electronic data interchange payments. trainers: gordon davis paul fortier additional wcb staff:...

MAINE WORKERS’ COMPENSATION BOARD

Electronic Data InterchangePayments

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Introductions

Trainers: Gordon Davis Paul Fortier

Additional WCB Staff:Kimberlee Barriere, Deb Morton, Carrie Pelletier

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Training Agenda

Introduction to EDI Fundamentals of EDI

Reporting EDI and Claims

Handling EDI Review and Case

Study

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Training Goals

At the conclusion of this training session, you should be able to:1. Name the three basic steps in

EDI reporting2. Recognize common EDI

acronyms and define common EDI terms

3. List the transaction processing documents

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Training Goals

At the conclusion of this training session, you should be able to:4. Provide examples of

legal/business requirements vs EDI reporting requirements

5. Explain the fundamentals of transaction editing and the AKC report

INTRODUCTION TO EDIA Brave New World

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What is EDI?

Electronic Data Interchange or EDI is an electronic communication system that provides standards for exchanging data via any electronic means. Reduces, or in some cases, eliminates

paper reporting. Allows jurisdictions to collect more data

to satisfy statutory and regulatory obligations.

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IAIABC

The goal for EDI in workers’ compensation is the seamless processing of information from its initial reporting source to a jurisdiction.

IAIABC EDI standards cover the transmission of Claims, Proof of Coverage, and Medical Bill Payment information through electronic reporting.

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IAIABC

The standards are developed and maintained through a consensus process that brings together volunteers from jurisdictions, claim administrators, vendors, and others interested in participating.

IAIABC EDI Claims Release 3 is the latest national standard for reporting claims information to jurisdictions.

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Note of Caution

While the IAIABC has developed a national standard for use by each of the jurisdictions, jurisdictional requirements vary widely.You must be familiar with the jurisdictional requirements for each of the states that you handle claims for.

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State of Maine

§152. AUTHORITY OF BOARD; ADMINISTRATION

2-A. Electronic filing rulemaking.  The board shall adopt rules requiring the electronic filing of information required by this Act and by board rule.

Consensus-based rulemaking. Standards and procedures for

implementation. Specific forms required to be filed. Testing required before adoption.

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State of Maine

Board Rules and Regulations Chapter 3 contains vital information regarding data element definitions, formats, values, and processing rules that may differ from those of IAIABC due to statutory or regulatory requirements.

The rules also outline the distribution requirements for forms filed via paper and EDI.

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State of Maine EDI Contacts

Legal - John Rohde John.Rhode@maine.gov

Technical – Paul Fortier Paul.Fortier@maine.gov and/or Brad Howard Brad.Howard@maine.gov

Audit – Gordon Davis Gordon.Davis@maine.gov Claims - Deb Morton Debbie.Morton@maine.gov

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Introduction to EDI Reporting

Step 1: Trading partner relationship established Claim administrator completes and

submits Trading Partner Documents to the jurisdiction

System test is performed between the CA and the Jurisdiction

CA is approved for Production environment

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Introduction to EDI Reporting

Step 2: Claim administrator sends a report to the jurisdictionDefined by the jurisdiction and the

EDI standard via the Event Table and Element Requirement Table

Based on a claims-handling activity (e.g. decision to pay or deny)

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Introduction to EDI Reporting

Step 3: Jurisdiction acknowledges success or failure of the reportBased on the Edit Matrix TableTA = transaction acceptedTR = transaction rejected

It is critical that adjusters know whether a transaction has been accepted. For instance, if a denial transaction is rejected, there exists the potential for a 14-day violation

FUNDAMENTALS OF EDI REPORTING

A Brave New World

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Key Definitions

Trading Partner: An entity that has entered into an agreement with another entity to exchange data electronically.

Trading Partner Agreement: A set of expectations and responses between two entities exchanging data electronically. These expectations include, but are not

limited to, what transactions to send, what format to use, what data elements to include, when and where data elements are to be sent, and testing to be performed.

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Key Definitions

Data Element: A single piece of information, e.g., Date of Injury, Date of Birth, etc. Data elements are: Defined Assigned a Data Element Number or DN Assigned values or codes, if applicable Assigned valid applicable edits Assigned a data format

Record: A group of related Data Elements to form a transaction.

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Key Definitions

Transaction: Can consist of 1 or more records to communicate a claim event. Each Transaction Type is contained in a batch, which is preceded by a Header Record and concluded with a Trailer Record.

Transmission: Consists of one or more batches sent or received during a communication session.

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Key Definitions

The FROI is a record sent to the jurisdiction to comply with the jurisdiction’s First Report of Injury requirements.

The SROI is a record sent to the jurisdiction to comply with the jurisdiction’s Subsequent Report of Injury requirements.

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Key Definitions

The FROI record is identified by the Transaction Set ID 148 (fixed length record). This record must be paired with its companion record R21(variable length record) to complete the FROI transaction.

The SROI record is identified by the Transaction Set ID A49 (variable length record). This record must be paired with its companion record R22 (variable length record) to complete the SROI transaction.

.

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Key Definitions

A Periodic report is a type of SROI transaction that must be filed at regular intervals (monthly, quarterly, sub-annual, annual, etc.).

The State of Maine only requires one periodic report (MTC SA). This report is required every 180 days until a “FN” is filed (think WCB-11 Statement of Compensation Paid).

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Key Definitions

The Maintenance Type Code or MTC is a code defining the specific purpose of individual records within the transaction being transmitted.In other words, the MTC is the type

of FROI or SROI transaction being transmitted, e.g. Original FROI, Initial Payment, Partial Denial, etc.

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Key Definitions

The Benefit Type Code or BTC is a code identifying the payment being made.

The Other Benefit Type Code or OBT is a code identifying miscellaneous benefits not otherwise specifically defined with a Benefit Type Code.

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Key Definitions

The Acknowledgement Record or AKC is a transaction returned by the jurisdiction as a result of a report sent. It contains enough data elements to identify the original transaction and any technical and business issues found with it.

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EDI Data Flow

1 •Data Element•Single piece of information

2 •Record•Group of related data elements

3 •Transaction•Group of records

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EDI Data Flow

4 •Batch•Each transaction type is a batch

5 •Transmission•One or more batches

6 •Acknowledgement Report•Each transaction TA or TR

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Transaction Processing Documents

Standard Elements:IA Implementation Guide

ME Implementation Guide

Trading Partner Tables

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Implementation Guides

The IAIABC EDI Implementation Guide For Claims includes information regarding the following:

Jurisdiction EDI Preparation Technical Documentation and

Acknowledgment Scenarios Business/Technical Process Rules Business Scenarios Data Dictionary

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Implementation Guides

The MWCB EDI Implementation Guide For Claims includes information specific to processing Maine workers’ compensation claims including:

Closure requirementsPaper filing requirements

Consent Between Employer and Employee

21 Day Notice Requirements Lump Sum Settlements

Permanent Impairment

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Data Dictionary

The Data Dictionary is Section 6 of the IA Implementation Guide. It contains the IAIABC data element definitions, formats, values, and processing rules.

Note: some definitions are dependent on jurisdictional requirements (see the MWCB EDI Implementation Guide For Claims . Example - Initial Date Disability Began DN0056: Per Board rules, when an employee is paid 1/2 day or more wages on the date of injury, the date of injury will not be considered a day of incapacity.

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Trading Partner Tables

Standard Tables:When to report = Event TableWhat to report = Element Requirement Table

How jurisdiction validates the data = Edit Matrix (actually consists of 5 separate tables)

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Event Table

The Event Table provides the information necessary for the claim administrator to understand the jurisdiction’s EDI reporting requirements.

It relates EDI information to claim events and under what circumstances and when the claim administrator must report those events.

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Event Table

Report Triggers – these are events in the life of a claim that cause a particular report to be filed with the jurisdiction (payments, denials, changes, suspensions, reinstatements, closure, etc.) Each report trigger has a

corresponding maintenance type code (MTC) which is a code defining the specific purpose of individual records within the transaction being submitted.

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Event Table

Basically the old paper forms are replaced by EDI reports that are identified by MTC.

You will need to learn the MTC codes the same way you learned the paper form numbers. The Event Table provides a form to MTC

crosswalk.

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SROI Maintenance Type Codes (MTC)

Non-payments: 04 CD PD

Initial Payments: AP EP IP

One-time Payments: PY

Suspensions: S1 S2 S4 S5 S6 S7 S8 S9 SD

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SROI Maintenance Type Codes (MTC)

Changes to Benefits: CA CB

Resumption of Benefits: ER RB

Periodic Reports: SA

Claim Closure: FN

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Event Table Pop Quiz

Refer to your Event Table:Which MTC(s) correspond to the following event triggers: Denial of a claim (full v. partial) Initial payment of a claim Suspension of benefits (EE RTW) Lump sum settlement

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Element Requirement Table

The Element Requirement Table is designed to let claim administrators know the jurisdiction’s business data element requirements.

Lists the data elements for each electronic report (i.e. each MTC) as required by statute, rule, or current version of EDI and includes the condition that triggers a conditional data element be sent to the Board.

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Element Requirement Table

Every piece of data is numbered and represented by a DN.

The Data Dictionary contains all the data elements along with their definitions, formats, values, and processing rules.

The Quick Code Reference List identifies the valid code values for each data element.

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Element Requirement Table

In Maine, the requirement codes generally fall into one of the following: Fatal (F) or Fatal Conditional (FC) Mandatory (M) or Mandatory Conditional (MC) If available (IA) Not applicable (NA) Exclude (X)

These data requirement codes also tell you how critical each data requirement is for each report type/MTC.

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Element Requirement Table

Variable Segments: Permanent

Impairments Death

Dependent/Payee Relationships

Benefits Payments Other Benefits Benefit ACR Recoveries

Reduced Earnings Concurrent

Employers Full Denial Reason

Codes Denial Reason

Narratives Suspension

Narratives

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Element Requirement Table Pop Quiz

Refer to your Element Requirement Table:

Which data element on the A49 record is required on an IP transaction, if available on an AP transaction, and excluded from an EP transaction?

What condition triggers the requirement for the Employee Tax Filing Status Code (DN 158)?

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Benefit Segments

Report indemnity benefits:Currently being paid (“Event”)

Have been paid (“Sweep”)

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Benefit Segments

“Event” Benefit Segment MTCs: 02, AP, CA, CB, EP, ER, IP, PY

(Benefit Type Codes other than 5XX), RB, S1-S9, SD

“Sweep” Benefit Segment MTCs:02 (if benefit segment data is not

changing), 04, CD, PD, FN, PY (Benefit Type Codes 5XX), SA

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“Event” Benefit Segment

When a benefit type is being affected (i.e. starting, changing from/to, or suspending) or when reporting a lump sum payment with a Benefit Type Code other than 5XX, the MTC is sent in the benefit segment of the affected benefits.

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“Sweep” Benefit Segment

If the claim administrator has paid any indemnity benefits, every SROI transaction must contain a “Sweep” Benefit Segment for every benefit type paid.

Previously reported benefits must be reported on each subsequent SROI transaction unless explained via certain codes.

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“Sweep” Benefit Segment

A “Sweep” Benefit Segment is sent with any “Event” Benefit Segment if a different Benefit Type Code has previously been paid and is not part of the “Event” that is currently being reported.

The segment is a snapshot of benefits that have been paid on the claim at the time of the report.

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“Sweep” Benefit Segment

Segment includes: Benefit Type Code, Benefit Period Start Date, Benefit Period Through Date, Benefit Type Claim Weeks, Benefit Type Claim Days, Benefit Type Amount Paid

Segment does not include: MTC (that would imply an “Event”), Gross Weekly Amount, Gross Weekly Amount Effective Date, Net Weekly Amount, Net Weekly Amount Effective Date, Benefit Payment Issue Date

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Edit Matrix Table

The Edit Matrix Table tells the claim administrators which data elements have edits applied to them and provides the standard error messages used in association with those edits.

The Edit Matrix Table actually consists of 5 separate tables.

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Edit Matrix Table

1. DN Error Message

2. Values

3. Match Data

4. Population Restrictions

5. Sequencin

g

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Edit Matrix Table

Components:1. DN-Error Message table contains edits

for individual data elements.2. Value table expresses the jurisdiction’s

acceptable code values.3. Match Data table describes the data

elements that are used determine if the report will create a new claim or find an existing claim or transaction in the jurisdiction’s database.

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Edit Matrix Table

Components continued:4. Population Restrictions table

contains the jurisdiction’s restrictions applied to the data element(s).

5. Sequencing table outlines the logical transaction sequencing for application of edit 063.

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Acknowledgement Report

The Acknowledgment Report (AKC) conveys the status of the transaction to the sender along with applicable error messages for specific data elements.

Reminder: the sender may or may not be the claim administrator.

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Acknowledgement Report

When the rule is adopted, transactions will be either accepted (TA) or rejected (TR), however, even accepted transactions may require action by the claim administrator based on any business issues found within the transaction.

These business issues are listed in the AKC report by data element along with the edit number and text description of the edit.

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Acknowledgement Report True or False

The Edit Matrix Table and Acknowledgement Report are for the “techies”?

As long as a transaction is accepted, that is all I need to care about?

EDI AND CLAIMS HANDLINGA Brave New World

Claim Adjusting

EDI Reporting

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Putting the Puzzle Together

Certain claim adjusting functions or business events trigger a reporting requirement to the jurisdiction.

These triggers are identified on the jurisdiction’s Event Table.

In many cases, EDI replaces paper reporting.

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Putting the Puzzle Together

Many claims management systems will automatically send EDI reports to the jurisdiction based on the jurisdiction’s filing requirements. In other words, a lot of EDI reporting happens “behind the scenes”.

However, in some cases a paper filing is required BEFORE an EDI transaction can be sent.

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Putting the Puzzle Together

Paper forms still filed with the Board: WCB-2 Wage Statement WCB-2A Schedule of Dependent(s) and

Filing Status Statement (pre 1/1/13 dates of injury)

WCB-2B Fringe Benefits Worksheet WCB-4A Consent Between Employer

and Employee WCB-7 Certificate Authorizing Release

of Unemployment Information

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Putting the Puzzle Together

Paper forms still filed with the Board: WCB-8 Certificate of Discontinuance

or Reduction of Compensation Pursuant to 39-A M.R.S.A. §205(9)(B)(1)

WCB-10 Lump Sum Settlement WCB-231A Employee's Return to

Work Report Pursuant to 39-A M.R.S.A. §205(9)(B)

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Putting the Puzzle Together

Paper forms that must be filed with the Board before the claim adjusting activity/report trigger:

• WCB-4A Consent Between Employer and Employee

WCB-8 Certificate of Discontinuance or Reduction of Compensation Pursuant to 39-A M.R.S.A. §205(9)(B)(1)

WCB-10 Lump Sum Settlement

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Consent Between ER and EE

When there is a voluntary payment of a retroactive closed-end period, change in a benefit amount, change in benefit type, or suspension of benefits as a result of a consent between the employer and employee, the WCB-4A form must be executed and filed in accordance with Board Rules.

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Consent Between ER and EE

Payment is due and the PY, CA, CB, and/or S9 transaction(s) must be filed within 10 calendar days from the date that the form is signed by all the parties.

Best practice: Insurer representative signs the form last so the insurer knows when the form is effective and the payment is due.

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Certificate of Discontinuance or Reduction

In all circumstances other than the following, the employee’s benefits may not be reduced or discontinued without 21 days notice in accordance with Title 39-A, Section 205(9)(A) and Board Rules. 

Employee Dies (not as a result of the injury)

Board Decision Statutory Offset(s) Receipt of Actual Wages Actual Return to Work (Employer of

Injury)

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Certificate of Discontinuance or Reduction

When there is a change in a benefit amount (CA), change in benefit type (CB), or suspension of benefits (S1-S8) that requires 21 days notice in accordance with Title 39-A, Section 205(9)(A), the WCB-8 form must be completed and filed in accordance with statute and Board Rules prior to the transaction. Transactions must be received within 14 days of the effective date of the change or discontinuance of benefits.

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Lump Sum Settlement

The employer/insurer, employee, and/or attorney files the Lump Sum Settlement form (WCB-10) to request approval of a lump sum settlement.

Payment is due and the PY transaction must be filed within 10 calendar days from the date that the form/order is signed by the Hearing Officer.

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EDI Exercise 1

Employee sprains his pinkie finger while performing his auto mechanic job. Employee is treated at the local emergency room and returned to work the same day. Costs incurred at the local emergency room for x-rays and treatment are $380.

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EDI Exercise 1

Using the Event Table:Is the injury required to be

reported to the jurisdiction?Does your answer change if the

claim is denied?Does your answer change if the

medicals are being paid voluntarily but the adjuster is denying a request for physical therapy?

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EDI Exercise 2

Employee pulls a muscle in his back while performing his landscaping job. Costs incurred at the local emergency room for x-rays and treatment are $450. Employee returns to work after 2 days out.

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EDI Exercise 2

Using the Event Table: Is the injury required to be reported

to the jurisdiction?What additional report may be

required?What if after a FROI is filed with ME

you learn that the employee lives in ME but the injury actually occurred in NH and the employee elects to file a claim in NH? Is there more than one option?

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EDI Exercise 3

Employee is killed as a result of a fall from a roof while removing ice and snow. The employee was single with no eligible dependents.

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EDI Exercise 3

Using the Event Table:Which reports must be submitted?How does your answer change if

the employee has a dependent eligible for benefits?

How does your answer change if the employee died of a heart attack while shoveling the roof rather than a fall?

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EDI Acknowledgements

Acknowledgment

Electronic

Report

Claim Administrator Jurisdiction

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EDI Acknowledgements

Acknowledgements include the following information:

Date and time the jurisdiction processed the transaction

Jurisdiction assigned claim number Claim administrator claim number MTC and MTC Date Acknowledgement code: TA or TR Edits (data element and edit description)

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Transaction Rejected

The transaction did not meet the jurisdiction’s technical filing requirements therefore the transaction was not accepted.

The error(s) must be resolved and the transaction resubmitted.Remember: Compliance and penalties may be at risk.

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Transaction Accepted

The transaction met the jurisdiction’s technical filing requirements therefore the transaction was accepted.

There may however be business issues identified within the transaction that need to be resolved.Remember: Compliance and penalties may be at risk.

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Transaction Sequencing

Regardless of the format (paper v. electronic), reports must be sent in the correct order.

The Sequencing edits (component of the Edit Matrix Table) ensures that certain transactions cannot be sent before other transactions.

Transactions sent out of sequence cannot be processed and the transaction will reject.

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EDI Exercise 4

Claim administrator reported a lost time injury by sending a FROI 00. During the investigation, the adjuster discovers that the employee was engaged in horseplay and decides to deny the claim by sending an FROI 04. The FROI 04 was rejected by the jurisdiction.

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EDI Exercise 4

Using the Event Table:Why did the FROI 04 reject?

What needs to be done to deny the claim?

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EDI Exercise 5

Claim administrator denied a claim by sending a FROI 04. After receiving an updated M-1 report, the adjuster decides to pay the claim voluntarily and sends a SROI IP. The SROI IP was rejected by the jurisdiction because DN0298 was left blank.

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EDI Exercise 5

Using the Element Requirement Table:

What is DN0298?When is DN0298 required?What information should be included in the payment narrative (DN0233)?

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EDI Exercise 6

Claim administrator sent a FROI 00 transaction to report a lost time injury and then filed a SROI IP transaction when indemnity payments began. After a brief return, the employee went back out of work and the claim administrator sent a SROI RB transaction to report the resumption of indemnity benefits. The RB transaction was rejected.

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EDI Exercise 6

Using the Event Table:Why did the RB transaction reject?

What needs to be done to correct the error?

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Making the Transition

Building a new system?

Adapting an existing system?

Utilizing a vendor system?

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Roles and Responsibilities

Employees Employers Insurers Trading Partners Other Vendors Etc.

Claim

Administrators Claim Handlers Compliance

Specialists Information

Management

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Roles and Responsibilities

“Front End” refers to what the end user sees and interacts with.

“Back end” refers to the computer software logic and applications that interpret end user interactions.

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Roles and Responsibilities

What is “legal”, what is “technical” and what is “operations”?

Who is responsible for overseeing an EDI vendor relationship?

How will electronic reports be triggered? Will reports auto-trigger or do they have to be triggered manually?

Who is responsible to map the jurisdiction’s requirements to the claims-handling process?

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Roles and Responsibilities

What is “legal”, what is “technical” and what is “operations”?

Why can’t I see the applicable DNs in my claims-handling system(s)?

Who receives the AKC report and who is responsible to monitor compliance and “fix” errors?

Who is responsible for form distribution? Etc.

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Roles and Responsibilities

Effective EDI claims handling is a successful partnership among legal, technical and operations

personnel.

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Other Considerations – Acquired Claims Processing

An acquired claim is any existing claim (open or closed) taken over from a prior claim administrator.

The first filing on all acquired claims must be either a FROI AQ or a FROI AU.

Payment information received from prior claim administrator, use OBT codes: 430 – unallocated prior indemnity benefits 440 – unallocated prior medical benefits

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Acquired Claims ProcessingPop Quiz

If the jurisdiction rejects the AQ transaction because it can’t find a match in its database, what report must the claim administration file on the acquired claim?

What MTC must the acquiring claim administrator file to report it first indemnity payment on the acquired claim?

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Other Considerations – “Full Denials”

A “full” denial (FROI 04 or SROI 04) on a medical only (Claim Type Code M), notification only (Claim Type Code N), or became medical only (Claim Type Code B) claim DOES NOT deny a future claim for compensation.

In other words, if a claim becomes Lost Time/Indemnity (Claim Type Code L), you must file a SROI 04 or SROI PD to dispute the claim for compensation.

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Other Considerations – “Legacy Claims”

A legacy claim is any claim (regardless whether open or closed) that already exists in the WCB database and has been assigned a JCN or WCB# prior to the implementation of claims EDI reporting.

When a SROI is due based on the Maine Workers’ Compensation Board Event Table contained in the Appendix of this rule and no electronic reports have been filed yet, the trading partner may submit the initial electronic transmission without regard to sequencing edits, data elements not previously required on paper forms and without regard to form filing penalties.

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Other Considerations – Form Distribution

Paper forms – distribute to: Worker’s Compensation Board, employee, and employer.

Electronic reports – upon acceptance (TA), certain transactions will return a PDF form that must be distributed to the employee, employer, and provider (if applicable) within one business day of the form’s transmission to the claim administrator.

EDI REVIEWA Brave New World

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EDI Review

1. Name the three basic steps in EDI reporting

2. Recognize common EDI acronyms and define common EDI terms

3. List the transaction processing documents

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EDI Review

4. Provide examples of legal/business requirements vs EDI reporting requirements

5. Explain the fundamentals of transaction editing and the AKC report