67

Must Be <= MTC Reason Code Date

Must Be a Valid Date (CCYYMMDD)

Must Be Alpha-Numeric (0 - 9, A-Z)

Must Be >= Date Disability Began

Must Be <= Date of Injury

Must Be >=Date of Injury

Must Be <= Current Date

EDI Claims Edit Matrix Table

All Digits Cannot Be the Same

Kansas Division of Workers Compensation
Mandatory Field Not Present

Must Be a Valid Time (HHMM)

No Match on Database

Must Be Numeric 0 - 9

IAIABC DN 0001 0002 0003 0004

IAIABC Data Element Name First Report Transaction Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction

MTC APPLIES TO:

001

028

029

030

031

033

034

035

037

039

040

041

042

0005

Agency Claim Number

0006 0007

Insurer FEIN Insurer Name

0008 0009 0010 0011 0012 0013 0014 0015

Third Party Administrator FEIN TPA Name Claim Administrator Address Line 1 Claim Administrator Address Line 2 Claim Administrator City Claim Administrator State Claim Administrator Postal Zip Claim Administrator Claim Number

0016 0017 0018 0019 0020 0021 0022 0023 0024

Employer FEIN Insured Name Employer Name Employer Address Line 1 Employer Address Line 2 Employer City Employer State Employer Postal Code Self Insured Indicator

All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original & Acquired Unallocated Denial All other FROI MTCs Original, Denial, & Acquired Unallocated Cancel All other FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated Cancel All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original Denial, Acquired Unallocated, Change, & Correction Cancel

M M M M

TR TR TR TR

TR

TR

TR* TR

TR TR TR

C M M M M M C C C C O O O O M M M M M M M M O M M M M M C

TR TR TR TR TR TR TR TR TR TR

TR TR TR TR TR TR TR TR

TE* TR TE* TE* TR TR TR TE* TE* TR TR

TR TR TR TR TR TR TR TR TR TR TR TR TR TR

TR

TE

TE* TR TR TE* TR TR

TR TR TR

0025

Industry Code

O

0026 0027 0028 0029 0030 0031

Insured Report Number Insured Location Number Policy Number Policy Effective Policy Expiration Date of Injury Denial & Cancel All other FROI MTCs Denial & Cancel All other FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Denial & Cancel All other FROI MTCs Original All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Denial, Acquired Unallocated, & Cancel All other FROI MTCs O C O C O M M M M O C M O M M M M O M TR TR TR TR TR TR TE TE TE TR TR TR TR TR TE* TE TR TR TE* TR TR TR

0032 0033 0034 0035 0036 0037 0038 0039

Time of Injury Postal Code of Injury Site Employers Premise Indicator Nature of Injury Code Part of Body Injured Code Cause of Injury Code Accident Description / Cause Initial Treatment Code

TR TR TR TR

TR

Not Statutorily Valid

Error Messages

KS MCO REQ

68
Duplicate Transmission / Transaction

Must Be <= Policy Expiration Date

EDI Claims Edit Matrix Table
No Matching FROI (148) Must Be <= Date of Hire

IAIABC DN 0001 0002 0003 0004

IAIABC Data Element Name First Report Transaction Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction

MTC APPLIES TO:

053

055

057

058

059

061

063

066

067

068

100

0005

Agency Claim Number

0006 0007

Insurer FEIN Insurer Name

0008 0009 0010 0011 0012 0013 0014 0015

Third Party Administrator FEIN TPA Name Claim Administrator Address Line 1 Claim Administrator Address Line 2 Claim Administrator City Claim Administrator State Claim Administrator Postal Zip Claim Administrator Claim Number

0016 0017 0018 0019 0020 0021 0022 0023 0024

Employer FEIN Insured Name Employer Name Employer Address Line 1 Employer Address Line 2 Employer City Employer State Employer Postal Code Self Insured Indicator

All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original & Acquired Unallocated Denial All other FROI MTCs Original, Denial, & Acquired Unallocated Cancel All other FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated Cancel All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original Denial, Acquired Unallocated, Change, & Correction Cancel

M M M M

TR TR* TR*

TR TR

TR*

TR*

C M M M M M C C C C O O O O M M M M M M M M O M M M M M C TR TE TE TE TR TE TE TE TE

TE

TE TE TR TR

TR TE TR TR TR

0025

Industry Code

O

0026 0027 0028 0029 0030 0031

Insured Report Number Insured Location Number Policy Number Policy Effective Policy Expiration Date of Injury Denial & Cancel All other FROI MTCs Denial & Cancel All other FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Denial & Cancel All other FROI MTCs Original All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Denial, Acquired Unallocated, & Cancel All other FROI MTCs O C O C O M M M M O C M O M M M M O M TE

TR TR

TR TR

0032 0033 0034 0035 0036 0037 0038 0039

Time of Injury Postal Code of Injury Site Employers Premise Indicator Nature of Injury Code Part of Body Injured Code Cause of Injury Code Accident Description / Cause Initial Treatment Code

TE TE TR TR TR

TR

No Leading or Embedded Spaces

Must Be >= Policy Effective Date

Kansas Division of Workers Compensation

Invalid Event Sequence

Value Not Consistent With Previous Report

Event Criteria Not Met

Invalid Record Count

Code / ID Invalid

Error Messages

KS MCO REQ

69

Must Be <= MTC Reason Code Date

Must Be a Valid Date (CCYYMMDD)

Must Be Alpha-Numeric (0 - 9, A-Z)

Must Be >= Date Disability Began

Kansas Division of Workers Compensation EDI Claims Edit Matrix Table
Mandatory Field Not Present

All Digits Cannot Be the Same

Must Be a Valid Time (HHMM)

Must Be <= Date of Injury

Must Be >=Date of Injury

Must Be <= Current Date

No Match on Database

Must Be Numeric 0 - 9

IAIABC DN

IAIABC Data Element Name First Report Transaction

MTC APPLIES TO:

001

028

029

030

031

033

034

035

037

039

040

041

042

0040

Date Reported to Employer

0041

Date Reported to Claims Administrator

0042

Social Security Number

0043

Employee Last Name

0044 0045 0046 0047 0048 0049 0050 0051 0052 0053 0054 0055 0056 0057 0058 0059 0060

Employee First Name Employee Middle Initial Employee Address Line 1 Employee Address Line 2 Employee City Employee State Employee Postal Code Employee Phone Employee Date of Birth Gender Code Marital Status Code Number of Dependents Date Disability Began Employee Date of Death Employment Status Code Class Code Occupation Description

0061

Date of Hire

0062 0063 0064 0065 0066 0067 0068

Wage Wage Period Number of Days Worked Date Last Day Worked Full Wages Pd for Date of Injury Indicator Salary Continued Indicator Date of Return To Work Subsequent Report Transaction Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Insurer FEIN TPA FEIN Claim Administrator Postal Zip Social Security Number Number of Dependents

Original & Denial Acquired Unallocated & Cancel Change & Correction Original & Denial Acquired Unallocated & Cancel Change & Correction Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs All FROI MTCs All FROI MTCs Cancel All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original, Change, & Correction All other FROI MTCs All FROI MTCs Original Acquired Unallocated Change & Correction All other FROI MTCs All FROI MTCs All FROI MTCs

M O C M O C M M M M M M O M O M M M O M M M O O C C C M C O M M M C O O O

TR

TR

TR

TR

TR

TR TR

TR TR

TR TR

TR TR

TR TR

TR TR TR TR TR TR TR TR TR TR TR TR TR TR

TR TR TR

TR

TR TR TE TR

TR

TE*

TE*

TR TR TR TR TR TR TR TE* TR TR

TR TR TR TR TR

TR TR TR TR TR TR TR TR TR TR

TR TR TE TR

TR TR TR

TR TR TR

TR TR TR

TR TR TR

All FROI MTCs

C

TR

TR

TR

TR

TR

0001 0002 0003 0004 0006 0008 0014 0042 0055

All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs Full Salary & Compensable Death All other SROI MTCs

M M M M M M C C M M

TR TR TR TR TR TR TR TR TR TR

TR TR TR TR TR TR TR

TR TE* TE* TE* TE* TE TE* TR TR TR TR TR

TR TR

TR TR

C

TR

TR

Not Statutorily Valid

Error Messages

KS MCO REQ

70
Duplicate Transmission / Transaction

Must Be <= Policy Expiration Date

EDI Claims Edit Matrix Table
No Matching FROI (148) Must Be <= Date of Hire

IAIABC DN

IAIABC Data Element Name First Report Transaction

MTC APPLIES TO:

053

055

057

058

059

061

063

066

067

068

100

0040

Date Reported to Employer

0041

Date Reported to Claims Administrator

0042

Social Security Number

0043

Employee Last Name

0044 0045 0046 0047 0048 0049 0050 0051 0052 0053 0054 0055 0056 0057 0058 0059 0060

Employee First Name Employee Middle Initial Employee Address Line 1 Employee Address Line 2 Employee City Employee State Employee Postal Code Employee Phone Employee Date of Birth Gender Code Marital Status Code Number of Dependents Date Disability Began Employee Date of Death Employment Status Code Class Code Occupation Description

0061

Date of Hire

0062 0063 0064 0065 0066 0067 0068

Wage Wage Period Number of Days Worked Date Last Day Worked Full Wages Pd for Date of Injury Indicator Salary Continued Indicator Date of Return To Work Subsequent Report Transaction Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Insurer FEIN TPA FEIN Claim Administrator Postal Zip Social Security Number Number of Dependents

Original & Denial Acquired Unallocated & Cancel Change & Correction Original & Denial Acquired Unallocated & Cancel Change & Correction Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original, Denial, & Acquired Unallocated All other FROI MTCs All FROI MTCs All FROI MTCs Cancel All other FROI MTCs All FROI MTCs All FROI MTCs All FROI MTCs Original, Change, & Correction All other FROI MTCs All FROI MTCs Original Acquired Unallocated Change & Correction All other FROI MTCs All FROI MTCs All FROI MTCs

M O C M O C M M M M M M O M O M M M O M M M O O C C C M C O M M M C O O O

TR TR TR TR

TR TE TR TR TR

TE

All FROI MTCs

C

0001 0002 0003 0004 0006 0008 0014 0042 0055

All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs Change & Correction All other SROI MTCs Change & Correction All other SROI MTCs All SROI MTCs All SROI MTCs Full Salary & Compensable Death All other SROI MTCs

M M M M M M C C M M

TR TR

TR TR

TR TE TE TE TE TE

TR TE

C

No Leading or Embedded Spaces

Must Be >= Policy Effective Date

Kansas Division of Workers Compensation

Invalid Event Sequence

Value Not Consistent With Previous Report

Event Criteria Not Met

Invalid Record Count

Code / ID Invalid

Error Messages

KS MCO REQ

71

Must Be <= MTC Reason Code Date

Must Be a Valid Date (CCYYMMDD)

Must Be Alpha-Numeric (0 - 9, A-Z)

Must Be >= Date Disability Began

Kansas Division of Workers Compensation EDI Claims Edit Matrix Table
Mandatory Field Not Present

All Digits Cannot Be the Same

Must Be a Valid Time (HHMM)

Must Be <= Date of Injury

Must Be >=Date of Injury

Must Be <= Current Date

No Match on Database

Must Be Numeric 0 - 9

IAIABC DN 0069

IAIABC Data Element Name Subsequent Report Transaction Pre-Existing Disability

MTC APPLIES TO:

001

028

029

030

031

033

034

035

037

039

040

041

042

0056

Date Disability Began

0070 0071 0072

Date of Maximum Medical Improvement Return to Work Qualifier Date of Return/Release to Work

0057

Employee Date of Death

0062

Wage

0063

Wage Period

Initial Payment, Full Salary, Compensable Death, & Acquired Payment All other SROI MTCs Initial Payment & Acquired Payment All other SROI MTCs All SROI MTCs Initial Payment & Acquired Payment All other SROI MTCs Full Salary Compensable Death All other SROI MTCs Initial Payment, Full Salary, Compensable Death, & Acquired Payment Denial All other SROI MTCs Initial Payment, Full Salary, Compensable Death, & Acquired Payment Denial All other SROI MTCs

M

TR

TR

TR

TR

TR

C C C C C C M C M

TR TR TR TR TR TR TR TR TR TR

TR TR TR TR TR TR TR

TR TR TR TR TR TR TR

TR TR TR TR TR TR TR TR TR

TR TR TR TR TR TR TR

O C M

TR TR

TR

O C

TR

0064 0067 0031 0026 0015 0005 0073 0074 0075 0076 0077 0078 0079 0080 0081 0082

Number Of Days Worked Salary Continued Indicator Date of Injury Insured Report Number Claim Administrator Claim Number Agency Claim Number Claim Status Claim Type Agreement to Compensate Code Date Of Representation Late Reason Code Number of Permanent Impairments Number of Payment/Adjustments Number of Benefit Adjustments Number of Paid to Date/Reduced Earnings/Recoveries Number of Death Dependant/Payee Relationships Permanent Impairment occurs Number Of Permanent Impairment Times Permanent Impairment Body Part Code (In Kansas, must = “99”) Permanent Impairment Percent Payment/Adjustments Occurs Number of Payment/Adjustment Times

All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs

M M M M M C M M M M M

TR TR TR TR TR TR TR TR TR TR TR

TR

TR

TE* TE* TE*

TR

TR

TR

TR

TR

0083 0084

All SROI MTCs All SROI MTCs

C C

TR TR TR

0085

Payment/Adjustment Code

Initial Payment & Acquired Payment Full Salary & Compensable Death All other SROI MTCs Initial Payment & Acquired Payment Full Salary & Compensable Death All other SROI MTCs Initial Payment & Acquired Payment Full Salary & Compensable Death All other SROI MTCs

M

TR

C M

TR TR

TR

0086

Payment/Adjustment Paid To Date

C M

TR TR

TR TR

0087

Payment/Adjustment Weekly Amount

C

TR

TR

Not Statutorily Valid

Error Messages

KS MCO REQ

72
Duplicate Transmission / Transaction

Must Be <= Policy Expiration Date

EDI Claims Edit Matrix Table
No Matching FROI (148) Must Be <= Date of Hire

IAIABC DN 0069

IAIABC Data Element Name Subsequent Report Transaction Pre-Existing Disability

MTC APPLIES TO:

053

055

057

058

059

061

063

066

067

068

100

0056

Date Disability Began

0070 0071 0072

Date of Maximum Medical Improvement Return to Work Qualifier Date of Return/Release to Work

0057 0062

Employee Date of Death Wage

0063

Wage Period

Initial Payment, Full Salary, Compensable Death, & Acquired Payment All other SROI MTCs Initial Payment & Acquired Payment All other SROI MTCs All SROI MTCs Initial Payment & Acquired Payment All other SROI MTCs Full Salary Compensable Death All other SROI MTCs Initial Payment, Full Salary, Compensable Death, & Acquired Payment Denial All other SROI MTCs Initial Payment, Full Salary, Compensable Death, & Acquired Payment Denial All other SROI MTCs

M

C C C C C C M C M

TE

O C M

TR

O C

TR

0064 0067 0031 0026 0015 0005 0073 0074 0075 0076 0077 0078 0079 0080 0081 0082

Number Of Days Worked Salary Continued Indicator Date of Injury Insured Report Number Claim Administrator Claim Number Agency Claim Number Claim Status Claim Type Agreement to Compensate Code Date Of Representation Late Reason Code Number of Permanent Impairments Number of Payment/Adjustments Number of Benefit Adjustments Number of Paid to Date/Reduced Earnings/Recoveries Number of Death Dependant/Payee Relationships Permanent Impairment occurs Number Of Permanent Impairment Times Permanent Impairment Body Part Code (In Kansas, must = “99”) Permanent Impairment Percent Payment/Adjustments Occurs Number of Payment/Adjustment Times

All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs All SROI MTCs

M M M M M C M M M M M

TR TR TR TE TR TR TR

TR TR TR TR TR

0083 0084

All SROI MTCs All SROI MTCs

C C

TR

0085

Payment/Adjustment Code

0086

Payment/Adjustment Paid To Date

0087

Payment/Adjustment Weekly Amount

Initial Payment & Acquired Payment Full Salary & Compensable Death All other SROI MTCs Initial Payment & Acquired Payment Full Salary & Compensable Death All other SROI MTCs Initial Payment & Acquired Payment Full Salary & Compensable Death All other SROI MTCs

M

TR

C M

TR

C M

C

No Leading or Embedded Spaces

Must Be >= Policy Effective Date

Kansas Division of Workers Compensation

Invalid Event Sequence

Event Criteria Not Met

Value Not Consistent With Previous Report

Invalid Record Count

Code / ID Invalid

Error Messages

KS MCO REQ

73

Must Be <= MTC Reason Code Date

Must Be a Valid Date (CCYYMMDD)

Must Be Alpha-Numeric (0 - 9, A-Z)

Must Be >= Date Disability Began

Kansas Division of Workers Compensation EDI Claims Edit Matrix Table
Mandatory Field Not Present

All Digits Cannot Be the Same

Must Be a Valid Time (HHMM)

Must Be <= Date of Injury

Must Be >=Date of Injury

Must Be <= Current Date

No Match on Database

Must Be Numeric 0 - 9

IAIABC DN 0088 0089 0090 0091

IAIABC Data Element Name Subsequent Report Transaction Payment/Adjustment Start Date Payment/Adjustment End Date Payment/Adjustment Weeks Paid Payment/Adjustment Days Paid Benefit Adjustments Occurs Number of Benefit Adjustments Times Benefit Adjustment Code Benefit Adjustment Weekly Amount Benefit Adjustment Start Date Paid To Date /Reduced Earnings /Recoveries Occurs Paid To Date /Reduced Earnings /Recoveries Times Paid To Date /Reduced Earnings /Recoveries Code Paid To Date /Reduced Earnings /Recoveries Amount Death Dependant/Payee Relationship Times Dependant/Payee Relationship Header & Trailer Records(HD1 & TR1) Sender ID Receiver ID Date Transmission Sent Time Transmission Sent Test / Production Indicator Interchange Version ID Detail Record Count

MTC APPLIES TO:

001

028

029

030

031

033

034

035

037

039

040

041

042

0092 0093 0094

0095 0096

All SROI MTCs All SROI MTCs

C C

TR TR TR

0097

0098 0099 0100 0101 0104 0105 0106

M M M M M M M

TR TR TR TR TR TR TR

TR TR

TR

TR TR

Not Statutorily Valid

Error Messages

KS MCO REQ

74
Duplicate Transmission / Transaction

Must Be <= Policy Expiration Date

EDI Claims Edit Matrix Table
No Matching FROI (148) Must Be <= Date of Hire

IAIABC DN 0088 0089 0090 0091

IAIABC Data Element Name Subsequent Report Transaction Payment/Adjustment Start Date Payment/Adjustment End Date Payment/Adjustment Weeks Paid Payment/Adjustment Days Paid Benefit Adjustments Occurs Number of Benefit Adjustments Times Benefit Adjustment Code Benefit Adjustment Weekly Amount Benefit Adjustment Start Date Paid To Date /Reduced Earnings /Recoveries Occurs Paid To Date /Reduced Earnings /Recoveries Times Paid To Date /Reduced Earnings /Recoveries Code Paid To Date /Reduced Earnings /Recoveries Amount Death Dependant/Payee Relationship Times Dependant/Payee Relationship Header & Trailer Records(HD1 & TR1) Sender ID Receiver ID Date Transmission Sent Time Transmission Sent Test / Production Indicator Interchange Version ID Detail Record Count

MTC APPLIES TO:

053

055

057

058

059

061

063

066

067

068

100

0092 0093 0094

0095 0096

All SROI MTCs All SROI MTCs

C C

TR

0097

0098 0099 0100 0101 0104 0105 0106

M M M M M M M

TR TR

TR TR TR

No Leading or Embedded Spaces

Must Be >= Policy Effective Date

Kansas Division of Workers Compensation

Invalid Event Sequence

Event Criteria Not Met

Value Not Consistent With Previous Report

Invalid Record Count

Code / ID Invalid

Error Messages

KS MCO REQ

75

Edit Matrix Tables Comments
FROI
DN# Data Element name EDIT # Edit Message Edit Comment

DN0006 DN0007 DN0008 DN0009 DN0014 DN0014 DN0014

Insurer FEIN Insurer Name Third Party Administrator FEIN Third Party Administrator Name Claim Administrator Postal Zip Claim Administrator Postal Zip Claim Administrator Postal Zip

058 058 058 058 028 030 058

Code / ID Invalid Code / ID Invalid Code / ID Invalid Code / ID Invalid Must Be Numeric 0 9 Must Be AlphaNumeric (0 - 9, A-Z)

A valid FEIN requires that all 9 positions are populated. 0-9 A/N ‘ , . # ( ) - & ! @ / \ ; : are valid. A valid FEIN requires that all 9 positions are populated. 0-9 A/N ‘ , . # ( ) - & ! @ / \ ; : are valid. If DN0013 is not a US value, then Edit 030 applies. If DN0013 is a US value, then Edit 028 applies. If DN0013 is a US value then Postal Code must have 5 or 9 positions populated; else if Canada 6 positions, else do not edit. blank 0-9 A/N ‘ , . # ( ) - & ! @ / \ ; : are valid. 0-9 A/N ‘ , . # ( ) - & ! @ / \ ; : are valid. If DN0013 is not a US value, then Edit 030 applies. If DN0022 is a US value then Postal Code must have 5 or 9 positions populated. Edit against official SIC / NAICS Code tables. 0-9 A/N ‘ , . # ( ) - & ! @ / \ ; : are valid. If DN0013 is not a US value, then Edit 030 applies. If DN0013 is a US value, then Edit 028 applies. If (DN0022) is "KS" then Postal Code must have 5 or 9 positions populated and be a valid KS postal code. Edit, else if Canada 6 positions, else do not edit. blank 0-9 A/N ‘ , . # ( ) - & ! @ / \ ; : are valid. 0-9 A/N ‘ , . # ( ) - & ! @ / \ ; : are valid. If DN0013 is not a US value, then Edit 030 applies. If DN0013 is a US value, then Edit 028 applies. If DN0013 is a US value then Postal Code must have 5 or 9 positions populated; else if Canada 6 positions, else do not edit.

DN0016 DN0017 DN0018 DN0023 DN0023 DN0025 DN0028 DN0033 DN0033 DN0033

Employer FEIN Insurer Name Employer Name Employer Postal Code Employer Postal Code Industry Code Policy Number Postal Code of Injury Site Postal Code of Injury Site Postal Code of Injury Site

058 058 058 028 058 058 058 028 030 058

Code / ID Invalid Code / ID Invalid Code / ID Invalid Must Be Numeric 0 9 (0 - 9, A-Z) Code / ID Invalid Code / ID Invalid Must Be Numeric 0 9 Must Be AlphaNumeric (0 - 9, A-Z)

DN0042 DN0043 DN0044 DN0050 DN0050 DN0050

Social Security Number Employee Last Name Employee First Name Employee Postal Code Employee Postal Code Employee Postal Code

058 058 058 028 030 058

Code / ID Invalid Code / ID Invalid Code / ID Invalid Must Be Numeric 0 9 Must Be AlphaNumeric (0 - 9, A-Z)

SROI
DN# Data Element name EDIT # Edit Message Edit Comment

DN0006 DN0008

Insurer FEIN Third Party Administrator FEIN

058 058

Code / ID Invalid Code / ID Invalid

DN0014 DN0083

Claim Administrator Postal Zip Permanent Impairment Body Part Code

058 058

Code / ID Invalid Code / ID Invalid

A valid FEIN requires that all 9 positions are populated. A valid FEIN requires that all 9 positions are populated. If DN0013 is a US Value then Postal Code must have 5 or 9 positions populated; else if Canada 6 positions, else do not edit. Must = "99"; compute KS impairment ratings on whole body only

76

IAIABC Release 1 Header, Trailer, and Acknowledgement Records
IAIABC RELEASE 1 HEADER RECORD (HD1) IAIABC GROUPING TRANSACTION

IAIABC DN 0001 0098

IAIABC DATA ELEMENT NAME Transaction Set ID Sender ID Sender FEIN Filler Sender Postal Code

IAIABC FORMAT 3 A/N 25 A/N 9 A/N 7 A/N 9 A/N 25 A/N 9 A/N 7 A/N 9 A/N Date Time Date Time 1 A/N 5 A/N 3 A/N 2 A/N

POSITIONS BEG 1 4 END 3 28

0099

Receiver ID Receiver FEIN Filler Receiver Postal Code

29

53

0100 0101 0102 0103 0104 0105

Date Transmission Sent Time Transmission Sent Original Transmission Date Original Transmission Time Test/Production Indicator Interchange Version ID Transmission Type Code Release Number

54 62 68 76 82 83

61 67 75 81 82 87

IAIABC RELEASE 1 TRAILER RECORD (TR1) IAIABC GROUPING TRANSACTION

IAIABC DN 0001 0106

IAIABC DATA ELEMENT NAME Transaction Set ID Detail Record Count

IAIABC FORMAT 3 A/N 9N

POSITIONS BEG 1 4 END 3 12

77

IAIABC Release 1 Header, Trailer, and Acknowledgement Records (contin.)
IAIABC RELEASE 1 ACKNOWLEDGMENT RECORD (AK1) IAIABC GROUPING TRANSACTION

IAIABC DN 0001 0107 0108 0109 0006 0014 0008 0110 0111 0028 0015 0005 0002 0003 0112 0113 0114

IAIABC DATA ELEMENT NAME Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer FEIN Claim Administrator Postal Code Third Party Administrator Fein Acknowledgement Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Agency Claim Number Maintenance Type Code Maintenance Type Date Request Code (Purpose) Free Form Text Number of Errors

IAIABC FORMAT 3 A/N 9N Date Time 9 A/N 9 A/N 9 A/N 3 A/N 2 A/N 25 A/N 25 A/N 25 A/N 2 A/N Date 3 A/N 60 A/N 2N

POSITIONS BEG 1 4 13 21 27 36 45 54 57 59 84 109 134 136 144 147 207

END 3 12 20 26 35 44 53 56 58 83 108 133 135 143 146 206 208

Variable Segment Error Code 0115 0116 0117 Error Code Occurs Number of Error Times Element Number Element Error Number Variable Segment Number 4N 3N 2N 209 213 216 212 215 217

78

Match Data Routine
IAIABC Match Data DN42 Employee ID (SSN) DN52 Employee Date of Birth DN44 Employee First Name DN43 Employee Last Name DN31 Date of Injury DN05 Agency Claim Number DN15 Claim Administrator Claim Number DN06 Insurer FEIN DN08 Claim Administrator FEIN (TPA FEIN) Non-IAIABC Match Data DN32 Time of Injury DN16 Employer FEIN

KDWC Match Data & Process
FROI W/O Agency Claim # Primary Third Third Primary FROI W/Agency Claim # Secondary Third Third Secondary Primary Primary Secondary Secondary Third Secondary All SROIs Secondary

Secondary Primary Primary Secondary Secondary

Primary Secondary Secondary Third Secondary

79

KDWC FROI and SROI Match Routine
Begin: If FROI without Agency Claim Number begin Match: Primary: Claim Administrator Claim Number (it’s the primary, unique ID on First Reports) Match "SSN" and "DOI" to verify Match or identify duplicates If Duplicate then perform Secondary Match: Secondary Match on: FROI Employer FEIN (A claim could be filed by two companies - Lessee/Lessor or Contractor/Subcontractor.) All - Insurer FEIN (A claim could be filed by the wrong insurer- coverage not determined at time of filing.) All - TPA FEIN (This will gain importance as parts of a claim may be handled by different Claim Administrators
and will affect processing of the Jurisdiction claim data.) Note: A successful match requires 2 of the Primary and Secondary Match DNs to match, if there are no duplicate claims. Non-Matching match data will trigger a "TE." If Duplicate, go to Third Level: If any one of three -"Time of Injury," "Date of Birth," or "Employee Last Name" are different, accept report; else return.]

Report Process (in this order): If Duplicate after secondary match, report duplicates and resolve manually; go to Next Claim If FROI Original or Denial or Acquired Unallocated and No Match on DB, Add Claim If on DB, apply Transaction Sequence Rules and Reject or process accordingly If out of sequence or not Original or Acquired Unallocated and No Match, Reject report If Change Transaction, overwrite the changed ID and other claim data If Claim Match successful but Match Data in error, TE Data Element End; Go to Next-Claim

If FROI with Agency Claim Number begin Match: [FROI such as Cancel, Denial, AU] Primary: Agency Claim Number (is the state's primary Unique ID) Claim Administrator Claim Number If Duplicate, Perform Secondary & Third Match else Report Process Match "SSN" and "DOI" to verify Match or Identify duplicates as part of secondary match process

If SROI (all must have Agency Claim Number) begin Match Primary: Agency Claim Number (is the state's primary Unique ID) Claim Administrator Claim Number If Duplicate, perform Secondary; else Report Process Match "SSN" and "DOI" to verify Match or Identify duplicates as part of secondary match process No third-level match process for SROI reports

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