EDI - Alerts/Updates
10/2015: Upcoming December WCAIS EDI Enhancements
Please note the WCAIS updates and enhancements scheduled for December 2015 and make sure that your system is updated accordingly. These updates will improve EDI transaction acceptances and will optimize the effectiveness and cost savings of your claims administration process ahead of the unveiling of the Forms Solution product, scheduled for June 2016. Forms Solution will enable you to complete the most common LIBC forms from your EDI transactions and eliminate the duplicate effort of preparing your forms separate from the EDI submissions. Look for more information on Forms Solution coming soon!
We are adding information to the Transaction Accepted (TA) Acknowledgement Report (ACK) that you receive when a transaction is accepted. The ACK will provide the WCAIS claim status (Closed, Open, Comp Denied, Medical Only, Suspended etc…) after the transaction has accepted. In addition, if the claim is Temporary, the system will provide the potential date that the TNCP will convert to an NCP (barring stoppage and denial or acceptance).
As announced earlier this summer, the Agreement to Compensate code will be required on the SROI PD. The update will allow the correct LIBC form to be generated with accurate information when Forms Solution goes live in June 2016. Be certain your operating system has been updated to identify the Claim Type code as mandatory, so that the proper form will be created and auto-filed with the Bureau before being returned to you for service upon the parties.
SROI PY will now accept on a closed or suspended claim (a claim on which a SROI Sx or SROI FN was received) to report an outstanding bill or report a last payment without having to re-open the claim and will eliminate the need for the current SROI 02 work-around. Upon receipt of the SROI PY, no change will be made to the claim status in WCAIS, so you will not need to re-file the SROI Sx or SROI FN to suspend or close the claim again.
09/2015: Upcoming EDI Code Changes
In March 2016 there will be four coding changes for which you need to update your EDI coding in order to prevent a rejection. These changes are necessary for completion of the Forms Solution project, which will allow elements provided on EDI transactions to generate LIBC forms starting June 2016.
Claim Type code (DN0074) 'M' (Medical Only) will no longer accept on a SROI IP to match IAIABC standard.
Starting in March, submission of a SROI PY with Claim Type code 'M' will be the only way to report the EDI equivalent of a medical-only NCP, TNCP, or Agreement. The IP is the EDI equivalent of an indemnity NCP or TNCP, whereas the PY is the EDI equivalent of a medical-only NCP or TNCP, so the IP shouldn't come into play with a medical Claim Type code. When we go live with Forms Solution, we want to make sure the correct form is generated with the correct fields.
Claim Type code will become mandatory on the SROI AP, to match the SROI IP.
The AP is the first indemnity payment reported on a claim after a new TPA has acquired it, so the standards we use for the IP should be the same on the AP.
The Initial Date Disability Began (DN0056) will be mandatory on the SROI IP and mandatory conditional on the SROI PY (DN0056 will be required if the Claim Type code on the PY is 'I' for Indemnity).
We will be using this date to populate the NCP and TNCP in Forms Solution, in addition to using the field to calculate the 90-day temporary period for an indemnity claim. If we don't have it, we cannot accurately populate the forms or determine when an indemnity claim will convert.
Average Wage (DN0286) will be mandatory on the SROI AP, IP and mandatory conditional on the SROI PY (DN00286 will be required if the Claim Type code on the PY is 'I' for Indemnity).
This field will be used to populate the Average Weekly Wage field on an indemnity NCP and TNCP generated by an EDI transaction. This field should be pulled from the Average Weekly Wage field on the Statement of Wages (LIBC-494C).
07/2015: Upcoming EDI Code Change
Effective September 2015, Claim Type code will be mandatory on all FROI transactions. You must update your systems to prevent rejections caused by a missing Claim Type code.
In April we announced we would be mandating the use of the Claim Type code on all FROIs to improve reporting in WCAIS. The update will improve the accuracy of each claim and will allow the bureau to provide the community with more accurate figures on how many indemnity and medical-only claims occur in Pennsylvania per year.
05/2015: Using the Correct FEIN: Why is this so important?
In February 2014, BWC created a new section to address data quality issues. The new unit, the Data Quality Section, researches and updates profile discrepancies for claimants, employers, insurers and TPAs in WCAIS, along with other data matching elements that are used to identify a claim.
The Data Quality Section, along with the EDI resource account, is seeing an increased number of incorrect employer FEINs being reported in the system. When the FEIN is entered incorrectly, the wrong party gets attached to the claim on the Interested Parties tab. WCAIS uses the information on the Interested Parties tab to generate correspondence and hearing notices and in the interactive Forms Generation and Forms Preparation features on the Actions tab of the claim. The use of an incorrect FEIN may result in unintended litigation expenses when the wrong party is named in a workers' compensation proceeding before a WCJ.
Please make certain to verify the employer FEIN before submitting an EDI transaction to BWC. If you are uncertain of the FEIN for the company, or if the company is out of business and you don't have the FEIN, please contact the EDI resource account at RA-CMDEDI@pa.gov
with the employer's name and address. The EDI section will research the employer and provide you with either the correct FEIN or a placeholder FEIN to use in future EDI transactions. To prevent confusion and inaccurate data in WCAIS, do not make up your own placeholder ID. If there is an existing claim in WCAIS with an incorrect employer listed, please e-mail the EDI resource account with the JCN and the name of the correct employer (and its address) and we will research this as well. If WCAIS has incorrect information, we will correct it; however, if WCAIS is accurate, we will provide you with the correct FEIN to use for that employer.
11/2014: WC insurers, self-insured employers and third party administrators are urged to pay particular attention to the issues noted below.
INADVERTENT SUBMISSION OF A DOCUMENT
If you inadvertently upload a document to the Actions tab of a claim in WCAIS or use the forms generation feature to submit a document in error, please contact our EDI unit at RA-CMDEDI@pa.gov
. Once a document is filed with the bureau, it is part of the legal record, so we cannot delete a document from the claim. However, if the document type (NCP, NCD etc…) doesn’t match the form submitted, or if the claim-specific data (claimant name, DOI, or SSN) doesn’t match the claim it was uploaded onto, we will re-index the document to the correct document type or claim. If both the document type and claim-specific data matches the form and claim it is housed in, we will not delete or re-index the document. In this situation, you must upload a written explanation stating that you created the document in error. You must then send this document to the claimant as well as upload the document to the Documents and Correspondences tab of the claim in WCAIS as a miscellaneous document. To make the purpose of the document clear, it is helpful to include a brief sentence to describe the intent of the document.
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:
The wrong EDI (Electronic Data Interchange) transaction is submitted, or
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.