EDI - Alerts/Updates

WC insurers, self-insured employers and third party administrators are urged to pay particular attention to the issues noted below.
 
REMINDER: USE OF AGREEMENT TO COMPENSATE CODE "W"
 
The Agreement to Compensate Code (DN0075) "W" (Without Liability) should only be used in a transaction that is being submitted to match a Notice of Temporary Compensation Payable (LIBC 501). Section 2.4 of the PA EDI Implementation Guide, under "Reporting Temporary Compensation on the Initial Payment Transaction," states:
When the claim administrator begins paying temporary compensation on a claim, the claim administrator is required to report those payments on an Initial Payment transaction. When submitting this transaction, the claim administrator must populate the Agreement to Compensate Code (DN0075) with a "W" to indicate they are not accepting liability for the claim.
The "W" should not be used in Pennsylvania when denying a claim because neither the FROI 04 nor the SROI 04 requires its use. Transactions submitted with the "W" will result in the claim status being updated to "Temporary." A claim in "Temporary" status may convert if no EDI transaction accepting or denying liability for the claim is submitted to update the claim status prior to the end of the 90-day temporary period. (Please see Section 2.4 of the Implementation Guide, under "Complying with the 90-Day Rule for Temporary Indemnity Claims," for more information.)
 
SROI PD AGREEMENT TO COMPENSATE CODE AND CLAIM TYPE CODE
 
The EDI section of the Claims Management Division is seeing some confusion over the affect the Agreement to Compensate code and Claim Type code have on the claim.
  • The Agreement to Compensate code tells us if the claim is temporary (W), or if the claim has been accepted (L).
     
  • The Claim Type code tells us if the claim is indemnity (I), or medical only (M).
We are seeing some adjusters using the Agreement to Compensate code W on transactions which then either leaves the claim in temporary status or updates the claim to temporary status when that is not the intent.
 
Although there are many other transactions with coding errors, the prime example of the confusion around the Agreement to Compensate code is regarding the SROI PD.
The intended use of the SROI PD is on a claim with a medical only LIBC-495 NCP:
 
SROI PY with Agreement to Compensate code L and Claim Type code M; followed by an indemnity LIBC-501 NTCP: SROI IP with Agreement to Compensate code W and Claim Type code I; which is then stopped with an LIBC-502 Notice Stopping Temporary Compensation and an LIBC-496 Notice of Compensation Denied, denying liability for the indemnity.
 
The SROI 04 may not be filed because the claim is already an accepted medical only claim, so the SROI PD is filed in this scenario.
 
The error we often see is when the SROI PD is filed with the Agreement to Compensate code W, which does not update claim status in WCAIS because W is used only for temporary claims. The SROI PD should come in with the Agreement to Compensate code L to properly stop the claim and revert it to the correct Medical Only status.
The other error we are seeing on the SROI PD is the use of Claim Type code I. Many adjusters mistakenly use this Claim Type code in error when they are really attempting to tell us that they are partially denying the indemnity portion of the claim.
The Claim Type code tells WCAIS the correct compensability; therefore, if Claim Type code I is used, the adjuster is telling WCAIS that the claim should be an indemnity claim, and the claim status is then set to Compensable.
 
To deny the indemnity portion of the claim, the accurate Claim Type code is M to tell WCAIS that the claim should be a medical only claim.
Please continue to send questions, concerns and suggestions regarding the PA Claim R3 EDI process to RA-CMDEDI@pa.gov.
 
INCORRECT CONVERSION OF CLAIMS
 
The Bureau of Workers' Compensation is seeing increasing numbers of claims incorrectly converting from a Comp Denied claim status to Temporary status. There are two major reasons for incorrect conversions of claims:
  1. The wrong EDI (Electronic Data Interchange) transaction is submitted, or
  2. Paper documentation is submitted but not the EDI transaction.
In the majority of cases, a PY transaction is being issued in error.
 
In WCAIS (Workers' Compensation Automation and Integration System), an EDI or Web portal transaction is required to electronically establish a claim in the system. Thereafter, SROI (Subsequent Report of Injury) updates to the claim information or claim status in WCAIS are also accomplished electronically by EDI transactions.
 
When a SROI PY is submitted to the bureau on a claim in Comp Denied or FROI (First Report of Injury) status with the Agreement to Compensate code of W, the claim status is updated to temporary because this is the EDI transaction that accompanies the Notice of Temporary Compensable Payable. (Refer to Section 2.4 of the EDI Implementation Guide under “Complying With the 90-Day Rule for Temporary Indemnity Claims” and “Complying With the 90-Day Rule for Temporary Medical-Only Claims,” which describe the EDI transactions that will stop conversion.
 
These SROI PYs are often issued to report a medical bill incurred prior to issuance of a denial, but the claims are meant to remain Comp Denied. Those medical bills are not required to be reported to Pennsylvania. If the adjuster wishes to have the bill on the claim as part of the official record, the bill may be uploaded as a miscellaneous document to the Documents and Correspondence tab of the claim in WCAIS. The adjuster also has the ability to include a form description when uploading that document
 
If the company's system coding requires a transaction to be issued and the company has a transaction partner, the transaction partner should be contacted for help with the correct coding in this case. When there is no transaction partner, the adjuster may report the medical bill by submitting a SROI 02 to avoid having the claim status change and incorrectly convert.
 
In other cases, the adjuster submits paper documentation but not the EDI transaction.
 
Paper SROI forms submitted to the bureau are date stamped and uploaded to the claim; however, this upload does not update the status of the claim. The appropriate EDI transaction must be submitted in order to reflect the correct claim status in WCAIS.
 
USE OF INVALID SOCIAL SECURITY NUMBERS
 
Use of Social Security Numbers (Data Element #DN0042) is required, if known, in all filings with the bureau, the Workers' Compensation Office of Adjudication, and the Workers' Compensation Appeal Board.
 
If the Social Security Number is not known, the Employee ID Assigned by Jurisdiction (Data Element #DN0154) should be used. Claim administrators should contact the bureau at 1-800-482-2383 (long-distance calls inside PA) or 717-772-4447 (local and outside PA) for the Employee ID Assigned by Jurisdiction and use it when submitting the FROI 00. NOTE: Employee ID Assigned by Jurisdiction is a numeric field, and no alpha characters will be accepted.
 
If the Employee ID Assigned by Jurisdiction is used and the Social Security Number becomes known, the claim administrator must file a FROI 02 (Change) transaction to update the record.
 
Thank you for your attention to these matters. Your cooperation in adhering to these guidelines will help to reduce the number of incorrect conversions, ensure accurate data in WCAIS, encourage uninterrupted submission of EDI transactions and help us to better serve you overall.
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