Electronic Data Interchange FAQs

  1. Q. What Is Electronic Data Interchange (EDI)?
    A. EDI is the computer-to-computer exchange of standard business data using telecommunications for workers' compensation. In exchange, each time the jurisdiction receives an electronic report from one of its trading partners, it returns an electronic acknowledgment of the receipt of the report to the sender. The electronic acknowledgment lets the sender know whether the report was accepted and entered into the jurisdiction's database, or was rejected, and therefore needs to be corrected before it is resubmitted.
     
  2. Q. What are the benefits of EDI Release 3?
    A. All stakeholders within the workers' compensation community will benefit. Benefits obtained by reporting claims through EDI include: Reduction of paperwork and associated savings, one time data entry, reduced errors, improved error detection, on-line data storage, faster management reporting, automatic reconciliation of reports, reduced clerical workload, improved productivity without increasing staff, reduced paper usage, rapid exchange of business data, elimination of mail charges, courier services, improved production cycle, uniform standards, and communications with all trading partners, ability to compare data in WCAIS with other jurisdictions.
     
  3. Q. Does Pennsylvania have a list of crossover documents available for reference?
    A. The Pennsylvania EDI crossover documents can be located at www.dli.state.pa.us/WCAIS and click on the Crossover tab on the left navigation bar.
     
  4. Q. I am in the process of filling out the transmission profile for my organization and I have some questions:
    1. Do I have to complete and send a form if my organization presently is using EDI with the state of PA?
    2. If yes to the above, are there instructions as to what information is mandatory and what information PA is looking for? Specifically, I am not sure what to enter for the following fields:
    a. Profile ID
    b. Description
    c. Transaction Information/Format for both FROI and SROI
    d. Transaction Information/Acknowledgement Information for both FROI and SROI
    e. Transmission Cut-Off Time
    A. 1. Yes, we are requiring all trading partners to file the Trading Partner Agreement and corresponding documents found at www.dli.state.pa.us/WCAIS, and click on the PA EDI Claims Implementation Guide link.
    2. Instructions regarding transmission requirements will also be found in the Implementation Guide.
    a. Profile ID – For office use. Leave blank.
    b. Description – Is already prefilled with "Release 3 BWC Transmission Requirements"
    c. Transaction Information/Format for both FROI and SROI – EDI
    d. Transaction Information/Acknowledgement Information for both FROI and SROI – EDI and All
    e. Transmission Cut-Off Time – Leave blank.
     
  5. Q. We are currently reporting FROI's & SROI's for claims that we are handling. We will be insuring new WC business but the claim handling and reporting will be handled by another claim administration company. Would the Trading Partner Agreement have to be updated to include the added claim administrator? Who be responsible for updating the trading profile, the claim administrator who would actually be reporting the transactions or the insurer?
    A. The claim administrator responsible for sending the transactions is responsible for updating the trading partner profile to include the new insurers. The following information is required:
    1. Trading Partner Name:
    2. Trading Partner FEIN:
    3. Insurer Name:
    4. Insurer FEIN:
    5. Insurer Bureau Code:

EDI Release 3 Technical Questions

 
 
 
  1. Q. I submitted an LIBC 495 to you but you sent it back indicating you needed a FROI 00. Why?
    A. The FROI 00 is required in order to create a claim in WCAIS. We cannot upload and attach the LIBC form if there is no claim to attach it to. Once you have submitted the FROI 00, and it is accepted, you may then submit the LIBC forms as needed.
     
  2. Q. How will the claim administrator communicate or update Body Part Codes on an IP or SROI 02 when there are multiple body parts being paid with or without a PA agreement "contract"?
    A. BWC requests that claim administrators use the Permanent Impairment Body Part Code field to report multiple body parts. The IAIABC standard allows for multiple body parts to be reported using this same field multiple times in the same EDI file. Your transaction partner should be able to assist further on how they want you to provide this data.
     
  3. Q. If our first notice of a claim is a Claim Petition, would our first EDI transaction be a FROI 04?
    A. It depends on the scenarios, it could be either a FROI 00 or a FROI 04. Please refer to the Implementation Guide FROI Event Table to determine which FROI to submit and remember to include the JCN in the first transaction to attach it to the existing claim.
     
  4. Q. Please clarify the EDI R3 transaction that should be used to update the Nature of Injury Code or the Part of Body Injury Code or Accident/Injury Description Narrative. Should the FROI 02 transaction be used to update these fields?
    A. Yes, the FROI 02 may be used to update the party and injury fields.
     
  5. Q. We have accounts where the employer pays the benefits to the injured worker, but we reimburse the employer. Therefore, we do not have control over the timing of the payments. Should we code them as employer paid and set the Employer Paid Salary in Lieu of Compensation Indicator to Yes?
    A. Yes, you may set the Employer Paid Salary in Lieu of Compensation Indicator to Yes.
     
  6. Q. What triggers the conversion of a temporary claim in WCAIS? I submitted a SROI PD but the claim remained temporary. What did I do wrong?
    A. WCAIS automatically converts a claim if no EDI transaction is received to accept or deny liability for the claim within the 90 day temporary window (DOI is 90 day begin on date for medical only and Initial Date Disability Began is 90 day begin on date for indemnity). If you are using the PD to stop conversion (and to make the claim medical only), you will need to use an agreement to compensate code of "L". "W" is only for temporary claims.
     
  7. Q. Regarding legacy claims, do I have to do a FROI first then a SROI on all my open claims?
    A. There are two scenarios. The first document we require on a claim that was not previously reported to the bureau is a FROI 00 or FROI 04. On all open legacy claims, a FROI or SROI UR must be filed before any other transaction will be accepted per the EDI Claims Release 3 Migration Strategy document in the PA Implementation Guide.
     
  8. Q. When do you expect companies to have all SROI UR's caught up? Do you have a deadline that all companies must have the old legacy claims filed with a SROI UR?
    A. PA does not have a mandated deadline for when the SROI URs must be caught up. However, the system will not accept any other transactions until the UR transaction is received.
     
  9. Q. Which set of ZIPs should we use to program as DN0014 on our transaction records (actual physical or mailing)?
    A. Mailing address
     
  10. Q. If an R3 EDI transaction is sent to PA, will all the R3 edits be applied on the entire file at that time, and identified issues be included in the acknowledgement?
    A. Transactions that fail at any step are rejected, and the respective error code(s) are provided in the acknowledgement (ACK) file. The TR transaction is not processed further. For example, if the Claim Administrator FEIN and SSN # are mandatory fields and the transaction does not include the Claim Administrator FEIN and SSN, the transaction will be rejected and all the error codes will be shared at once. This is as per the IAIABC standards mentioned on page 49 of the IAIBC Implementation Guide. PA is processing the transactions in the following order.
    1. Sender/Claim administrator relationship
    2. Record relationship
    3. Fatal technical/Mandatory requirement
    4. Variable segment rules:
    5. Match data/duplicate transactions
    6. Transaction sequencing
    7. Check if JCN and DOI and SSN in PA database matches with the data provided in the EDI file
    8. Check if the claim administrator and insurer FEIN provided in the file matches with the data provided in the EDI file
     
     
  11. Q. Regarding the benefit segment in SROI 02 transactions, if no benefit segment data is being changed as part of a SROI 02 transaction, and the benefit segment MTC is blank, does it matter what other data elements are included in the benefit segment?
    A. No
     
  12. Q. Concerning the A49RE, when the claim administrator reduces benefits because the employee returns to work earning less than their pre-injury wage entitling them to temporary partial benefits, is PA expecting the gross light duty wages the employee is earning on the RE transaction?
    A. Yes
     
  13. Q. Do we send an RE transaction each time we pay the employee their partial wage if it is an ongoing weekly type of a payment scenario?
    A. You need do it that way only if there are changes. Or you may sweep the data periodically to report several changes at one time just as you would have in the Further Matters Agreed Upon section of a Supplemental Agreement.
     
  14. Q. Sometimes we are asked to make a payment on a flat denied claim. How is this handled and will this generate an error in the system.
    A. If the claim is still in denied status you only need to file a SROI 02 transaction to report the payment that was incurred prior to the issuance of the denial. You should not use an Agreement to Compensate code so that the claim status is not changed.
     
  15. Q. We are an insurance carrier in the process of having our claims service providers/third party administrators complete the required EDI forms (Trading Partner Agreement; Transmission Profile; Claim Administrator Address List; and, Administrator ID List) – since they are the entities that actually file the First Report of Injury and pay the claims. However, I do not see on the forms where the claims service providers/third party administrators can indicate the various insurance companies they represent. Please advise whether an attachment to one of the forms identifying the insurers should be included with the documents that are completed by the claims service providers/third party administrators.
    A. The Claims Administrator ID List is used by your TPA to identify the companies on whose behalf they are filing. They list Company Name, Bureau Code and FEIN for those companies. Your TPA will identify by name and FEIN the insurance carrier for whom they are submitting the claim information (Form/EDI Transaction). Be sure your TPA has included your information on these required documents.
     
  16. Q. Can the FROIs and SROIs be sent in the same file or do they have to be sent separately?
    A. BWC requires FROI and SROI transactions to be sent in separate files.
     
  17. Q. If we file the FROI 01 (Cancel) in error, do we need to start over with the FROI or can we pick up where we left off?
    A. Yes, you may pick up where you left off if you canceled the claim in error.
     
  18. Q. We have claims where our investigation indicates a denial is in order, but the employer directed the employee to seek initial treatment with one of our panel providers and we therefore owe payment for the medical bill. We would pay the bill, but fully deny the claim. Will you accept a FROI 04 or SROI 04 if there are medical payments reported as part of the transaction.
    A. If you wish to report a medical bill on a denied claim you may do so on the initial SROI 04.
     
  19. Q. For claims that have been denied however money is "set aside" (reserved) on these claims, should these claims be reported as FROI originals, even if claimant did not lose time?
    A. BWC recommends submitting a FROI 04 in this scenario. The transaction will function as both an original and denial.
     
  20. Q. Should a SROI FN be filed on an MO claim if a FROI 00 was filed?
    A. Yes
     
  21. Q. What type of SROI would we file to re-open a claim?
    A. SROI RB
     
     
  22. Q. You require the county where the accident occurred on the FROI. Do you require that if it occurred in a state other then PA?
    A. Please populate "Out of State" in the county field if the accident occurred in a state other than PA.
     
  23. Q. In the Edit Matrix on the Sequencing tab, the FN must have an SX or PY. If we report a SROI PD, is the FN required?
    A. Correct, the FN would also be required when the Final Statement of Account is due after a PD was submitted.
     
  24. Q. If we are suspending under an LIBC-751, I know we have seven days from the suspension date to report the suspension. Is that seven days from the suspension effective date to get the SROI S1 transaction accepted, seven days from the suspension effective date to get the notarized NOS received by the state, or do we have seven days to get both processes completed?
    Under sections 413(c) and (d) of the Act, 77 P.S. § 774.2 and 774.3, an insurer is required to send to the department and employee the Notice of Suspension or Modification (the LIBC-751) within seven days of date of the suspension/modification of compensation. The insurer should send the Notice of Suspension or Modification (the LIBC-751) within seven days of date of the suspension/modification of compensation, and also complete the EDI transaction in that period.
     
  25. Q. Can you clarify what data you are expecting on the med only PY and when you want that PY. Will Pennsylvania accept a PY with no indemnity and no OBT $$ in advance of any monies of any kind being reported on the claim? Reporting the payment of any kind of $$ on a claim prior to it actually occurring doesn't seem to be the correct thing to do. Can you clarify?
    A. The PY may be submitted whether medical payments have been made or not if the claim administrator wants to either temporarily accept or accept liability for a medical-only claim just as you would have in the legacy system with the Medical Only NTCP or NCP.
     
  26. Q. Will a blank event benefit segment be accepted and are those the only data field requirements that can be blank? Each of your event table trigger values for PD indicate that before you can file a PD, an IP must be on file. Is that correct? Will an IP be accepted without a benefit segment included?
    A. The PD transaction does not require the benefit event segment be filled out. The accepted scenario for the PD is if you already accepted medical liability (SROI PY "L" "M"), you then temporarily accept indemnity (on the SROI IP "W" "I" that you mentioned- which would have an AWW and comp rate but not necessarily any other benefits) and now you are denying the indemnity. Since you have already accepted medical, a flat denial is no longer possible so the PD must be filed instead.
     
  27. Q. Can a CB initiate TPD benefits? Can an RE follow a CB transaction?
    A. If the claim starts out with TPD benefits, an IP is required to initiate TPD benefits, then an RE could follow if the amounts change. If the claim starts out as TTD benefits then turns to TPD benefits, an IP would be needed to initiate TTD benefits, then a CB to change to TPD benefits, then an RE could follow if the amounts change.
     
  28. Q. Can a FROI UR and a SROI UR be sent multiple times on a legacy claim?
    A. No, only one UR will be accepted per legacy claim.
     
  29. Q. We are programming the denial reason codes in our system and we are looking for confirmation that PA does not accept 1G for Traveling Employee. It's clear on the guide that the code is not statutorily valid, but we would like to verify the 1G code requirement is correct in the state guide. (B) Is it not allowed because it never occurs in PA, or can it be a possible reason to deny but a carrier must not send a FROI-04 if reason is 1G? Can we map to "Other"?
    A. Your understanding is correct. Full denial reason code 1G – Traveling Employee is not allowed. (B) PA will accept the "Other" full denial reason codes as well.
     
  30. Q. Do I need to keep my Trading Partner Claim Admin Address List updated in order to continue to pass your edits?
    A. Yes, any updates should be emailed to our EDI resource account at RA-CMDEDI@pa.gov
     
  31. Q. As a TPA administering claims on behalf of an insurer, is it acceptable to list the physical address of the TPA as the location where claims are administered and not its "home" office. Or, how does the TPA ensure that the address regarding claims information should be directed to the office location where claims are administered and not necessarily it's corporate home office/business office.
    A. The address listed should be the address that is considered the mailing address.
     
     
  32. Q. On the First Report of Injury, does PA require a DN0056 initial disability date on a death claim?
    A. BWC requires the initial date disability began in this scenario.
     
  33. Q. If, based on the initial claim coding, we report a claim to PA on the FROI 00 as lost time, and upon our investigation it turns out it is a medical only, our system will generate an 02 transaction and change the claim type. Will that be sufficient for the rest of the life of the file? Or will you expect us to continue to report on that claim?
    A. The FROI 02 will be sufficient as long as you have not already accepted liability for the lost time.
     
  34. Q. We are self-insured and are using a transaction partner to submit EDI R3 transactions. Do we have to be signed up for WCAIS. How and where can we access forms that are not required to be filed with the bureau?
    A. Even though you will be using a transaction partner, you should register to use WCAIS. This will allow you to check your claim status online 24/7. Information about LIBC forms is available in the PA EDI Implementation Guide and on the Forms link on the WCAIS website, www.dli.state.pa.us/wcais.
     
  35. Q. On a lump sum payment/settlement code (DN 0293) settlement full (SF). We want to be sure we're reporting benefit type codes accurately. Example: C & R for $100,000.00; IW will pay his attorney a fee of $20,000.00; $80,000.00 the IW Benefit Type Code; (BTC) 500 $40,000.00 (Indemnity); (BTC) 501 $40,000.00 (Medical); (BTC) 500 $20,000.00 attorney (Indemnity); total settlement reported $100,000.00. If there was a side attorney fee stipulation for a benefit that was obtained for the IW would the payment be paid and reported as an Other Benefit Type code 340?
    A. Lump sum settlements in Pennsylvania should be reported in two categories: indemnity and medical (attorneys' fees should be included in the Indemnity Benefit Type Code you are using). Amounts allocated to future medical expenses, including Medicare Set-Asides, should be reported as Benefit Type Code 501 (medical lump sum payment/settlement). The payments do not need to be broken down further for EDI Release 3 reporting because Pennsylvania doesn't report on or track anything other than indemnity and medical expenses. Please refer to our website for information regarding EDI Release 3 at www.dli.state.pa.us/WCAIS, and click on the PA EDI Claims Implementation Guide link.
     
  36. Q. What if we have not settled the claim and we are just paying an attorney fee/stipulation? For example, we owed a benefit to the claimant and because it was owed but not paid correctly, timely etc. to the claimant, the attorney has assessed a fee/stipulation on that benefit, this benefit stipulation is paid directly to the claimant's attorney not to the injured worker. This is not a benefit that the claimant receives. Do we continue to report this attorney fee/stipulation that was paid directly to the claimant's attorney under a Payment Reason Code and Benefit Type Code, or should we just report it under the OBT 340 (that can be suppressed since it is not required)?
    A. This can be reported under the OBT 340.
     
  37. Q. Can you clarify whether or not PA will be accepting FROI CO and SROI CO? Your Element Requirement Tables have some tabs that have COs.
    A. PA does not accept any CO transactions.
     
  38. Q. With regard to EDI transactions that involve agreements, I would assume that the agreement would need to be signed prior to having an agreement date to go in the Award/Order Date (DN0299). Is my assumption correct?
    A. Correct
     

Web Portal

  1. Q. How does the Web portal work?
    A. Adjusters will fill out transaction and claim specific details in designated fields on an entry screen. Carriers using the EDI Web portal must submit one EDI transaction at a time for each claim and each transaction will be processed upon receipt. You will then be able to immediately check the Search EDI Web Portal screen to see if the transaction was accepted or rejected and then, as needed, move on to the next transaction.
     
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