Mastering Electronic Data Interchange Payments

Electronic Data Interchange

Payments

Trainers:



Gordon Davis



Paul Fortier

Additional WCB Staff:

Kimberlee Barriere, Deb Morton,

Carrie Pelletier

2



Introduction to EDI



Fundamentals of EDI

Reporting



EDI and Claims Handling



EDI Review and Case

Study

3

At the conclusion of this training

At the conclusion of this training

session, you should be able to:

session, you should be able to:

1.

Name the three basic steps in EDI

Name the three basic steps in EDI

reporting

reporting

2.

Recognize common EDI acronyms

Recognize common EDI acronyms

and define common EDI terms

and define common EDI terms

3.

List the transaction processing

List the transaction processing

documents

documents

4

At the conclusion of this training

At the conclusion of this training

session, you should be able to:

session, you should be able to:

4.

Provide examples of legal/business

Provide examples of legal/business

requirements vs EDI reporting

requirements vs EDI reporting

requirements

requirements

5.

Explain the fundamentals of

Explain the fundamentals of

transaction editing and the AKC

transaction editing and the AKC

report

report

5

A Brave New World



Electronic Data Interchange or EDI 

is an

electronic communication system that

provides standards for exchanging data

via any electronic means.



Reduces, or in some cases, eliminates paper

reporting.



Allows jurisdictions to collect more data to

satisfy statutory and regulatory obligations.

7



The goal for EDI in workers’

compensation is the seamless processing

of information from its initial reporting

source to a jurisdiction.



IAIABC EDI standards cover the

transmission of Claims, Proof of

Coverage, and Medical Bill Payment

information through electronic reporting.

8



The standards are developed and

maintained through a consensus process

that brings together volunteers from

jurisdictions, claim administrators,

vendors, and others interested in

participating.



IAIABC EDI Claims Release 3 is the latest

national standard for reporting claims

information to jurisdictions.

9



While the IAIABC has developed a

national standard for use by each of

the jurisdictions, jurisdictional

requirements vary widely.

You must be familiar with the

jurisdictional requirements for each of

the states that you handle claims for.

10

§152. AUTHORITY OF BOARD; ADMINISTRATION

2-A. Electronic filing rulemaking.  The board shall

adopt rules requiring the electronic filing of

information required by this Act and by board

rule.



Consensus-based rulemaking.



Standards and procedures for

implementation.



Specific forms required to be filed.



Testing required before adoption.

11



Board Rules and Regulations Chapter 3

contains vital information regarding data

element definitions, formats, values, and

processing rules that may differ from

those of IAIABC due to statutory or

regulatory requirements.



The rules also outline the distribution

requirements for forms filed via paper

and EDI.

12

Legal

  - John Rohde 

John.Rhode@maine.gov

Technical

 – Paul Fortier 

Paul.Fortier@maine.gov

and/or Brad Howard 

Brad.Howard@maine.gov

Audit

– Gordon Davis 

Gordon.Davis@maine.gov

Claims

 -

 Deb Morton 

Debbie.Morton@maine.gov

13



Step 1: 

Trading partner relationship

established



Claim administrator completes and

submits Trading Partner Documents to the

jurisdiction



System test is performed between the CA

and the Jurisdiction



CA is approved for Production

environment

14



Step 2

: Claim administrator sends a report

to the jurisdiction



Defined by the jurisdiction and the EDI

standard via the Event Table and Element

Requirement Table



Based on a claims-handling activity (e.g.

decision to pay or deny)

15



Step 3

: Jurisdiction acknowledges success or

failure of the report



Based on the Edit Matrix Table



TA = transaction accepted



TR = transaction rejected



It is critical that adjusters know whether

a transaction has been accepted.  For

instance, if a denial transaction is

rejected, there exists the potential for a

14-day violation

16

A Brave New World



Trading Partner

:  

An entity that has entered

into an agreement with another entity to

exchange data electronically.



Trading Partner Agreement

:  

A set of

expectations and responses between two

entities exchanging data electronically.



These expectations include, but are not limited to,

what transactions to send, what format to use, what

data elements to include, when and where data

elements are to be sent, and testing to be performed.

18



Data Element

: 

A single piece of information,

e.g., Date of Injury, Date of Birth, etc. Data

elements are:



Defined



Assigned a Data Element Number or DN



Assigned values or codes, if applicable



Assigned valid applicable edits



Assigned a data format



Record

: 

A group of related Data Elements to

form a transaction.

19



Transaction

: 

Can consist of 1 or more records

to communicate a claim event. Each

Transaction Type is contained in a batch, which

is preceded by a Header Record and concluded

with a Trailer Record.



Transmission

: 

Consists of one or more batches

sent or received during a communication

session.

20



The 

FROI 

is a record sent to the

jurisdiction to comply with the

jurisdiction’s 

First Report of Injury

requirements.



The 

SROI

 is a record sent to the

jurisdiction to comply with the

jurisdiction’s 

Subsequent Report of

Injury 

requirements.

21



The 

FROI

 record is identified by the

Transaction Set ID 

148

 (fixed length

record). This record must be paired with

its companion record 

R21

(variable length

record) to complete the FROI transaction.



The 

SROI

 record is identified by the

Transaction Set ID 

A49

 (variable length

record).  This record must be paired with

its companion record 

R22

 (variable

length record) to complete the SROI

transaction.



.

22



A 

Periodic report

 is a type of SROI

transaction that must be filed at regular

intervals (monthly, quarterly, sub-

annual, annual, etc.).



The State of Maine only requires one

periodic report (MTC SA).  This report is

required every 180 days until a “FN” is

filed (think WCB-11 Statement of

Compensation Paid).

23



The

 Maintenance Type Code or

MTC is a 

code defining the specific

purpose of individual records within

the transaction being transmitted.



In other words, the MTC is the type of

FROI  or SROI transaction being

transmitted, e.g. Original FROI, Initial

Payment, Partial Denial, etc.

24



The

 Benefit Type Code or BTC 

is a

code identifying the payment being

made.



The 

Other Benefit Type Code or

OBT 

is a code identifying

miscellaneous benefits not otherwise

specifically defined with a Benefit

Type Code.

25



The 

Acknowledgement Record or

AKC 

is a transaction returned by the

jurisdiction as a result of a report

sent.  It contains enough data

elements to identify the original

transaction and any technical and

business issues found with it.

26

27

28

Standard Elements:



IA Implementation Guide



ME Implementation

Guide



Trading Partner Tables

29

The 

IAIABC EDI Implementation Guide

For Claims

 includes information regarding

the following:



Jurisdiction EDI Preparation



Technical Documentation and

Acknowledgment Scenarios



Business/Technical Process Rules



Business Scenarios



Data Dictionary

30

The 

MWCB EDI Implementation Guide For

Claims

 includes information specific to

processing Maine workers’ compensation

claims including:



Closure requirements



Paper filing requirements



Consent Between Employer and

Employee



21 Day Notice Requirements



Lump Sum Settlements



Permanent Impairment

31

The Data Dictionary

 is Section 6 of the IA

Implementation Guide.  It contains the IAIABC

data element definitions, formats, values, and

processing rules.



Note: some definitions are dependent on

jurisdictional requirements (see the 

MWCB

EDI Implementation Guide For Claims

 .



Example - Initial Date Disability Began

DN0056: Per Board rules, when an

employee is paid 1/2 day or more wages

on the date of injury, the date of injury

will not be considered a day of incapacity.

32

Standard Tables:



When

 to report = Event Table



What

 to report = Element

Requirement Table



How

 jurisdiction validates the data

= Edit Matrix (actually consists of 5

separate tables)

33

The Event Table

 provides the information

necessary for the claim administrator to

understand the jurisdiction’s EDI reporting

requirements.



It relates EDI information to claim events

and under what circumstances and when

the claim administrator must report

those events.

34

Report Triggers

 – these are events in the life

of a claim that cause a particular report to

be filed with the jurisdiction (payments,

denials, changes, suspensions,

reinstatements, closure, etc.)



Each report trigger has a corresponding

maintenance type code (MTC) which is a

code defining the specific purpose of

individual records within the transaction

being submitted.

35



Basically the old paper forms are

replaced by EDI reports that are

identified by MTC.



You will need to learn the MTC

codes the same way you learned the

paper form numbers.



The Event Table provides a form to MTC

crosswalk.

36

Non-payments:



04



CD



PD

Initial Payments:



AP



EP



IP

One-time Payments:



PY

Suspensions:



S1



S2



S4



S5



S6



S7



S8



S9



SD

37

Changes to Benefits:



CA



CB

Resumption of Benefits:



ER



RB

Periodic Reports:



SA

Claim Closure:



FN

38

Refer to your 

Event Table

:



Which MTC(s) correspond to the

following event triggers:



Denial of a claim (full v. partial)



Initial payment of a claim



Suspension of benefits (EE RTW)



Lump sum settlement

39

The Element Requirement Table

 is

designed to let claim administrators know

the jurisdiction’s business data element

requirements.



Lists the data elements for each electronic

report (i.e. each MTC) as required by statute,

rule, or current version of EDI and includes

the condition that triggers a conditional data

element be sent to the Board.

40



Every piece of data is numbered and

represented by a DN.



The 

Data Dictionary

 contains all the

data elements along with their

definitions, formats, values, and

processing rules.



The Quick Code Reference List

identifies the valid code values for each

data element.

41



In Maine, the requirement codes generally fall

into one of the following:



Fatal (F) or Fatal Conditional (FC)



Mandatory (M) or Mandatory Conditional (MC)



If available (IA)



Not applicable (NA)



Exclude (X)



These data requirement codes also tell you how

critical each data requirement is for each report

type/MTC.

42

Variable Segments:



Permanent

Impairments



Death

Dependent/Payee

Relationships



Benefits



Payments



Other Benefits



Benefit ACR



Recoveries



Reduced Earnings



Concurrent

Employers



Full Denial Reason

Codes



Denial Reason

Narratives



Suspension

Narratives

43

Refer to your 

Element Requirement

Table

:



Which data element on the A49 record

is required on an IP transaction, if

available on an AP transaction, and

excluded from an EP transaction?



What condition triggers the

requirement for the Employee Tax

Filing Status Code (DN 158)?

44

Report indemnity benefits:



Currently being paid (“Event”)



Have been paid (“Sweep”)

45

“Event” Benefit Segment



MTCs: 02, AP, CA, CB, EP, ER, IP, PY

(Benefit Type Codes other than 5XX), RB,

S1-S9, SD

“Sweep” Benefit Segment



MTCs:02 (if benefit segment data is not

changing), 04, CD, PD, FN, PY (Benefit Type

Codes 5XX), SA

46

When a benefit type is being

affected (i.e. starting, changing

from/to, or suspending) or

when reporting a lump sum

payment with a Benefit Type

Code other than 5XX, the MTC

is sent in the benefit segment of

the affected benefits.

47



If the claim administrator has paid any

indemnity benefits, every SROI

transaction must contain a “Sweep”

Benefit Segment for every benefit type

paid.



Previously reported benefits must be

reported on each subsequent SROI

transaction unless explained via certain

codes.

48



A “Sweep” Benefit Segment is sent with

any “Event” Benefit Segment if a

different Benefit Type Code has

previously been paid and is not part of

the “Event” that is currently being

reported.



The segment is a snapshot of benefits

that have been paid on the claim at the

time of the report.

49



Segment includes: Benefit Type Code,

Benefit Period Start Date, Benefit Period

Through Date, Benefit Type Claim Weeks,

Benefit Type Claim Days, Benefit Type

Amount Paid



Segment does not include: MTC (that would

imply an “Event”), Gross Weekly Amount,

Gross Weekly Amount Effective Date, Net

Weekly Amount, Net Weekly Amount

Effective Date, Benefit Payment Issue Date

50

The Edit Matrix Table

 tells the

claim administrators which data

elements have edits applied to

them and provides the standard

error messages used in

association with those edits.



The Edit Matrix Table actually

consists of 5 separate tables.

51

52

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53

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54

The Acknowledgment Report

(AKC)

 conveys the status of the

transaction to the sender along

with applicable error messages

for specific data elements.



Reminder: the sender may or may not

be the claim administrator.

55

When the rule is adopted, transactions

will be either accepted (TA) or rejected

(TR), however, even accepted

transactions may require action by the

claim administrator based on any

business issues found within the

transaction.



These business issues are listed in the

AKC report by data element  along

with the edit number and text

description of the edit.

56



The Edit Matrix Table and

Acknowledgement Report

are for the “techies”?



As long as a transaction is

accepted, that is all I need

to care about?

57

A Brave New World



Certain claim adjusting functions or

business events trigger a reporting

requirement to the jurisdiction.



These triggers are identified on the

jurisdiction’s Event Table.



In many cases, EDI replaces paper

reporting.

60



Many claims management systems will

automatically send EDI reports to the

jurisdiction based on the jurisdiction’s

filing requirements.  In other words, a lot

of EDI reporting happens “behind the

scenes”.



However, in some cases a paper filing is

required BEFORE an EDI transaction can

be sent.

61

Paper forms still filed with the Board:



WCB-2

 Wage Statement



WCB-2A

 Schedule of Dependent(s) and

Filing Status Statement (pre 1/1/13 dates of

injury)



WCB-2B

 Fringe Benefits Worksheet



WCB-4A

 Consent Between Employer and

Employee



WCB-7

 Certificate Authorizing Release of

Unemployment Information

62

Paper forms still filed with the Board:



WCB-8

 Certificate of Discontinuance or

Reduction of Compensation Pursuant to

39-A M.R.S.A. §205(9)(B)(1)



WCB-10

 Lump Sum Settlement



WCB-231A

 Employee's Return to Work

Report Pursuant to 39-A M.R.S.A.

§205(9)(B)

63

Paper forms that must be filed with the

Board before the claim adjusting

activity/report trigger:

•

WCB-4A

 Consent Between Employer

and Employee



WCB-8

 Certificate of Discontinuance or

Reduction of Compensation Pursuant to

39-A M.R.S.A. §205(9)(B)(1)



WCB-10

 Lump Sum Settlement

64



When there is a voluntary payment

of a retroactive closed-end period,

change in a benefit amount, change

in benefit type, or suspension of

benefits as a result of a consent

between the employer and

employee, the WCB-4A form must

be executed and filed in accordance

with Board Rules.

65

Payment is due and the PY, CA, CB,

and/or S9 transaction(s) must be filed

within 10 calendar days from the date

that the form is signed by all the

parties.



Best practice

: Insurer representative

signs the form last so the insurer knows

when the form is effective and the

payment is due.

66

In all circumstances other than the following

,

the employee’s benefits may not be reduced or

discontinued without 21 days notice  in

accordance with Title 39-A, Section 205(9)(A) and

Board Rules.



Employee Dies (not as a result of the injury)



Board Decision



Statutory Offset(s)



Receipt of Actual Wages



Actual Return to Work (Employer of Injury)

67



When there is a change in a benefit amount

(CA), change in benefit type (CB), or

suspension of benefits (S1-S8) that requires 21

days notice in accordance with Title 39-A,

Section 205(9)(A), the WCB-8 form must be

completed and filed in accordance with statute

and Board Rules prior to the transaction.

Transactions must be received within 14 days

of the effective date of the change or

discontinuance of benefits.

68



The employer/insurer, employee,

and/or attorney files the Lump Sum

Settlement form (WCB-10) to request

approval of a lump sum settlement.



 Payment is due and the PY

transaction must be filed within 10

calendar days from the date that the

form/order is signed by the Hearing

Officer.

69



Employee sprains his pinkie finger

while performing his auto mechanic

job. Employee is treated at the local

emergency room and returned to

work the same day. Costs incurred

at the local emergency room for

x-rays and treatment are $380.

70

Using the 

Event Table

:



Is the injury required to be reported to

the jurisdiction?



Does your answer change if the claim is

denied?



Does your answer change if the

medicals are being paid voluntarily but

the adjuster is denying a request for

physical therapy?

71



Employee pulls a muscle in his

back while performing his

landscaping job. Costs incurred

at the local emergency room for

x-rays and treatment are $450.

Employee returns to work after 2

days out.

72

Using the 

Event Table

:



Is the injury required to be reported to the

jurisdiction?



What additional report may be required?



What if after a FROI is filed with ME you

learn that the employee lives in ME but

the injury actually occurred in NH and

the employee elects to file a claim in NH?

Is there more than one option?

73



Employee is killed as a

result of a fall from a roof

while removing ice and

snow.  The employee was

single with no eligible

dependents.

74

Using the 

Event Table

:



Which reports must be submitted?



How does your answer change if the

employee has a dependent eligible for

benefits?



How does your answer change if the

employee died of a heart attack while

shoveling the roof rather than a fall?

75

76

Acknowledgements include the following

information:



Date and time the jurisdiction processed the

transaction



Jurisdiction assigned claim number



Claim administrator claim number



MTC and MTC Date



Acknowledgement code: TA or TR



Edits (data element and edit description)

77

The transaction did not meet the

jurisdiction’s technical filing

requirements therefore the transaction

was not accepted.



The error(s) must be resolved and the

transaction resubmitted.



Remember

: Compliance and

penalties may be at risk.

78

The transaction met the jurisdiction’s

technical filing requirements therefore

the transaction was accepted.



There may however be business

issues identified within the

transaction that need to be resolved.



Remember

: Compliance and

penalties may be at risk.

79



Regardless of the format (paper v.

electronic), reports must be sent in the

correct order.



The Sequencing edits (component of the

Edit Matrix Table) ensures that certain

transactions cannot be sent before other

transactions.



Transactions sent out of sequence cannot

be processed and the transaction will

reject.

80



Claim administrator reported a lost

time injury by sending a FROI 00.

During the investigation, the

adjuster discovers that the employee

was engaged in horseplay and

decides to deny the claim by sending

an FROI 04.  The FROI 04 was

rejected by the jurisdiction.

81

Using the 

Event Table

:



Why did the FROI 04 reject?



What needs to be done to

deny the claim?

82



Claim administrator denied a claim

by sending a FROI 04.  After

receiving an updated M-1 report, the

adjuster decides to pay the claim

voluntarily and sends a SROI IP.

The SROI IP was rejected by the

jurisdiction because DN0298 was left

blank.

83

Using the 

Element Requirement

Table

:



What is DN0298?



When is DN0298 required?



What information should be

included in the payment

narrative (DN0233)?

84



Claim administrator sent a FROI 00

transaction to report a lost time injury

and then filed a SROI IP transaction

when indemnity payments began.  After

a brief return, the employee went back

out of work and the claim administrator

sent a SROI RB transaction to report the

resumption of indemnity benefits.  The

RB transaction was rejected.

85

Using the 

Event Table

:



Why did the RB transaction

reject?



What needs to be done to

correct the error?

86



Building a new system?



Adapting an existing system?



Utilizing a vendor system?

87



Employees



Employers



Insurers



Trading Partners



Other Vendors



Etc.



Claim Administrators



Claim Handlers



Compliance Specialists



Information

Management

88



“Front End” refers to what the end

user sees and interacts with.



“Back end” refers to the computer

software logic and applications that

interpret end user interactions.

89

What is “legal”, what is “technical”

and what is “operations”?



Who is responsible for overseeing an EDI

vendor relationship?



How will electronic reports be triggered?

Will reports auto-trigger or do they have to

be triggered manually?



Who is responsible to map the jurisdiction’s

requirements to the claims-handling

process?

90

What is “legal”, what is “technical”

and what is “operations”?



Why can’t I see the applicable DNs in my

claims-handling system(s)?



Who receives the AKC report and who is

responsible to monitor compliance and

“fix” errors?



Who is responsible for form distribution?



Etc.

91

Effective EDI claims handling is a

successful partnership among legal,

technical and operations personnel.

92



An acquired claim is any existing claim

(open or closed) taken over from a prior

claim administrator.



The first filing on all acquired claims

must be either a FROI AQ or a FROI AU.



Payment information received from prior

claim administrator, use OBT codes:



430 – unallocated prior indemnity benefits



440 – unallocated prior medical benefits

93



If the jurisdiction rejects the AQ

transaction because it can’t find a match

in its database, what report must the

claim administration file on the acquired

claim?



What MTC must the acquiring claim

administrator file to report it first

indemnity payment on the acquired

claim?

94

A “full” denial (FROI 04 or SROI 04) on a

medical only (Claim Type Code M),

notification only (Claim Type Code N), or

became medical only (Claim Type Code B)

claim DOES NOT deny a future claim for

compensation.



In other words, if a claim becomes Lost

Time/Indemnity (Claim Type Code L), you

must file a SROI 04 or SROI PD to dispute the

claim for compensation.

95



A legacy claim is any claim (regardless whether

open or closed) that already exists in the WCB

database and has been assigned a JCN or WCB#

prior to the implementation of claims EDI

reporting.



When a SROI is due based on the Maine Workers’

Compensation Board Event Table contained in the

Appendix of this rule and no electronic reports

have been filed yet, the trading partner may

submit the initial electronic transmission without

regard to sequencing edits, data elements not

previously required on paper forms and without

regard to form filing penalties.

96



Paper forms – distribute to: Worker’s

Compensation Board, employee, and

employer.



Electronic reports – upon acceptance

(TA), certain transactions will return a

PDF form that must be distributed to the

employee, employer, and provider (if

applicable) within one business day of

the form’s transmission to the claim

administrator.

97

A Brave New World

1.

Name the three basic steps in

Name the three basic steps in

EDI reporting

EDI reporting

2.

Recognize common EDI

Recognize common EDI

acronyms and define common

acronyms and define common

EDI terms

EDI terms

3.

List the transaction processing

List the transaction processing

documents

documents

99

4.

Provide examples of

Provide examples of

legal/business requirements vs

legal/business requirements vs

EDI reporting requirements

EDI reporting requirements

5.

Explain the fundamentals of

Explain the fundamentals of

transaction editing and the AKC

transaction editing and the AKC

report

report

100