectified the DWC Liaison will close the error.
75 Responding to Reconciliation Errors On the Search Results screen you can see the last person to respond to a message and the status of the errors. The overall error status will remain open until ALL errors have been addressed and closed.
76 Results can be saved as a text file and imported into a spreadsheet.
77 This may make it easier to copy and paste the JCN or your Claim Number to bring up each record in the warehouse.From WordPad, copy & paste to Excel
78 Responding to Reconciliation Errors On the Search Results screen you will find the JCN, your claim number, and many other fields as you scroll to the right.All of this data will all save to your text file.
79 Responding to Reconciliation Errors If the same Reconciliation Error is generated on more than 1 transaction for the same claim:If error was fixed via MTC 02, you only need to respond on the most recent TA-FL (helpful to note if there are other identical TA-FL errors);DWC will close all identical errors for earlier transactions.
80 Responding to Reconciliation Errors Reminder:If the Reconciliation Error generated requires an MTC 02 to correct data in the Benefits, Payment, ACR, OBT or Recovery segment….
81 Responding to Reconciliation Errors … MTC 02 must be included in the Benefits segment(s), or the changes in the segment(s) will not be loaded/updated.
82 Responding to Reconciliation Errors If MTC 02 is not sent in the Benefits segment, the following statement will appear in blue above the Benefits segment in the Data Warehouse…
83 Responding to Reconciliation Errors Recap:If you send an 02 to change the Payment Issue Date of the initial payment (a/k/a Date 1st Payment Mailed) …,
84 Responding to Reconciliation Errors Recap:… MTC 02 must be sent in the Benefits segment, ANDA Payments segment must be sent with the corrected date.This date will not be corrected from the Benefits segment.
85 Note: Overpayments are no longer displayed as an open ‘TA-FL’ errors in the warehouse (since 8/09). Filings that only have an overpayment and no other reconciliation error associated with it will reflect ‘OVER PMT’ in the Error Status column (vs. Open) ...
86 Overpayment only OVER PMT O/P + non-reconciled non-fatal error OPEN
87 O/P’s are currently still posted to the ‘Errors and Problem Resolution Notes’ tab, but DWC does not require a response to these ‘errors’.At some point in the future, o/p’s will be identified in a “Notification Listing’ via the Main Menu.
88 In addition to the ‘OVER PMT’ Error Status, non-fatal ‘PERM TOT’ errors are also posted in the warehouse. This classification of PT Error Status is a fairly recent change to the data warehouse…
89 …Filings with non-fatal reconciliation errors that pertain to PT cases are identified as ‘PERM TOT’ in the Error Status column. Sort by Error Status column.
90 DWC’s PT Section also receives internal reports re: filing discrepancies, and may solicit responses from the Claim Admin. via letter or .
96 Rejected Not Resubmitted List EDI DWC-1 equivalents (e.g., 00/IP, 04, etc.) that reject and have not been successfully resubmitted will be included when this query is run.Claim Admin.’s can and should check this list frequently and resubmit any outstanding rejections.
97 Rejected Not Resubmitted List the EDI Team if the EDI DWC-1 was re-filed (TA’d) under a different SSN or DOI from that on the Rejected Not Resubmitted List.Provide the EE’s Name, File # and Div Rec’d Date for the rejected filing, so the transaction(s) can be excluded from the listing.
98 Rejected Not Resubmitted List Also notify the EDI Team if an EDI DWC-1 that rejected was actually sent in error and will never be re-sent (e.g., Medical Only), so the transaction(s) can be removed from the list.
99 Rejected Not Resubmitted List This data is updated every Saturday.
100 Claim Admin Selects Rejected Not Resubmitted List
101 Claim Admin Selects Rejected Not Resubmitted List (All outstanding TR’s)
102 New Feature:Rejected But Not Resubmitted Listing now includes:Incomplete EDI DWC-1 filings (i.e., 00 sent without the SROI).List previously only identified complete combo’s that rejected.
103 New Feature:Also, the Rejected But Not Resubmitted Listing has been revised to list an outstanding filing (MTC) only once on the report, vs. listing all attempts and multiple rejections for the same filing/MTC per claim.
104 Other New Features in the Claims EDI Data Warehouse
105 New Feature:Quick Search: If your query returns a listing of various filings, and you want to drill down to just the filings for one EE in the list,Click on a BOLDED hyperlink to obtain historical filing information for the EE.
106 Quick Search Hyperlinks: Partner ID: Returns all filings found for that EE Name;DAN (if applicable): Returns all filings found for that DAN;Claim Admin Claim #: Returns all filings found for that claim #; andJCN: Returns all filings for JCN.
107 For example, click on the ‘Partner ID’ for the desired EE:
108 All filings for DOI’s, Claim #’s, JCN’s associated with that EE Name you have sent to DWC will be presented.
109 Scroll further to the right on the desired row to locate JCN hyperlink if you want to view all filings sent under a particular JCN.
110 Another New Feature:Search by Filing Type: You can now search by MTC/Filing Type. For example, you can retrieve all 00/IP filings, FROI 04 filings, etc., and further narrow down the results by selecting a date range and processing result (e.g., Rejected).
111 On the main ‘Search” screen, click on any MTC/MTC combo from the drop down menu under “Filing Type’.
112 In this example, all rejected 00/IP’s for the selected time period are presented.
113 New Feature:Indicator of Last Viewed Record – To help keep track of previously viewed records (such as when you are going down a list of various filings for the same or different EE), the EE name hyperlink will change colors (blue to purple).
114 When you return to the list, the ‘purple’ will indicate which Henny Penny filing you already viewed.
115 New Feature:SSN has been masked for security reasons (along with EE address, nature of injury, and accident description for confidential profiles.)DAN will be displayed.
116 New Feature:If the filing consists of both FROI and SROI MTC’s / tabs, the data warehouse view will default/open to the SROI tab first.
117 New Feature:Changed label in A/C/R segment from ‘ACR PMT’ to ‘Ben Type Code’ for clarification.