April 7, 2008 Austin, Texas IAIABC All Committee Conference

1. EDI CLAIMS 201Reporting for Workers’ Compensation Claim TransactionsFirst and Subsequent Reports of Injury April 7, 2008 Austin, Texas IAIABC All Committee Conference

2. EDI 201 - Introductions About Your Trainers... • Faith Howe EDI Manager IAIABC email: fhowe@iaiabc.org

3. EDI 201 - Introductions About Your Trainers... • Pat Cannon Director, Business DevelopmentINGENIX – ROES (Red Oak E-Commerce Solutions) IAIABC EDI Claims & Systems Committee Member email: patrick.cannon@ingenix.com

4. EDI 201 Outline • Trading Partner Tables • Claim Event Table & Triggers • Data Element Requirement Table • Edit Matrix • Match Table • Sequencing Table • Claim Transaction Vocabulary and Sequencing • Activity: ‘EDI Poker’ • EDI Work Process Flows • System to system data flow • Claim administrator/Jurisdiction Preparation • Q & A

5. EDI Trading Partner Tables Claims Releases 1.0 and 3.0

6. EDI Trading Partner Tables • IAIABC Claims Standards • Uses data that originates in claim handling process to meet jurisdictional reporting requirements • “Claim event” driven reporting standard • Reporting requirements expressed in EDI trading partner tables

7. EDI Trading Partner Tables • Specifically, Jurisdiction requirements in the trading partner tables include: • Required report types (claim events) • When they are required (triggers) • When they are due • Data requirements that travel on those reports • Required edits • State’s response to each report (Acknowledgments)

8. Claim Events & Triggers • Each state will set guidelines (events) and triggers that will tell the trading partner what reports need to be filed • Events refer to the ‘claim events’ or reports required by the jurisdiction • In EDI referred to as Maintenance Type Codes or MTCs

9. Claim Events & Triggers • Trigger criteria codes • Events that cause a particular report to be due for submission to the jurisdiction Trigger Criteria Codes A = New Claim B = Cumulative Medical $ C = Lost Time D = Cumulative Wage Replacement E = Days Open F = Formula J = Jurisdiction Defined L = Determination of Compensable Death M = MTC Defined N = Cumulative Indemnity $ Q = Employee Death

10. Claim Events & Triggers • Trigger values further define the reporting requirements by defining the specific values associated with each particular criterion • i.e, if C=Lost time for criteria code, trigger value could be > 4 days

11. Claim Event Table • When the report is due i.e., within 10 days of beginning of lost time • Follow-up form sometimes identifies the statutory regulation and/or hardcopy documents that need to be filed in addition to EDI

12. Claim Event Table Examples • Release 1.0 • Significant changes to 3.0 Releases • Easier to read

13. Claim Event Table: R3

14. Claim Event Table: R3

15. Claim Event Table: R3

16. Claim Event Table: R3

17. Data Element Requirement Table: R1 An Element Requirement Table will tell you exactly what elements are ‘M’andatory ‘C’onditional ‘O’ptional for EACH MTC that is required by the State Note: You must always use the state-specific table, not the standard guide.

18. Data Element Requirement Table: R1 • Sorted by DN Name, DN #, or Category • Identifies the Data Element Category (i.e. Insured, Employee, Employer, etc.) • Lists the Data Numbers (DN) • Lists the Name of the Data Element • Indicates which DN is applicable to each MTC (DN 5 Agency Claim Number is applicable on an 02 - Change MTC) • Indicates which DN is Mandatory, Conditional, or Optional for each MTC

19. Data Element Requirement Table: R3 • Changes in new Data Elem. Tables for Releases 3.0 • ‘M-C-O’ changed to: • Mandatory (M) • Mandatory/Conditional (MC) • Becomes mandatory under conditions established by state • i.e., if Benefit type code indicates death benefits, then Date of Death becomes mandatory

20. Data Element Requirement Table: R3 • Expected (E) • Data element expected on MTC but transaction will be accepted if it is the only edit failure • Expected/Conditional (EC) • DN becomes expected under conditions established by state

21. Data Element Requirement Table: R3 • If Available (IA) • The data may or may not be populated • If present, may be edited for valid value and/or format • Jurisdiction may or may not return an error on validity edits • Not Applicable (NA) • The data element is not applicable to the jurisdiction’s requirements for the MTC and may or may not be sent • Edits must not be applied

22. Edit Matrix Table • Edits applied by a jurisdiction are indicated on the jurisdiction’s Edit Matrix • This helps the sender understand the edits the jurisdiction will apply and the data quality it expects • Identifies the Error Number, DN, and text description of error - returned by the State in Acknowledgment File • Usually sorted by DN • Lists DN Name • Indicates ‘Standard’ Error Numbers/Description for each applicable DN (i.e. Edit/Error 033- Must Be <= Date of Injury) • State may specify their specific edits and/or error messages

23. Edit Matrix Table • Indicates ‘Standard’ Error Number/ Description for each applicable DN (i.e. Edit/Error 033 - Must Be <= Date of Injury) • State may specify its specific edits and/or error messages

24. Edits: Error Message Rules • Jurisdictions should use the standard definitions when determining edits to be performed in their systems • Trading partners will use the definitions for the Error Message numbers to interpret errors received on their transaction acknowledgments • Adherence to these definitions will avoid reconciliation problems and will expedite responses to errors • Messages identified as ‘Release 1.0 Only’ are obsolete and have been replaced

25. Edit Matrix Table • Report-level editing • Match table • Sequencing

26. Match Table • Report-level editing: Match Table • describes the data elements the jurisdiction will use to determine if the report will create a new claim or will find an existing claim or transaction in its database • The constant and unchanging information can be used as match data • Examples: SSN, date of injury • Match Data is used to identify a transaction as: • a new claim to create • "match” to an existing claim or transaction for duplicate checking, updating, and processing

27. Match Table Release 3

28. Match TableRelease 1 example: Kansas

29. Sequencing Table • The Sequencing Table allows jurisdictions to elaborate on standard error messages related to transaction “sequencing” • The Edit Matrix SequencingTable illustrates the sequence in which business events (MTCs) typically occur during the life of a claim • Illustrates application of edits related to Event sequencing: • 063 - Invalid Event Sequence

30. Sequencing Table

31. Sequencing Table • 1. Establish Claim • a. Determination not made UI (FROI) • b. First Report of Injury 00 • c. Denial 04 (FROI)

32. Sequencing Table Jurisdiction accepts 00 or 04 to establish a claim. No FROI sequencing edits are applied NA NA NA

33. Sequencing Table • 2. Initial Payment or equivalent • a. Non-payment of Indemnity • Full Denial 04 (SROI) • Compensable Death CD • Volunteer VE • Determination not made UI (SROI) • Partial Denial PD b. Salary in Lieu of Compensation • Employer Paid EP c. Initial Payment of Weekly Benefits • Initial Payment IP

34. Sequencing Table • Jurisdiction requires a First Report 00 before a first payment or equivalent. • If jurisdiction receives an Initial Payment or Equivalent (Event 2) before a 00 report has been accepted, the report will be rejected.

35. Sequencing Table Jurisdiction indicates that the edit will be applied for each IP or Equivalent from its Event Table; NA if not accepted

36. Claim Transaction Vocabulary and Sequencing Releases 1.0 and 3.0

37. EDI Claims Transactions • Reports or Maintenance Type Codes (MTCs) • Transaction Vocabulary • Definitions • Categories of Reports

38. Transaction Vocabulary Important! • Standards for EDI reporting are developed by the states who use their laws/rules/ policies to set requirements. • Each report or transaction is named for the claim event it represents. • Each report is assigned a MTC code to meet the technical reporting requirements.

39. Transaction Vocabulary Transaction Types or Records • 148 - FROI or First Report of Injury • R21 FROI Companion Record • R21 FROI Companion Record will accompany the 148 Record to form a FROI transaction • Contains Release 2 and new Release 3 elements related to the 148, and • Release 1 data elements that do not have the same data element number, functionality, definition, and format

40. Transaction Vocabulary Transaction Types or Records • A49 - SROI - Subsequent Report of Injury • R22 SROI Companion Record • R22 SROI Companion Record will accompany the A49 Record to form a SROI transaction • contains Release 2 and new Release 3 elements related to the A49, and • Release 1 data elements that do not have the same data element number, functionality, definition, and format

41. Transaction Vocabulary AK1 (R1) & AKC (R3) - Acknowledgments are the transactions the jurisdiction sends back to you to let you know your file was received and its status! • Acknowledgment Code • TA - Transaction Accepted • TE - Transaction Accepted with Errors • TR - Transaction Rejected • Error Code- Use the Error Edit Matrix to determine the error message

42. Transaction Vocabulary First Report of Injury Transactions

43. Transaction Vocabulary 00 - Original • Original or first report transmitted between partners • Re-transmission of first report due to critical errors 01 - Cancel • Original or first report sent in error

44. Transaction Vocabulary 04 - Denial • Entire claim is being denied • Denial as first report 02 - Change • Claim administrator initiates the 02 Change when there is a change in a data element the state calls for on the element requirement table. 02 Change is NOT sent in response to a TE acknowledgment.

45. Transaction Vocabulary CO - Correction • Corrected data element values are transmitted in response to an acknowledgment containing non-critical errors • CO is only sent in response to Transaction Accepted with Errors (TE) acknowledgment AU - Acquired/Unallocated • The equivalent of an initial first report (MTC 00) • filed by new claim administrator in response to an AQ transaction that has been rejected because of no claim match on database, or • when an AU is sent in lieu of an AQ based on the Jurisdiction’s Event Table

46. Transaction Vocabulary • Subsequent Report of Injury Transactions • More numerous than FROI • Examples of key events

47. Transaction Vocabulary Starting Benefits IP – Initial Payment • The first payment for an indemnity benefit other than a settlement has been issued by a claim administrator AP - Acquired Payment • The claim administrator who acquired the claim has processed AP Acquired/Payment - the first payment of indemnity benefits • Requires previous filing of AU or AQ

48. Transaction Vocabulary Update Benefits • These apply to SROI as well as to FROI • 02 - Change • CO – Correction • 04 - Denial • PY - Payment Record • Identifies payment information that the jurisdiction requires • E.g. first payment for funeral, employer legal, penalty, or settlement

49. Transaction Vocabulary Changing/Reinstating Benefits • CB - Change in Benefit Type • A benefit type being paid has changed and payments are being continued under a different benefit type, without a break in continuity of benefits • RB - Reinstatement of Benefits • Indemnity payments have been resumed, but the reinstated benefit type may or may not have been paid previously • Rules - A previous subsequent report has been filed with a Suspension • For every RB there must be a corresponding suspension MTC • The Benefit Type Code being resumed may or may not have been previously paid

50. Transaction Vocabulary Suspending Benefits S1 - Suspension, RTW or Medically Determined/Qualified to RTW • All payments of indemnity benefits have stopped because the employee has returned to work or has been medically determined as qualified to return to work S7 - Suspension, Benefits Exhausted • All payments of indemnity benefits have stopped because limits of benefit or entitlement have been reached