FROI Element Requirement Table

REC DN# 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 R21 R21 R21 R21 R21 R21 R21 R21 0001 0002 0003 0004 0005 0006 0012 0013 0014 0015 0016 0021 0022 0023 0025 0027 0028 0029 0030 0031 0032 0033 0035 0036 0037 0039 0040 0041 0044 0048 0049 0050 0052 0053 0054 0055 0056 0057 0058 0059 0061 0062 0063 0064 0065 0066 0068 0001 0295 0296 0186 0015 0187 0188 0135 DATA ELEMENT NAME Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Code Jurisdiction Claim Number Insurer FEIN Claim Administrator Mailing City Claim Administrator Mailing State Code Claim Administrator Mailing Postal Code Claim Administrator Claim Number (Key Match) Employer FEIN Employer Physical City Employer Physical State Code Employer Physical Postal Code Employer Industry Code (Formerly "SIC Code") Insured Location Identifier Policy Number Policy Effective Date Policy Expiration Date Date of Injury Time of Injury Accident Site Postal Code Nature of Injury Code Part of Body Injury Code Cause of Injury Code Initial Treatment Code Date Employer Had Knowledge of the Injury Date Claim Administrator Had Knowledge of Injury Employee First Name Employee Mailing City Employee Mailing State Code Employee Mailing Postal Code Employee Date of Birth Employee Gender Code Employee Marital Status Code Employee Number of Dependents Initial Date Disability Began Employee Date of Death Employment Status Code Manual Classification Code Employee Date of Hire Wage Wage Period Code Number of Days Worked Per Week Initial Date Last Day Worked Full Wages Paid for Date of Injury Indicator Initial Return to Work Date Transaction Set ID Maintenance Type Correction Code Maintenance Type Correction Code Date Jurisdiction Branch Office Code Claim Administrator Claim Number (Key Match) Claim Administrator FEIN Claim Administrator Name Claim Administrator Mailing Information/Attention Line FORMAT 3 A/N 2 A/N DATE 2 A/N 25 A/N 9 A/N 15 A/N 2 A/N 9 A/N 25 A/N 9 A/N 15 A/N 2 A/N 9 A/N 6 A/N 15 A/N 18 A/N DATE DATE DATE HHMM 9 A/N 2 A/N 2 A/N 2 A/N 2 A/N DATE DATE 15 A/N 15 A/N 2 A/N 9 A/N DATE 1 A/N 1 A/N 2N DATE DATE 2 A/N 4 A/N DATE $9.2 2 A/N 1N DATE 1 A/N DATE 3 A/N 2 A/N DATE 2 A/N 25 A/N 9 A/N 40 A/N 50 A/N

00
F F F F X M E E M F E EC EC EC E MC IA IA IA M E EC E E E IA E E M E E M E E E EC EC EC E IA E EC EC IA IA EC EC F X X NA F M M IA

02
F F F F MC M E E M F E EC EC EC E MC IA IA IA M E EC E E E IA E E M E E M E E E EC EC EC E IA E EC EC IA IA EC EC F X X NA F M M IA

FROI MTC'S 04 AQ AU
F F F F X M E E M F E EC EC EC E MC IA IA IA M E EC E E E IA E E M E E M E E E EC EC EC E IA E EC EC IA IA EC EC F X X NA F M M IA F F F F NA M IA IA M F E IA IA IA IA NA IA IA IA M IA IA IA IA IA IA IA IA M IA IA M IA IA IA IA IA IA IA IA IA IA IA IA IA IA IA F X X NA F M M IA F F F F X M E E M F E EC EC EC E MC IA IA IA M E EC E E E IA E E M E E M E E E EC EC EC E IA E EC EC IA IA EC EC F X X NA F M M IA

UR
F F F F X M E E M F E EC EC EC E MC IA IA IA M E EC E E E IA E E M E E M E E E EC EC EC E IA E EC EC IA IA EC EC F X X NA F M M IA

CO
F F F F MC M E E M F E EC EC EC E MC IA IA IA M E EC E E E IA E E M E E M E E E EC EC EC E IA E EC EC IA IA EC EC F X X NA F M M IA

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FROI Element Requirement Table
R21 R21 R21 R21 R21 0010 0011 0136 0270 * 0042 0152 0153 0154 0156 0255 0150 0157 0043 0045 0046 0047 0155 0051 0146 0290 0228 0189 0224 0314 0017 0184 0026 0007 0185 0292 0249 0118 0119 0120 0121 0122 0123 0280 0281 0018 0329 0019 0020 0164 0159 0160 0163 0165 0166 0167 0168 0169 0170 0060 0199 0522 0073 0074 Claim Administrator Mailing Primary Address 40 A/N Claim Administrator Mailing Secondary Address 40 A/N Claim Administrator Mailing Country Code 3 A/N Employee ID Type Qualifier 1 A/N Employee ID Employee SSN 15 A/N Employee Employment Visa 15 A/N Employee Green Card 15 A/N Employee ID Assigned by Jurisdiction 15 A/N Employee Passport Number 15 A/N Employee Last Name Suffix 4 A/N Employee Authorization to Release Medical Records Indicator 1 A/N Employee Social Security Number Release Indicator 1 A/N Employee Last Name 40 A/N Employee Middle Name/Initial 15 A/N Employee Mailing Primary Address 40 A/N Employee Mailing Secondary Address 40 A/N Employee Mailing Country Code 3 A/N Employee Phone Number 15 A/N Death Result of Injury Code 1 A/N Type of Loss 2 A/N Return to Work with Same Employer Indicator 1 A/N Return to Work Type Code 1 A/N Physical Restrictions Indicator 1 A/N Insured FEIN 9 A/N Insured Name 40 A/N Insured Type Code 1 A/N Insured Report Number 25 A/N Insurer Name 40 A/N Insurer Type Code 1 A/N Insolvent Insurer FEIN 9 A/N Accident Premises Code 1 A/N Accident Site County/Parish 20 A/N Accident Site Location Narrative 50 A/N Accident Site Organization Name 50 A/N Accident Site City 15 A/N Accident Site Street 40 A/N Accident Site State Code 2 A/N Accident Site Country Code 3 A/N Date Employer Had Knowledge of Initial Disability DATE Employer Name 40 A/N Employer UI Number 15 A/N Employer Physical Primary Address 40 A/N Employer Physical Secondary Address 40 A/N Employer Physical Country Code 3 A/N Employer Contact Business Phone Number 15 A/N Employer Contact Name 40 A/N Employer Mailing Information/Attention Line 50 A/N Employer Mailing City 15 A/N Employer Mailing Country Code 3 A/N Employer Mailing Postal Code 9 A/N Employer Mailing Primary Address 40 A/N Employer Mailing Secondary Address 40 A/N Employer Mailing State Code 2 A/N Occupation Description 50 A/N Full Denial Effective Date DATE ICD-9 CM Diagnosis Code 6 A/N Claim Status Code 1 A/N Claim Type Code 1 A/N E IA NA M MC X X MC X IA NA NA M IA M IA IA E EC IA IA EC NA IA E EC IA M EC EC E IA EC EC IA IA IA IA EC M IA EC IA IA IA IA IA E IA M M IA E E X IA IA IA E IA NA M MC X X MC X IA NA NA M IA M IA IA E EC IA IA EC NA IA E EC IA M EC EC E IA EC EC IA IA IA IA EC M IA EC IA IA IA IA IA E IA M M IA E E X IA IA IA E IA NA M MC X X MC X IA NA NA M IA M IA IA E EC IA IA EC NA IA E EC IA M EC EC E IA EC EC IA IA IA IA EC M IA EC IA IA IA IA IA E IA M M IA E E X IA IA IA E IA NA M MC X X MC X IA NA NA M IA M IA IA IA IA IA IA IA NA IA E IA IA M EC EC IA IA IA IA IA IA IA IA IA M IA IA IA IA IA IA IA IA IA IA IA IA IA IA X IA IA IA E IA NA M MC X X MC X IA NA NA M IA M IA IA E EC IA IA EC NA IA E EC IA M EC EC E IA EC EC IA IA IA IA EC M IA EC IA IA IA IA IA E IA M M IA E E X IA IA IA E IA NA M MC X X MC X IA NA NA M IA M IA IA E EC IA IA EC NA IA E EC IA M EC EC E IA EC EC IA IA IA IA EC M IA EC IA IA IA IA IA E IA M M IA E E X IA IA IA E IA NA M MC X X MC X IA NA NA M IA M IA IA E EC IA IA EC NA IA E EC IA M EC EC E IA EC EC IA IA IA IA EC M IA EC IA IA IA IA IA E IA M M IA E E X IA IA IA

R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21 R21

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FROI Element Requirement Table
R21 0077 Late Reason Code 2 A/N R21 0273 Employer Paid Salary in Lieu of Compensation Indicator A/N 1 Variable Segment Counters R21 0274 Number of Accident/Injury Description Narratives 2N R21 0277 Number of Denial Reason Codes 2N R21 0276 Number of Denial Reason Narratives 2N R21 0278 Number of Managed Care Organizations 2N R21 0279 Number of Witnesses 2N Variable Segments Accident/Injury Description Narratives R21 0038 Accident/Injury Description Narrative 50 A/N Full Denial Reason Codes R21 0198 Full Denial Reason Code 2 A/N Full Denial Reason Narratives R21 0197 Full Denial Reason Narrative 50 A/N Managed Care Organizations R21 0207 Managed Care Organization Code 2 A/N R21 0209 Managed Care Organization Name 50 A/N R21 0208 Managed Care Organization Identification Number 40 A/N Witnesses R21 0238 Witness Name 40 A/N R21 0237 Witness Business Phone Number 15 A/N IA IA F F F F F IA IA F F F F F IA IA F F F F F IA IA F F F F F IA IA F F F F F IA IA F F F F F IA IA F F F F F

E X X IA IA IA IA IA

E X X IA IA IA IA IA

E X X IA IA IA IA IA

E X X IA IA IA IA IA

E X X IA IA IA IA IA

E X X IA IA IA IA IA

E X X IA IA IA IA IA

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FROI Conditional Requirements FROI DATA ELEMENT
Req Code F F F F MC M M F EC EC EC MC EC M EC REC 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148 148

DN#
0001 0002 0003 0004 0005 0006 0014 0015 0021 0022 0023 0027 0033 0050 0055 0056 0057 0062 0063 0066 0068

DATA ELEMENT NAME Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Code Jurisdiction Claim Number Insurer FEIN Claim Administrator Mailing Postal Code Claim Administrator Claim Number Employer Physical City Employer Physical State Code Employer Physical Postal Code Insured Location Identifier Accident Site Postal Code Employee Mailing Postal Code Employee Number of Dependents Initial Date Disability Began Employee Date of Death Wage Wage Period Code Full Wages Paid for Date of Injury Indicator Initial Return to Work Date

CONDITION(S)

NOTE

EC
EC EC

EC EC EC

The transaction will be rejected for any transaction set ID indicated other than (HD1, 148, R21, TR1). The transaction will be rejected for any MTC other than (00, 02, 04, AQ, AU, UR, CO). Required to have the MTC Date The transaction will be rejected for any code other than MN. The jurisdiction claim number should be sent for MTC 02 and CO. Must be a valid FEIN on file with the Minnesota Department of Labor and Industry. Must be a valid zip code for the claim administrator. Key match to Claim Administrator Claim Number in the R21 record. The Employer Physical City must be sent if different than the Employer Mailing City. The Employer Physical State Code must be sent if different than the Employer Mailing State Code. The Employer Physical Postal Code must be sent if different than the Employer Mailing Postal Code. Required if Minnesota Department of Employee Relations (DOER) (NA for all other trading partners). Expected if the Accident Site Location Narrative is not specified. Must be a valid zip code for the employee. Expected for fatalities. Expected for lost time cases. Expected for fatalities. Must be a valid date if the Death Result of Injury Code is set. Expected. Must be greater than $10/week unless the employment status is volunteer. Expected unless the employment status is VO. Expected if there was lost time on the date of injury. Expected if the Return to Work Type is 'A' (Actual).

SROI transactions are currently not accepted. MTC 01 and UI are not accepted.

See DN0015 (R21).

Must contain the agency ID. See DN0119.

See DN0057 and DN0146. See DN0146. See DN0063. See DN0062. Should be blank if there was not lost time on the date of injury. See DN0189.

MC MC X X MC

R21 0042 0152 0153 0154

*

Employee ID Employee SSN Employee Employment Visa Employee Green Card Employee ID Assigned by Jurisdiction

Mandatory when DN0270 Employee ID Type Qualifier=S. Exists in the Employee ID field. DN0270 Employee ID Type Qualifier=E not accepted. DN0270 Employee ID Type Qualifier=G not accepted. Mandatory when DN0270 Employee ID Type Qualifier=A. Exists in the Employee ID field. 4 of 11

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FROI Conditional Requirements
X
F EC EC EC R21 R21 R21 R21 R21 R21 R21 R21 0156 0015 0019 0119 0120 0146 0185 0189 0292 Employee Passport Number Claim Administrator Claim Number Employer Physical Primary Address Accident Site Location Narrative Accident Site Organization Name Death Result of Injury Code Insurer Type Code Return to Work Type Code Insolvent Insurer FEIN

DN0270 Employee ID Type Qualifier=P not accepted. Key match to Claim Administrator Claim Number in the See DN0015 (148). 148 record. The Employer Physical Primary Address must be sent if different than the Employer Mailing Primary Address. Expected if the Accident Site Postal Code is not specified. See DN0033. Expected if the Accident Site Location Narrative is not specified. Expected for fatalities. Expected if the Insolvent Insurer FEIN is used. Also used to indicate self-insured. Expected if the Initial Return to Work Date is populated. Expected if the Insurer Type Code is 'G' (Guarantee Fund).

EC EC EC EC

See DN0057. See DN0292. See DN0068. See DN0185.

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Edit Matrix 059 Non-match data value not consistent with value previously reported

107 Variable segment counter > maximum value allowed

Edit Matrix Population Legend: F = Edit applies to the data elements deemed essential for a transmission/transaction to be processed. L = Edit applies to the data elements based on the requirements indicated on the Element Requirement Table. Applicable to Jurisdiction's Requirements: F = Essential data element; must be edited for successful transaction processing Y = Yes - indicates that all edits marked for the data element will be applied; some may be based on conditions defined in the Element Requirement Table N = No - indicates that all edits marked for the data elements will be applied For Population Restrictions: For Data Elements that have certain ‘population values’ allowed for specific data elements, a “P” is indicated in the ‘Population Restrictions Indicator’ column and the associated data element population restriction is detailed in the Population Restrictions Table. Error Message

DN 0000 0001 0002 0003 0004 0005 0006 0007 0010 0011 0012 0013 0014 0015 0016 0017 0018 0019 0020 0021 0022 0023 0025 0026 0027 0028 0029 0030 0031 0032 0033 0035 0036 0037 0038 0039 0040

IAIABC Data Element Name Entire Batch Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Code Jurisdiction Claim Number Insurer FEIN Insurer Name Claim Administrator Mailing Primary Address Claim Administrator Mailing Secondary Address Claim Administrator Mailing City Claim Administrator Mailing State Code Claim Administrator Mailing Postal Code Claim Administrator Claim Number Employer FEIN Insured Name Employer Name Employer Physical Primary Address Employer Physical Secondary Address Employer Physical City Employer Physical State Code Employer Physical Postal Code Employer Industry Code Insured Report Number Insured Location Identifier Policy Number Policy Effective Date Policy Expiration Date Date of Injury Time of Injury Accident Site Postal Code Nature of Injury Code Part of Body Injured Code Cause of Injury Code Accident/Injury Description Narrative Initial Treatment Code Date Employer Had Knowledge of the Injury
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L F F F F L F F L L L L L L L L L L L L L

L L

L L

L L L L

F L L F

L L

L L L L L

L

L L

L L L L L

L L L L L L L L L L L L L L L L L
6 of 11

F

L

L

117 Match data value not consistent with value previously reported L L

103 Same code received in multiple variable segments

110 Date Must be >= Jurisdiction Implementation Date

060 Previous paper documentation not received

Applicable to Jurisdiction Requirements

114 Must be >= Current Date Last Day Worked

037 Must be <= Maintenance Type Code Date

104 Must be >= Current Date Disability Began

105 Must be <= Current Date Disability Began

112 Must be >=Initial Date Last Day Worked

053 No matching First Report of Injury (148)

035 Must be >= Initial Date Disability Began

102 Must be <= Initial Date Disability Began

050 No matching Subsequent Report (A49)

113 Must be >= Initial Return to Work Date

054 Must be valid occurrence for segment

018 Number of Days Worked must be 0-7

036 Must be <= Employee Date of Death

065 Corresponding report/data not found

029 Must be a valid date (CCYYMMDD)

Population Restrictions Indicator

109 Must be >=Employee Date of Hire

068 Must be <= Policy Expiration Date

055 Must be < Employee Date of Hire

044 Value is > required by jurisdiction

045 Value is < required by jurisdiction

101 MTC not approved for production

Sorted by Error Message & DN

067 Must be >= Policy Effective Date

066 Invalid record/transaction count

062 Required segment not present

100 No leading/embedded spaces

040 All digits cannot be the same

057 Duplicate Batch/Transaction

030 Must be A-Z, 0-9, or spaces

061 Event Table criteria not met

001 Mandatory field not present

108 Expected field not present

033 Must be <= Date of Injury

034 Must be >= Date of Injury

041 Must be <= current date

064 Invalid data relationship

063 Invalid event sequence

039 No match on database

106 Invalid batch structure

038 Must be >= Start Date

111 Must be valid content

028 All digits must be 0-9

031 Must be a valid time

042 Not statutorily valid

019 Days must be 0-6

058 Code/ID invalid

0041 0042 0043 0044 0045 0046 0047 0048 0049 0050 0051 0052 0053 0054 0055 0056 0057 0058 0059 0060 0061 0062 0063 0064 0065 0066 0068 0073 0074 0077 0098 0099 0100 0101 0102 0103 0104 0105 0106 0118 0119 0120 0121 0122 0123 0135 0136 0146 0150 0152 0153 0154 0155 0156 0157 0159 0160 0163 0164 0165 0166 0167 0168 0169 0170 0184

Date Claim Administrator Had Knowledge of the Injury Employee SSN F Employee Last Name F Employee First Name F Employee Middle Name/Initial Employee Mailing Primary Address F Employee Mailing Secondary Address Employee Mailing City Employee Mailing State Code Employee Mailing Postal Code F Employee Phone Number Employee Date of Birth Employee Gender Code Employee Marital Status Code Employee Number of Dependents Initial Date Disability Began Employee Date of Death Employment Status Code Manual Classification Code Occupation Description Employee Date of Hire Wage Wage Period Code Number of Days Worked Per Week L Initial Date Last Day Worked Full Wages Paid for Date of Injury Indicator Initial Return to Work Date Claims Status Code Claim Type Code Late Reason Code Sender ID F Receiver ID F Date Transmission Sent F Time Transmission Sent F Original Transmission Date Original Transmission Time Test/Production Code F Interchange Version ID F Detail Record Count F Accident Site County/Parish Accident Site Location Narrative Accident Site Organization Name Accident Site City Accident Site Street Accident Site State Code Claim Administrator Mailing Information/Attention Line Claim Administrator Mailing Country Code Death Result of Injury Code Employee Authorization to Release Medical Records Indicator Employee Employment Visa Employee Green Card Employee ID Assigned by Jurisdiction F Employee Mailing Country Code Employee Passport Number Employee Social Security Number Release Indicator Employer Contact Business Phone Number Employer Contact Name Employer Mailing Information/Attention Line Employer Physical Country Code Employer Mailing City Employer Mailing Country Code Employer Mailing Postal Code F Employer Mailing Primary Address F Employer Mailing Secondary Address Employer Mailing State Code Insured Type Code
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L L

L

L L L

Edit Matrix L L L L L L L L L L L L L L L L

L L L L

L L L L L L L L L L L

L L L

L L L L L L L L L L L L L L L L L L L L L L

L L

L

L L L L

L L

L

L L

L

L L L

L L L L L L
7 of 11

0185 0186 0187 0188 0189 0191 0197 0198 0199 0207 0208 0209 0224 0228 0237 0238 0249 0255 0270 0273 0274 0276 0277 0278 0279 0280 0281 0290 0292 0295 0296 0314 0329 0522

Insurer Type Code Jurisdiction Branch Office Code Claim Administrator FEIN Claim Administrator Name Return to Work Type Code Transaction Count Full Denial Reason Narrative Full Denial Reason Code Full Denial Effective Date Managed Care Organization Code Managed Care Organization Identification Number Managed Care Organization Name Physical Restrictions Indicator Return to Work With Same Employer Indicator Witness Business Phone Number Witness Name Accident Premises Code Employee Last Name Suffix Employee ID Type Qualifier Employer Paid Salary in Lieu of Compensation Indicator Number of Accident/Injury Description Narratives Number of Full Denial Reason Narratives Number of Full Denial Reason Codes Number of Managed Care Organizations Number of Witnesses Accident Site Country Code Date Employer Had Knowledge of Initial Disability Type of Loss Code Insolvent Insurer FEIN Maintenance Type Correction Code Maintenance Type Correction Code Date Insured FEIN Employer UI Number ICD-9 CM Diagnosis Code

Edit Matrix F F F L L L

L

L

L L L L

L

L

L L L L L L

L

L L L L L L L L L L L L L L L L L L L L L L L L L L L L

F F F F F

L L L L L

L

L L

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Jurisdiction Data Element Valid Values
Capture

DN Element Name
0001 Transaction Set ID 0002 Maintenance Type Code 0004 Jurisdiction Code 0039 Initial Treatment Code 0053 Employee Gender Code 0054 Employee Marital Status Code 0058 Employment Status Code* 0063 Wage Period Code 0066 Full Wages Paid for Date of Injury Indicator 0073 Claim Status Code 0074 Claim Type Code 0077 Late Reason Code 0104 Test/Production Code 0146 Death Result of Injury Code 0150 Employee Authorization to Release Medical Records Indicator 0157 Employee Social Security Number Release Indicator 0184 Insured Type Code 0185 Insurer Type Code 0189 Return to Work Type Code 0207 Managed Care Organization Code 0224 Physical Restrictions Indicator 0228 Return to Work With Same Employer Indicator 0249 Accident Premises Code 0270 Employee ID Type Qualifier 0273 Salary Continued in Lieu of Compensation Indicator 0290 Type of Loss Code

Valid Codes
HD1 TR1 148 R21 AKC 00 MN 0 F U C 01 Y O M L1 P Y Y Y I I R 00 Y Y E A Y 01 1 M M 9 02 N C I L2 T N N N S S A 01 N N L S N 02 03 X (E,G,P not accepted) 02 03 04 05 G (U not accepted) U R N L3 X B L4 L L5 T L6 L7 L8 L9 LA C1 D1 D2 D3 D4 D5 D6 E1 E2 E3 E4 E5 E6 S 8 04 A 06 B 07 1 2 2 3 4 5 (U not accepted) (K not accepted) (3,6,4,5,7 not accepted) 02 04 AQ AU CO UR (A49, R22 not accepted) (01, UI not accepted)

*(see hierarchical order in dictionary)

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Event Table
Report Type FROI FROI FROI FROI FROI FROI FROI FROI FROI Event Rule Date From Thru Maintenance Type Code 00 00 00 02 04 AQ AU CO UR Description Original Original Original Change Denial Acquired Claim Acquired/Un allocated Correction Upon Request
Trigger Criteria Codes A = New Claim B = Cumulative Medical $ C = Lost Time E = Days Open F = Formula J = Jurisdiction Defined M = MTC Defined Q = Employee Death Report Due From Codes A = From Date of Accident/Injury B = From Date of Disability C = From Employer Notification E = From Jurisdiction Notification F = From Carrier Notification G = From Initial Payment (IP) I = From Date of Death K = Prior to Final Report (FN) Type B = Business Days C = Calendar Days Receiver Codes EE = Employee ER = Employer PR = Provider Others as defined by jurisdiction

What triggers the report? Trigger Trigger Value Criteria C N Q 3 Calendar Days Any Dollar Amount (> $1)

When is the Report Due? Value 14 14 2-Verbal 7-Written Type C C C From Later of B or C G C

Follow-up Form FR01 FR01 FR01

Receiver EE EE

D = Cumulative Wage Replacement D = From Administrator Notification

L = Determination of Compensable Death H = Immediate N = Cumulative Indemnity $ J = From Report Trigger

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Match Data Rules

The Match Data Table is designed to convey which data elements should be used as primary or secondary “match” data elements. It is used to identify a transaction as a new claim to create, or match to an existing claim for duplicate checking, updating and processing. Refer to the Match Data Rules. Secondary “match” data elements are primarily employed on a Change (MTC-02). A jurisdiction should provide Claim Administrators with primary match data element(s) and two or more secondary match data elements. The suggested data element names are listed below. Place a “P” (primary) or “S” (secondary) in the appropriate column in order to identify the match data. MTC and MTC Date are prepopulated for Corrections. If the jurisdiction intends to accept “Correction” transactions, they must be able to recognize the transaction being corrected. GROUPING CLAIM DN DATA ELEMENT NAME New Claims Existing Corrections Claims S P P S P

Claimant

Claim Administrator Employer

Insurer Transaction

0004 Jurisdiction Code 0005 Jurisdiction Claim Number 0015 Claim Administrator Claim Number Employee ID §   Employee SSN – Preferred (DN0042) §   Employee ID Assigned By Jurisdiction (DN0154) 0031 Date of Injury 0043 Employee Last Name 0044 Employee First Name 0052 Employee Date of Birth 0187 Claim Administrator FEIN 0014 Claim Administrator Mailing Postal Code 0026 Insured Report Number 0016 Employer FEIN 0018 Employer Name 0023 Employer Physical Postal Code 0028 Policy Number 0006 Insurer FEIN 0295 Maintenance Type Correction Code (DN0002-From Original Transaction)** 0296 Maintenance Type Correction Code Date (DN0003-From Original Transaction)** 0002 Maintenance Type Code 0003 Maintenance Type Code Date

P

P

P

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