Supplemental Report (WKC-13) Format

Below is the event table for electronic supplemental reports being sent to State of Wisconsin, Worker’s Compensation.  It will detail what fields are mandatory, conditional and optional for the various maintenance type codes (MTC) that we accept.

*NOTE: If a code does not exist in the MTC Requirements, then WC does not accept that code.
MTC Requirements are M(mandatory), C(conditional) or O(optional).

STATE OF WISCONSIN

SUPPLEMENTAL REPORT (WKC-13) FORMAT

REVISED 04/13/2000

REQUIREMENTS BY MAINTENANCE TYPE CODE - IAIABC RELEASE 1 SUBSEQUENT RPT OF INJURY (A49)

IAIABC

IAIABC

IAIABC

IAIABC

POSITIONS

MTC REQUIREMENTS

GROUPING

DN

DATA ELEMENT NAME

FORMAT

BEG

END

02

CO

FN

IP

S1

TRANSACTION

0001

Transaction Set ID

3 A/N

1

3

M

M

M

M

M

 

0002

Maintenance Type Code

2 A/N

4

5

M

M

M

M

M

 

0003

Maintenance Type Code Date

DATE

6

13

M

M

M

M

M

JURISDICTION

0004

Jurisdiction

2 A/N

14

15

M

M

M

M

M

CLAIM 
ADMINISTRATOR

0006

Insurer FEIN

9 A/N

16

24

M

M

M

M

M

 

0008

Third Party Administrator FEIN

9 A/N

25

33

C

C

C

C

C

 

0014

Claim Administrator Postal Code

9 A/N

34

42

C

C

C

C

C

 

0042

Social Security Number

9 A/N

43

51

M

M

M

M

M

 

0055

Number of Dependents

2 N

52

53

O

O

O

O

O

 

0069

Pre-Existing Disability

1 A/N

54

54

O

O

O

O

O

 

0056

Date Disability Began

DATE

55

62

M

M

M

M

M

 

0070

Date of Maximum Medical Improvement

DATE

63

70

C

C

C

C

C

 

0071

Return to Work Qualifier

1 A/N

71

71

C

C

C

C

C

 

0072

Date of Return/Release to Work

DATE

72

79

O

O

M

O

M

 

0057

Employee Date of Death

DATE

80

87

C

C

C

C

C

WAGE

0062

Wage

$9.2

88

98

M

M

M

M

M

 

0063

Wage Period

2 A/N

99

100

M

M

M

M

M

 

0064

Number of Days Worked

1 N

101

101

O

O

O

O

O

 

0067

Salary Continued Indicator

1 A/N

102

102

M

M

M

M

M

ACCIDENT

0031

Date of Injury

DATE

103

110

M

M

M

M

M

 

0026

Insured Report Number

25 A/N

111

135

O

O

O

O

O

 

0015

Claim Administrator Claim Number

25 A/N

136

160

C

C

C

C

C

 

0005

Agency Claim Number

25 A/N

161

185

C

C

C

C

C

CLAIM STATUS

0073

Claim Status

1 A/N

186

186

O

O

O

O

O

 

0074

Claim Type

1 A/N

187

187

O

O

O

O

O

 

0075

Agreement to Compensate Code

1 A/N

188

188

O

O

O

O

O

 

0076

Date of Representation

DATE

189

196

O

O

O

O

O

PAYMENTS

0077

Late Reason Code

2 A/N

197

198

C

C

C

C

C

VARIABLE 
SEGMENT 
COUNTERS

0078

Number of Permanent Impairments

2 N

199

200

M

M

M

M

M

 

0079

Number of Payments/Adjustments

2 N

201

202

M

M

M

M

M

 

0080

Number of Benefit Adjustments

2 N

203

204

M

M

M

M

M

 

0081

Number of Paid to Date/Reduced Earnings/Recoveries

2 N

205

206

M

M

M

M

M

 

0082

Number of Death Dependent/Payee Relationships

2 N

207

208

M

M

M

M

M

VARIABLE 
SEGMENTS

Permanent Impairments Occurs Number of Permanent Impairments times.

 

0083

Permanent Impairment Body Part Code

3 A/N

1

3

C

C

C

C

C

 

0084

Permanent Impairment Percentage

3.2 N

4

8

C

C

C

C

C

 

Payment/Adjustments Occurs Number of Payment/Adjustments times.

 

0085

Payment/Adjustment Code

3 A/N

1

3

M

M

M

M

M

 

0086

Payment/Adjustment Paid to Date

$9.2

4

14

M

M

M

M

M

 

0087

Payment/Adjustment Weekly Amount

$9.2

15

25

C

C

C

C

C

 

0088

Payment/Adjustment Start Date

DATE

26

33

C

C

C

C

C

 

0089

Payment/Adjustment End Date

DATE

34

41

C

C

C

C

C

 

0090

Payment/Adjustment Weeks Paid

4 N

42

45

C

C

C

C

C

 

0091

Payment/Adjustment Days Paid

1 N

46

46

C

C

C

C

C

 

Benefit Adjustments Occurs Number of Benefit Adjustments times.

 

0092

Benefit Adjustment Code

4 A/N

1

4

C

C

C

C

C

 

0093

Benefit Adjustment Weekly Amount

$9.2

5

15

C

C

C

C

C

 

0094

Benefit Adjustment Start Date

DATE

16

23

C

C

C

C

C

 

Paid to Date/Reduced Earnings/Recoveries Occurs Number of Paid to Date/Reduced Earning/Recoveries times.

 

0095

Paid To Date/Reduced Earnings/Recoveries Code

3 A/N

1

3

C

C

C

C

C

 

0096

Paid To Date/Reduced Earnings/Recoveries Amount

$9.2

4

14

C

C

C

C

C

 

Death Dependent/Payee Relationship Occurs Number of Death Dependent/Payee Relationship times.

 

0097

Dependent/Payee Relationship

2 A/N

1

2

C

C

C

C

C