Two Sample Scenarios for Electronic and Paper Filing of Payment Information

Below are two different examples of a worker’s compensation claim, along with a step by step discussion of how each can be handled and then some explanatory notes.  The first example will require mixed EDI and Internet (or paper) filing of the payment information.  The second concerns a situation whereby the entire claim, except for the medical report, can be filed via EDI.

Example 1:

An employee is injured on 02/09/2004, misses work until 02/23/2004, returns to work part time on 02/16/2004 and then returns to full time work on 02/23/2004.  The employee has surgery and begins losing time again on 03/09/2004 and does not return to work until 06/22/2004.  Permanent partial disability was assessed and payments are due monthly until it is all accrued.

How can this be submitted?

  1. Employee is injured on 02/09/2004 and misses work until 02/23/2004.

    • File a 148 00, via EDI, in order to submit the first report of injury.
       
      File an A49 IP, via EDI, in order to report the first payment date and amount. Payment type TTD (050) and MTC Date (Maintenance_Type_Code_Date) = First payment date.
       
      Payment/Adjustment Paid To Date = First payment amount.
       
  2. Employee returns to work part time on 02/16/2004.

    •  
      File an A49 S1, via EDI, notifying us of the end of TTD and the total amount paid for that disability type.

      Alternatively you may file an Internet WKC-13 showing the end of TTD and accumulated amount paid for that period of disability. Hold off on submitting the start of TPD, unless the person has returned to work full duty and you know this date. You should not start a period of TPD unless you know the return to work date because doing so will create a worksheet that runs from the last day worked until the Sunday before the date you are filing the Internet WKC-13. Thus, on the Internet WKC-13 confirmation screen you should answer YES to the question,Will there be more temporary disability payments made on this claim in the future?, because you will have to report the TPD return to work date when it is known to you.
       
  3. Employee returns to full time work on 02/23/2004.


    • File an Internet WKC-13 showing the beginning (Sunday 02/15/2004) and end of the TPD period, along with the accumulated amount paid. This will generate the Internet TPD worksheet, and you will then need to enter the worksheet detail.
       
  4. Employee has surgery and begins losing time again on 03/09/2004.


    • File an Internet WKC-13 showing the beginning of a new period of TTD.
       
  5. Employee does not return to work until 06/22/2004.


    • File an Internet WKC-13 showing the end of TTD and the accumulated amount paid.
       
  6. Permanent disability payments are paid monthly until they end.


    • File a paper final medical report showing the amount of Permanent Disability

      File an A49 FN, via EDI, showing the accumulated total of PPDsch (030) or PPDnon (040) payments. Alternatively, this could be filed via the Internet WKC-13 or on paper.
       

The following is a clarification of the IP, S1 and FN transmissions mentioned above. Reference will be made to the IAIABC EDI Implementation Guide, Release 1, dated February 15, 2002.

The Dictionary, page 6-26 defines IP as follows: Initial Payment.  We interpret this to stand for the first payment date and amount made on a claim.  There is only one "first" payment on any given claim, therefore only one IP transmission per claim.  The first payment date is equal to the Maintenance_Type_Code_Date (see the Dictionary, page 6-28).  The first payment amount is equal to Payment/Adjustment Paid To Date (see the Dictionary, page 6-37).

The Dictionary, page 6-25 defines S1 as follows: Suspension, returned to work, or medically determined/qualified to return to work.  We interpret this to mean that all lost time benefits have ceased due to one of the three reasons stated in the definition.  The claim remains open for a final medical and possible Permanent Disability.  See Section 5, pages 5-50 and 5-51 for an example.  Note that the narrative does not state that claim has been closed by the claim administrator.

The Dictionary, page 6-25 defines FN as follows: Final.  We interpret this to mean that all benefits due the injured employee have been paid and the insurance carrier is closing their claim.  In Section 5, see pages 5-31 and 5-32 for an example.

Example 2:

An employee is injured on 02/09/2004, misses work until 03/05/2004 and returns to work full time on that date.  A final medical report is received and Permanent Disability Benefits are paid.

How can this be submitted?

  1. Employee is injured on 02/09/2004, misses work until 03/05/2004 and returns to work full time on that date.

    •  

      File a 148 00, via EDI, in order to submit the first report of injury.

      File an A49 IP, via EDI, in order to report the first payment date and amount. Payment type TTD (050) and MTC Date (Maintenance_Type_Code_Date) = First payment date.  Payment/Adjustment Paid To Date = First payment amount.
       

      File an A49 S1, via EDI, in order to report the accumulated amount paid for TTD.  (The claim administrator is still waiting for the final medical report so he or she is unable to close the claim).

  2. Final medical received and Permanent Disability Benefits paid.

    • File a paper final medical report showing the amount of Permanent Disability.

      File an A49 FN, via EDI, showing the accumulated total of PPDsch (030) or PPDnon (040) payments made.  (The claim administrator has paid all of the benefits due and he or she is closing the claim.)

NOTE: Either TTD or TPD can be reported via EDI, but not both for the same claim.  PPD can be reported via EDI, but not in the same transmission as another payment type.  These situations, however, can be reported using our Internet WKC-13, on our pending reports website.