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Electronic Data Interchange (EDI) >1 Release 3 Claims Standard Training Fundamentals for Pennsylvania.

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Presentation on theme: "Electronic Data Interchange (EDI) >1 Release 3 Claims Standard Training Fundamentals for Pennsylvania."— Presentation transcript:

1 Electronic Data Interchange (EDI) >1 Release 3 Claims Standard Training Fundamentals for Pennsylvania

2 General EDI Information >2 The Bureau of Workers’ Compensation (BWC) is moving from the IAIABC EDI Release 1 Claim Standard for First Report of Injury (FROI) claim filings to the IAIABC EDI Release 3 Claims Standard for FROI and 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 September 9, 2013.

3 EDI Claims Tables >3 Element Requirements Table Edit Matrix Event Table 2. Data needed on the Report(s) 3. Applied Editing 1.Required Report(s)

4 Subsequent Report of Injury (SROI) Event Table >4 Establishes the events accepted by Pennsylvania, and; Tells claim administrators when to report an event based on laws and regulations, as well as what, if any, paper forms are required to be sent to BWC and the claimant. A report of an event is identified, or described, using a Maintenance Type Code (MTC). Event Table

5 Partial Display of the FROI & SROI Event Tables >5 The full tables can be viewed on our website at

6 Maintenance Type Codes (MTC’s) >6 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 MTC’s other than those accepted by Pennsylvania will be rejected as not jurisdictionally valid. A listing of the MTC’s accepted by Pennsylvania is available in the Implementation Guide.

7 Element Requirements Table >7 This table defines the event data, by data element name and number (DN), required for a Maintenance Type Code (MTC), 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

8 >8 FROI and SROI Data Element Requirements worksheets; these worksheets list the specific elements required for each FROI & SROI MTC. IA is NOT the same as N/A. IA elements should be provided, unless the information is not available. FROI and SROI Conditional Requirements worksheets; these worksheets list data elements that are conditionally required as well as the scenarios that require them. Event Benefits Segment Requirements worksheet; this worksheet identifies data elements which are required when payments are made on a claim. Components of the Element Requirements Table

9 Edit Matrix Table >9 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 the error messages associated with these edits. Edit Matrix

10 Five Worksheets in Edit Matrix >10 DN-Error Message – contains “standard” edits and error messages which will assist claim administrators in determining the specific cause of an error message. Value Table – lists BWC’s 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). 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.

11 Five Worksheets in Edit Matrix >11 Population Restrictions – is a listing of restrictions applied to the data elements (identified in the DN Error Message Worksheet by a “P”). Sequencing Tables – describes how BWC will apply sequencing edits and the order in which specific events are expected to be reported.

12 Reporting Data >12 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 file date.

13 PA EDI Transaction Sequencing >13 This diagram, which is shown in the PA Implementation guide, illustrates the expected sequence of EDI transactions per the BWC business scenario requirements.

14 >14 FROI 00, 01, 02, 04, AQ, AU or UR, EDI Release 3 (A FROI 04 will also require a Denial, LIBC-496.) LIBC-494 A/C submitted (by mail or uploaded into WCAIS) when transactions are received that establish or change the AWW. FROI 04 or SROI 04 and an LIBC- 496 CA, IP (Indemnity), PY (Med Only) or RB (Agreement to Compensate Code (DN0075) “W” – without liability) and an LIBC-501 LIBC-502 submitted (by mail or submitted or uploaded into WCAIS) prior to SROI 04 or PD. SROI 02, IP (Indemnity), PD, PY (Med Only), RB or CA (Agreement to Compensate Code (DN0075) “L” – with liability) and an LIBC-495 SROI 02, IP, PD, PY (Med Only) or RB (Award/Order Date (DN0299) should be present in the transaction) and an LIBC- 336 SROI 02, AB, CA, CB, P1, RB, RE, S1 or S8 (Award/Order Date (DN0299) should be present in the transaction) and an LIBC-337 SROI 02, CB or IP (Award/Order Date (DN0299) should be present in the transaction) and an LIBC-338 SROI 02, CA, PY or S7 (Award/Order Date (DN0299) should be present in the transaction) and an LIBC-339 First Report of Injury (FROI 00, EDI Release 1) Statement of Wages (LIBC-494 A/C) Notice of Denial (LIBC-496) Notice of Temporary Compensation Payable (LIBC-501) Notice Stopping Temporary Compensation (LIBC-502) Notice of Compensation Payable (LIBC-495) Agreement of Compensation (LIBC-336) Supplemental Agreement (LIBC-337) Agreement for Compensation for Death (LIBC-338) Supplemental Agreement for Compensation for Death (LIBC- 339) What’s received by BWC:

15 Today’s Process vs. Tomorrow’s EDI Release 3 Process >15 What’s received by BWC: Notification of Suspension or Modification (LIBC-751) Notice of Change of Workers’ Compensation Disability Status (LIBC-764) Final Receipt (LIBC-340) Commutation of Compensation (LIBC-498)Third-Party Settlement (LIBC-380) Notice of Workers’ Compensation Benefit Offset (LIBC- 761) Notice of Suspension – Failure to Return Form LIBC-760 (LIBC-762) Notice of Reinstatement of Workers’ Compensation Benefits (LIBC-763) Final Statement of Account (Final Receipt) (LIBC-392A) P1, RE or S1 and an LIBC-751 CB SROI 02 or S1 and an LIBC-340 PY SROI 02 or CA (if change is due to Subrogation/Third Party Offset) and the LIBC-380 CAS3 RB S4 (with a death certificate or Coroner’s Report sent to BWC) or FN

16 Claim Reporting >16 Agreement for Compensation for Disability or Permanent Injury LIBC-336 Supplemental Agreement for Compensation for Disability or Permanent Injury LIBC-337 Agreement for Compensation for Death LIBC-338 Supplemental Agreement for Compensation for Death LIBC-339 Agreement to Stop Weekly Workers’ Compensation Payments (Final Receipt) LIBC-340 Third Party Settlement LIBC-380 Statement of Wages LIBC-494 A/C Notification of Compensation Payable LIBC-495 Notice of Workers’ Compensation Denial LIBC-496 Notice of Temporary Compensation Payable LIBC-501 Notice Stopping Temporary Compensation LIBC-502 Notification of Suspension or Modification LIBC-751 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:

17 Claim Reporting, Continued >17 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, by attaching the form to the individual claim or by mail.

18 Claim Reporting, Continued >18 The LIBC-502, Notice Stopping Temporary Compensation, can be submitted electronically through WCAIS or it will be available for download from the department’s website, to be completed offline. If the LIBC-502 is not submitted through WCAIS, it can be submitted to BWC by electronic batch, attaching the form to the individual claim by upload or mailed. The LIBC-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.

19 Claim Reporting, Continued >19 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.

20 Claim Reporting, Continued >20 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 PA law. This should be done as close to the transaction date as possible, preferably the same day.

21 Claim Reporting, Continued >21 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.

22 Acknowledgements >22 The acknowledgement record is a transaction returned by the jurisdiction which contains information to identify the original report sent and communicates any technical business issues found. Transactions must be analyzed so the appropriate data can be sent in the next file, including the Jurisdiction Claim Number (JCN), which must be used on subsequent transactions. 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

23 EDI Claims Web Portal >23 Trading Partners can submit FROI / SROI transactions directly to BWC by using the WCAIS EDI Claims Web Portal. The web portal 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.

24 EDI Claims Web Portal, Continued >24 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 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.

25 Draft EDI Web Portal Screen >25

26 Draft EDI Web Portal Screen >26

27 Draft EDI Web Portal Screen >27

28 Draft EDI Web Portal Screen >28

29 EDI Claims Release 3 Migration Strategies >29 Pennsylvania has established a three-week transition window for migrating from paper BWC forms and EDI Release 1 FROI reports to EDI Release 3 FROI and SROI. Conversion of data from the current system into WCAIS will occur from August 17, 2013 to September 8, 2013.

30 EDI Claims Release 3 Migration Strategies Continued >30 The Bureau of Workers’ Compensation will continue to accept time-sensitive Subsequent Reports of Injury (SROI) paper forms from August 17, 2013 to September 8, They will be date stamped to preserve the filing date and might not be processed by BWC until after our go-live date, September 9, 2013, which may result in delays in viewing claim updates. Please consult your legal counsel for guidance in identifying the forms to consider as time sensitive.

31 EDI Claims Release 3 Migration Strategies Continued >31 Claim administrators may continue to submit FROI reports using the existing BWC website and send EDI Release 1 FROI transactions until 11:59p.m., August 29, Claim administrators are asked to delay submission of FROIs from August 30, 2013 until after the September 9, 2013 go-live date. After go-live, claim administrators must submit EDI Release 3 FROI transactions for their new claims.

32 EDI Claims Release 3 Migration Strategies Continued >32 Beginning September 9, 2013, claim administrators must send BWC a single SROI UR transaction as their first transaction on each open legacy BWC claim. BWC recommends that these SROI UR transactions must be submitted in a single file. SROI UR transactions must be filed one time as a catch up to baseline the claim.

33 EDI Claims Release 3 Migration Strategies Continued >33 The timeline below illustrates the PA EDI migration strategy:

34 EDI Claims Release 3 Migration Strategies Continued >34 Claims is going to include reminders with all Request for Information letters. These will serve to remind claim administrators to send only time-sensitive forms to BWC Aug. 28 thru Sept. 9. Reminders will also be included with all returned incomplete forms sent to BWC.

35 EDI Claims Release 3 Migration Strategies Continued >35 Post go live, the following forms will be returned with instructions to file the appropriate EDI transaction in place of the form: LIBC-392A – FINAL STATEMENT OF ACCOUNT OF COMPENSATION PAID LIBC 498-COMMUTATION OF COMPENSATION LIBC-761 – NOTICE OF WORKERS’ COMPENSATION BENEFIT OFFSET LIBC-762 – NOTICE OF SUSPENSION FOR FAILURE TO RETURN FORM LIBC-760 LIBC-763 – NOTICE OF REINSTATEMENT OF WORKERS’ COMPENSATION BENEFITS

36 EDI Claims Release 3 Migration Strategies Continued >36 A separate memo will be included in SFR administrative determinations, discrepancies and all other SFR-related correspondence advising that effective September 9 th, all SFR applications must be filed in WCAIS. Applications received from August 17, 2013 to September 8, 2013 will be returned unprocessed with a request to resubmit the application electronically on or after September 9, 2013.

37 Training Webinars >37 Release 3 FROI Training: June 18, 2013, 9 a.m., 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 Acknowledgements. Release 3 SROI Training: July 11, 2013, 9 a.m., repeated at 1 p.m. – This training will provide SROI specific information including MTC’s, Tables Information, changes from EDI Release 1 to EDI Release 3, requirements and Acknowledgements. Web Portal Training: July 18, 2013, 9 a.m., repeated at 1 p.m. – An overview of the WCAIS EDI Claims Web Portal.

38 Questions? >38


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