Pertinent Information on Subsequent Reports
We use the standard IAIABC header and footer for all transmissions, and any dataset without these will be rejected. The SROI transmission is through the same Advantis, AT&T, or ClaimPort mailbox as the FROI. We accept all datasets from each trading partner, determine the type of transmission from the header and then load all FROI datasets prior to SROI datasets.
We do not require an IP to accompany a FROI as some other jurisdictions do, so insurers do not have to send an IP before an S1 or FN provided that the IP was sent previously via the Internet WKC-13, on our pending reports website. If we receive an S1 or FN transmission without having the IP information (date and amount of the first payment) in our database, then we will reject the transmission.
For all A49 transmissions we search for the claim in the database based on SSN + injury date (plus or minus six days); we do not search by the Agency Claim Number. If the claim is not found the transmission is rejected with a message that reads CLAIM NOT FOUND IN DATABASE.
For all A49 transmissions we accept any of the medical expense codes (350, 360, 370) and any of the Vocational Rehabilitation codes (380, 390, 400) in the PTD/REDUCED EARNINGS/RECOVERIES segments. All other codes in these fields are ignored.
For A49 IP transmissions, we expect the date of the first payment in the Maintenance_Type_Code_Date field and the amount of the first payment in the Payment/Adjustment_Paid_To_Date field. This means that it is very important that the IP be sent out as soon as possible with the actual first indemnity check date. A Maintenance_Type_Code_Date which is later than the actual first indemnity check date may result in the recording of a delayed first payment and a late payment letter, if the delay is long enough to trigger such a letter.
If the payment is late we evaluate the Late_Reason_Code and then issue a standard late payment letter, with the letter going to either the insurer or employer depending on the code. If the code is blank and the payment is late, then we accept the transmission and send the letter to the insurer.
Insurers must send a minimum of two transmissions (an IP and a FN) to close each compensable claim, unless the IP information was previously reported via the Internet. If the IP information was previously reported via the Internet then an FN may be sufficient to close the claim.
For the A49 S1 and FN, we only accept the payment codes for TTD (050), TPD (070), Salary Continued (240), PPDSch (030) and PPDNon (040).
- We only accept a single period of TTD, TPD or Salary Continued, because the Release 1 A49 does not support intermittent payments. If you attempt to send intermittent payments as if they are a single period of paid disability then the transmission will be rejected.
- We reject transmissions with more than one payment record (e.g. intermixed TTD and TPD or TTD and PPD) because the data from such transmissions is unreliable.
- If a claim on our database already has a period of temporary disability and an S1 or FN for a previous or subsequent period of temporary disability (with either the same or different temporary disability type than is already on the claim) is transmitted, then it will be rejected.
- If a claim on our database already has two periods of temporary disability and an S1 or FN with either PPDSch or PPDNon is transmitted, then it will be rejected.
For the above four scenarios, the information that would be rejected if sent via EDI can be submitted via the Internet WKC-13, on our pending reports website.
If a claim on our database already has a single period of TTD, TPD or Salary Continued, then an S1 or FN with either PPDSch or PPDNon can be submitted via EDI and the transmission will be accepted.
Our interpretation of the difference between FN and S1 transmissions determines whether or not we try to close the claim. We interpret an S1 transmission to mean that there will be future payment(s) and/or a future medical report, so we will not close the claim. Upon receipt of an FN transmission we try to close the claim. If, however, we determine the healing period is greater than 3 weeks and we do not have a final medical report, the claim will remain open and go into "Waiting for Final Medical Report" status. Further, if the weekly wage for the year of injury is less than the maximum wage value for that year and we do not have an accepted or verified WKC-13A Wage Supplement for the claim, the claim will remain open and go into “Expecting Wage Information” status.
For S1s and FNs the value in the Payment/Adjustment_Code field must equal 050 for TTD, 070 for TPD, 240 for Salary Continued, 030 for PPDSch and 040 for PPDNon. We use the Date_Disability_Began field to derive the Last Day Worked (LDW) by subtracting one day from the submitted value. In WI the LDW is defined as an exclusive date. The value in the Date_Of_Return/Release_To_Work field gives us the Return to Work (RTW) date and the value in the Payment/Adjustment_Paid_To_Date field gives us the amount paid. The value in the Payment/Adjustment_Weekly_Amount field is the TTD rate, but rather than using the submitted value in this field we derive the TTD rate from the WKC-13A Wage Supplement (submitted via the Internet on our pending reports website). We also derive the days and weeks paid from the LDW and RTW dates rather than accepting the values in the Payment/Adjustment_Weeks_Paid and Payment/Adjustment_Days_Paid fields.
We do not use the Payment/Adjustment_Start_Date and Payment/Adjustment_End_Date fields for two reasons. First, these fields can be misleading in determining if the waiting period is deducted. Second, we have the impression that various carriers interpret the start and end dates differently, so in the interest of consistency we ignore them.
- Injury date 07/09/2007 (Monday)
- Date disability began 07/10/2007 (Tuesday)
- Date returned to work 07/16/2007 (Monday)
- Last Day Worked (derived from date disability began) 07/09/2007 (Monday)
- Waiting period 07/10/2007 through 07/12/2007 (Tuesday through Thursday)
- Payment start date 07/13/2007 (Friday)
- Payment end date 07/14/2007 (Saturday)
The correct payment for this example is two days. The payment start date is the first day payable after the three-day waiting period, and the payment end date is the day of the last payment, which is a Saturday because Sunday 07/15/2007 is not compensable. Notice that using payment start and end date makes it impossible to determine the actual LDW and RTW, which in turn makes it impossible to determine if the waiting period was deducted correctly.
The Worker's Compensation Administrative Code (80.02(2)e) requires the insurer to forward a hard copy of the WKC-13 to the claimant. For those reported electronically, however, the insurer can generate a letter from the SROI data and send that to the claimant rather than sending a WKC-13 form per se. The following is a list of required fields that must be included in the letter:
- Name of claimant
- Address of claimant
- Social Security Number
- Date of Accident or illness
- Name of employer
- Name of insurer
- Address of insurer
- Type of payment (TTD, PPDSCH, PPDNON, TPD, SALARY)
- Number of weeks and/or days paid
- Date last worked
- Date released to return to work
- Total amount of compensation paid
For more information about EDI Workers Compensation you can e-mail the EDI Coordinator or call (608) 267-6890.