Electronic Data Interchange (EDI)
Release 3 Claims Standard Training
Fundamentals for Pennsylvania
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General EDI Information
•The Bureau of Workers’ Compensation (BWC) is moving from
the IAIABC EDI Release 1 Claim Standard for First Report of
Injury (FROI) claim filings to the IAIABC EDI Release 3 Claims
Standard for FROI and Subsequent Report of Injury (SROI)
claim filings.
•EDI is a structured transmission of data between
organizations by electronic means.
•Implementation date for EDI Release 3 is September 9, 2013.
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EDI Claims Tables
1. Required
Report(s)
2. Data needed on
the Report(s)
Event
Table
Element
Requirements
Table
Edit Matrix
3. Applied
Editing
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Subsequent Report of Injury (SROI)
Event Table
•Establishes the events accepted by Pennsylvania, and;
•Tells claim administrators when to report an event based on laws
and regulations, as well as what, if any, paper forms are required to
be sent to BWC and the claimant.
•A report of an event is identified, or described, using a
Maintenance Type Code (MTC).
Event
Table
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Partial Display of the FROI & SROI Event
Tables
The full tables can be viewed on our
website at www.dli.state.pa.us/wcais.
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Maintenance Type Codes (MTC’s)
•The IAIABC defines these as codes defining the specific
purpose of individual records within the transaction being
submitted.
•They are used to report claim events and describe the
types of SROI transactions being submitted.
•Any MTC’s other than those accepted by Pennsylvania will
be rejected as not jurisdictionally valid.
•A listing of the MTC’s accepted by Pennsylvania is available
in the Implementation Guide.
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Element Requirements Table
•This table defines the event data, by data element name and
number (DN), required for a Maintenance Type Code (MTC),
•Mandatory conditional (MC) data elements which are mandatory
if the condition defined is met and
•Business rules that apply to specific data elements when there is
an MC indicator.
Element
Requirements
Table
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Components of the Element Requirements
Table
•FROI and SROI Data Element Requirements worksheets;
these worksheets list the specific elements required for each
FROI & SROI MTC. IA is NOT the same as N/A. IA elements
should be provided, unless the information is not available.
•FROI and SROI Conditional Requirements worksheets;
these worksheets list data elements that are conditionally
required as well as the scenarios that require them.
•Event Benefits Segment Requirements worksheet; this
worksheet identifies data elements which are required when
payments are made on a claim.
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Edit Matrix Table
This table is made up of five worksheets which:
•Communicate the edits that will be applied to the data being
sent to BWC, as well as the standard error messages for those
edits when the data is not acceptable, and
•describes the proper sequence of submissions, acceptable code
values, data used for matching to existing claims and the error
messages associated with these edits.
Edit
Matrix
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Five Worksheets in Edit Matrix
•DN-Error Message – contains “standard” edits and error
messages which will assist claim administrators in
determining the specific cause of an error message.
•Value Table – lists BWC’s acceptable code values. It
identifies if a code value is statutorily valid, not statutorily
valid or accepted, but not required, by Pennsylvania. BWC
will not accept codes that are not statutorily valid (grayed
out).
•Match Data – describes which data elements will be used
to determine if the information matches an existing claim,
or if a new claim must be created.
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Five Worksheets in Edit Matrix
•Population Restrictions – is a listing of restrictions
applied to the data elements (identified in the DN Error
Message Worksheet by a “P”).
•Sequencing Tables – describes how BWC will apply
sequencing edits and the order in which specific events are
expected to be reported.
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Reporting Data
•Claim administrators should always submit the most current
data on each MTC.
•Data may be removed in BWC’s system if a space is sent on
the MTC where data had previously been sent.
•The cut-off time for processing files will be 11:59 PM
Eastern Time. All files located in the “IN” directory will be
processed by BWC. Data that arrives after this cut-off time
will be processed with the next day’s file date.
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PA EDI Transaction Sequencing
This diagram,
which is shown in
the PA
Implementation
guide, illustrates
the expected
sequence of EDI
transactions per
the BWC business
scenario
requirements.
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What’s received by BWC:
First Report of Injury (FROI 00, EDI Release 1)
FROI 00, 01, 02, 04, AQ, AU or UR, EDI Release 3 (A FROI 04
will also require a Denial, LIBC-496.)
Statement of Wages (LIBC-494 A/C)
LIBC-494 A/C submitted (by mail or uploaded into WCAIS)
when transactions are received that establish or change the
AWW.
Notice of Denial (LIBC-496)
FROI 04 or SROI 04 and an LIBC- 496
Notice of Temporary Compensation Payable (LIBC-501)
CA, IP (Indemnity), PY (Med Only) or RB (Agreement to
Compensate Code (DN0075) “W” – without liability) and an
LIBC-501
Notice Stopping Temporary Compensation (LIBC-502)
LIBC-502 submitted (by mail or submitted or uploaded into
WCAIS) prior to SROI 04 or PD.
Notice of Compensation Payable (LIBC-495)
Agreement of Compensation (LIBC-336)
Supplemental Agreement (LIBC-337)
SROI 02, IP (Indemnity), PD, PY (Med Only), RB or CA
(Agreement to Compensate Code (DN0075) “L” – with
liability) and an LIBC-495
SROI 02, IP, PD, PY (Med Only) or RB (Award/Order Date
(DN0299) should be present in the transaction) and an LIBC336
SROI 02, AB, CA, CB, P1, RB, RE, S1 or S8 (Award/Order
Date (DN0299) should be present in the transaction) and an
LIBC-337
Agreement for Compensation for Death (LIBC-338)
SROI 02, CB or IP (Award/Order Date (DN0299) should be
present in the transaction) and an LIBC-338
Supplemental Agreement for Compensation for Death (LIBC339)
SROI 02, CA, PY or S7 (Award/Order Date (DN0299) should
be present in the transaction) and an LIBC-339
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Today’s Process vs. Tomorrow’s EDI Release
3 Process
What’s received by BWC:
Notification of Suspension or Modification (LIBC-751)
P1, RE or S1 and an LIBC-751
Notice of Change of Workers’ Compensation Disability
Status (LIBC-764)
CB
Final Receipt (LIBC-340)
SROI 02 or S1 and an LIBC-340
Commutation of Compensation (LIBC-498)
Third-Party Settlement (LIBC-380)
PY
SROI 02 or CA (if change is due to Subrogation/Third
Party Offset) and the LIBC-380
Notice of Workers’ Compensation Benefit Offset (LIBC761)
CA
Notice of Suspension – Failure to Return Form LIBC-760
(LIBC-762)
S3
Notice of Reinstatement of Workers’ Compensation Benefits
(LIBC-763)
RB
Final Statement of Account (Final Receipt) (LIBC-392A)
S4 (with a death certificate or Coroner’s Report sent to
BWC) or FN
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Claim Reporting
•EDI will be used to report ALL claim events, however the
following forms continue to be required to be sent by upload,
or mail, to BWC:
LIBC-336
• Agreement for Compensation for Disability or Permanent Injury
LIBC-338
• Supplemental Agreement for Compensation for Disability or Permanent
Injury
• Agreement for Compensation for Death
LIBC-339
• Supplemental Agreement for Compensation for Death
LIBC-340
• Agreement to Stop Weekly Workers’ Compensation Payments (Final Receipt)
LIBC-380
• Third Party Settlement
LIBC-337
LIBC-494 A/C • Statement of Wages
LIBC-495
• Notification of Compensation Payable
LIBC-496
• Notice of Workers’ Compensation Denial
LIBC-501
• Notice of Temporary Compensation Payable
LIBC-502
• Notice Stopping Temporary Compensation
LIBC-751
• Notification of Suspension or Modification
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Claim Reporting, Continued
•Written notice to the employee has not changed due to
EDI. Paper forms must be sent to the claimant for ALL
transactions, whether they are forms currently generated
by insurer systems, the SROI Template (LIBC-91)*
available in WCAIS or LIBC forms downloaded from the
department’s website.
* The LIBC-91 cannot be used in place of the Notice of
Compensation Payable (LIBC-495), Notice of Workers’
Compensation Denial (LIBC-496) or the Notice of
Temporary Compensation Payable (LIBC-501). These
forms can be submitted to BWC by electronic batch, by
attaching the form to the individual claim or by mail.
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Claim Reporting, Continued
•The LIBC-502, Notice Stopping Temporary
Compensation, can be submitted electronically through
WCAIS or it will be available for download from the
department’s website, to be completed offline. If the
LIBC-502 is not submitted through WCAIS, it can be
submitted to BWC by electronic batch, attaching the
form to the individual claim by upload or mailed.
•The LIBC-494 (both A and C), Statement of Wages, will
be available for download from the department’s
website, to be completed offline, and then either
submitted to BWC by electronic batch, attaching the
form to the individual claim by upload or mailed.
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Claim Reporting, Continued
•The LIBC-751, Notification of Suspension or Modification
can be prepared and printed in WCAIS or downloaded
and completed offline. Once the form is notarized and
signed, it can be submitted to BWC by electronic batch,
attaching the form to the individual claim by upload or
by mail.
•Agreements, which can be the current form in insurer
systems or a form downloaded from the department’s
website, can be submitted to BWC by electronic batch,
attaching the form to the individual claim by upload or
by mail.
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Claim Reporting, Continued
•If a claim administrator chooses to use an agreement to initiate
payment or to change, stop or reinstate benefits paid on a claim,
in addition to the appropriate EDI transaction, an agreement
must be uploaded or mailed to BWC, as required by PA law.
•This should be done as close to the transaction date as possible,
preferably the same day.
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Claim Reporting, Continued
•The presence of an agreement should be indicated by
populating the Award / Order Date (DN0299) with the date
the parties entered into the agreement in their EDI
transaction.
•If a claim administrator chooses to use a Notification of
Suspension or Modification (LIBC-751) to modify or suspend
benefits, the signed, dated and notarized form MUST be filed
within seven days of the modification / suspension date, per
the Workers’ Compensation Act.
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Acknowledgements
•The acknowledgement record is a transaction returned by the
jurisdiction which contains information to identify the original
report sent and communicates any technical business issues
found.
•Transactions must be analyzed so the appropriate data can be
sent in the next file, including the Jurisdiction Claim Number
(JCN), which must be used on subsequent transactions.
•Transactions are either accepted or rejected:
TA – Transaction Accepted – No errors.
TR – Transaction Rejected – errors were found and the
transaction was NOT accepted.
HD – Batch Rejected
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EDI Claims Web Portal
•Trading Partners can submit FROI / SROI transactions directly
to BWC by using the WCAIS EDI Claims Web Portal.
•The web portal will have data entry screens which allow
Trading Partners to enter information that would otherwise be
required to be submitted using one of the approved
Transaction Partners or by filing directly.
•The data elements captured through the web portal screens
will correspond to IAIABC EDI Release 3 Claims data
elements.
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EDI Claims Web Portal, Continued
•Trading Partners using the web portal to submit the EDI
transactions will not receive acknowledgements. Instead, they will
receive an onscreen confirmation.
•Trading Partner Documents are NOT required to be sent to BWC if
you choose to use the web portal. These documents identify the
Transaction Partner a Trading Partner will be using to submit their
EDI transactions and web portal users will not be doing this.
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Draft EDI Web Portal Screen
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Draft EDI Web Portal Screen
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Draft EDI Web Portal Screen
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Draft EDI Web Portal Screen
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EDI Claims Release 3 Migration Strategies
•Pennsylvania has established a three-week
transition window for migrating from paper
BWC forms and EDI Release 1 FROI reports to
EDI Release 3 FROI and SROI.
•Conversion of data from the current system
into WCAIS will occur from August 17, 2013 to
September 8, 2013.
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EDI Claims Release 3 Migration Strategies
Continued
•The Bureau of Workers’ Compensation will
continue to accept time-sensitive Subsequent
Reports of Injury (SROI) paper forms from
August 17, 2013 to September 8, 2013.
•They will be date stamped to preserve the
filing date and might not be processed by
BWC until after our go-live date, September
9, 2013, which may result in delays in
viewing claim updates.
•Please consult your legal counsel for
guidance in identifying the forms to consider
as time sensitive.
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EDI Claims Release 3 Migration Strategies
Continued
•Claim administrators may continue to
submit FROI reports using the existing BWC
website and send EDI Release 1 FROI
transactions until 11:59p.m., August 29,
2013.
•Claim administrators are asked to delay
submission of FROIs from August 30, 2013
until after the September 9, 2013 go-live
date.
•After go-live, claim administrators must
submit EDI Release 3 FROI transactions for
their new claims.
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EDI Claims Release 3 Migration Strategies
Continued
•Beginning September 9, 2013, claim
administrators must send BWC a single SROI
UR transaction as their first transaction on
each open legacy BWC claim.
•BWC recommends that these SROI UR
transactions must be submitted in a single
file. SROI UR transactions must be filed one
time as a catch up to baseline the claim.
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EDI Claims Release 3 Migration Strategies
Continued
The timeline below illustrates the PA EDI migration strategy:
WCAIS EDI Migration Strategy
8/17/13
Start
Of
Transition Period
8/18/13 - 8/30/13
Claim Administrators
Continue FROI Submissions
9/9/13
9/10/13
- 9/14/13
Claim
Administrators
Start
Claim Administrators
Submitting
SROIUR
UR
Submit SROI
transactions
Transactions
14 Aug, 2013
14 Sep, 2013
8/18/13 - 9/9/13
Claim Administrators
Continue BWC LIBC Form Submissions
9/9/13
WCAIS Release 2
Go-Live
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EDI Claims Release 3 Migration Strategies
Continued
•Claims is going to include reminders with all
Request for Information letters.
•These will serve to remind claim administrators to
send only time-sensitive forms to BWC Aug. 28 thru
Sept. 9.
•Reminders will also be included with all returned
incomplete forms sent to BWC.
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EDI Claims Release 3 Migration Strategies
Continued
Post go live, the following forms will be
returned with instructions to file the
appropriate EDI transaction in place of the
form:
•LIBC-392A – FINAL STATEMENT OF ACCOUNT OF
COMPENSATION PAID
•LIBC 498-COMMUTATION OF COMPENSATION
•LIBC-761 – NOTICE OF WORKERS’
COMPENSATION BENEFIT OFFSET
•LIBC-762 – NOTICE OF SUSPENSION FOR FAILURE
TO RETURN FORM LIBC-760
•LIBC-763 – NOTICE OF REINSTATEMENT OF
WORKERS’ COMPENSATION BENEFITS
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EDI Claims Release 3 Migration Strategies
Continued
•A separate memo will be included in SFR
administrative determinations, discrepancies and
all other SFR-related correspondence advising
that effective September 9th, all SFR applications
must be filed in WCAIS.
•Applications received from August 17, 2013 to
September 8, 2013 will be returned unprocessed
with a request to resubmit the application
electronically on or after September 9, 2013.
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Training Webinars
Release 3 FROI Training: June 18, 2013, 9 a.m.,
repeated at 1 p.m. – This training will provide FROI
specific information which includes MTCs, Tables
Information, changes from EDI Release 1 to EDI Release 3,
requirements and Acknowledgements.
Release 3 SROI Training: July 11, 2013, 9 a.m.,
repeated at 1 p.m. – This training will provide SROI
specific information including MTC’s, Tables Information,
changes from EDI Release 1 to EDI Release 3, requirements
and Acknowledgements.
Web Portal Training: July 18, 2013, 9 a.m., repeated
at 1 p.m. – An overview of the WCAIS EDI Claims Web
Portal.
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Questions?
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