02/11/2008

1730539.xls, FROI Format

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IAIABC RELEASE 1 FIRST REPORT OF INJURY (148)
IAIABC GROUPING TRANSACTION IAIABC DN 0001 0002 0003 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0014 0015 0016 0017 0018 0019 0020 0021 0022 0023 0024 0025 0026 0027 0028 0029 0030 0031 0032 0033 0034 0035 0036 0037 0038 0039 0040 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 0067 0068 IAIABC DATA ELEMENT NAME Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Agency Claim Number Insurer FEIN Insurer Name Third Party Administrator FEIN Third Party Administrator Name Claim Administrator Address Line 1 Claim Administrator Address Line 2 Claim Administrator City Claim Administrator State Claim Administrator Postal Code Claim Administrator Claim Number Employer FEIN Insured Name Employer Name Employer Address Line 1 Employer Address Line 2 Employer City Employer State Employer Postal Code Self Insured Indicator Industry Code Insured Report Number Insured Location Number Policy Number Filler Policy Effective Date Policy Expiration Date Date of Injury Time of Injury Postal Code of Injury Site Employers Premises Indicator Nature of Injury Code Part of Body Injured Code Cause of Injury Code Accident Description/Cause Initial Treatment Date Reported to Employer Date Reported to Claim Administrator Social Security Number Employee Last Name 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 Date of Hire Wage Wage Period Number of Days Worked Date Last Day Worked Full Wages Paid for Date of Injury Indicator Salary Continued Indicator Date of Return to Work IAIABC FORMAT 3 A/N 2 A/N DATE 2 A/N 25 A/N 9N 30 A/N 9N 30 A/N 30 A/N 30 A/N 15 A/N 2 A/N 9 A/N 25 A/N 9N 30 A/N 30 A/N 30 A/N 30 A/N 15 A/N 2 A/N 9 A/N 1 A/N 6 A/N 10 A/N 15 A/N 18 A/N 12 A/N DATE DATE DATE HHMM 9 A/N 1 A/N 2 A/N 2 A/N 2 A/N 150 A/N 2 A/N DATE DATE 9N 30 A/N 15 A/N 1 A/N 30 A/N 30 A/N 15 A/N 2 A/N 9 A/N 10 N DATE 1 A/N 1 A/N 2N DATE DATE 2 A/N 4 A/N 30 A/N DATE $9.2 2 A/N 1N DATE 1 A/N 1 A/N DATE BEG POS END POS 1 3 4 5 6 13 14 15 16 40 41 49 50 79 80 88 89 118 119 148 149 178 179 193 194 195 196 204 205 229 230 238 239 268 269 298 299 328 329 358 359 373 374 375 376 384 385 385 386 391 392 401 402 416 417 434 435 446 447 454 455 462 463 470 471 474 475 483 484 484 485 486 487 488 489 490 491 640 641 642 643 650 651 658 659 667 668 697 698 712 713 713 714 743 744 773 774 788 789 790 791 799 800 809 810 817 818 818 819 819 820 821 822 829 830 837 838 839 840 843 844 873 874 881 882 892 893 894 895 895 896 903 904 904 905 905 906 913

JURISDICTION CLAIM ADMINISTRATOR

INSURED

POLICY

ACCIDENT

EMPLOYEE

EMPLOYMENT

02/11/2008

1730539.xls, FROI Requirements

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IAIABC RELEASE 1 FIRST REPORT OF INJURY (148)
IAIABC GROUPING TRANSACTION IAIABC DN 0001 IAIABC DATA ELEMENT NAME Transaction Set ID REQUIRED CDE M MTC 00,02,CO 00 00,02,CO 00 0002 Maintenance Type Code M 00,02,CO 00 00,02,CO CO CO 0003 Maintenance Type Code Date M 00,02,CO 00,02,CO JURISDICTION 0004 Jurisdiction M 00,02,CO 00,02,CO 0005 Agency Claim Number M 02, CO 00,02, CO 02,CO 02,CO 02,CO 02,CO 02,CO CLAIM ADMINISTRATOR 0006 Insurer FEIN M 00,02, CO 00,02,CO 00 00,02, CO 00,02,CO 00 02,CO 0007 Insurer Name M 00,02,CO 02,CO 0008 Third Party Administrator FEIN C 02, CO 00, 02, CO 00 00,02, CO 02,CO 0009 Third Party Administrator Name Claim Administrator Address Line 1 C 00,02,CO 02,CO 0010 M 00,02,CO 02,CO 0011 Claim Administrator Address Line 2 O 00, 02, CO 02,CO 0012 Claim Administrator City M 00,02,CO 02,CO 0013 Claim Administrator State M 00,02,CO 00,02,CO 02,CO 0014 Claim Administrator Postal Code M 00,02,CO 00,02,CO 02,CO 0015 Claim Administrator Claim Number M 00,02,CO 00 02,CO INSURED 0016 Employer FEIN M 00,02,CO 00,02,CO 00 00,02,CO 02,CO 0017 0018 0019 0020 0021 0022 Insured Name Employer Name Employer Address Line 1 Employer Address Line 2 Employer City Employer State M M M O M M 00,02,CO 00,02,CO 02,CO 00,02,CO 02,CO 02,CO 00,02,CO 02,CO 00,02,CO 00,02,CO 02,CO Field changes Blank or shows "Unknown" Field changes Blank Not a valid state code Field changes Blank First 5 digits the same or not in valid range Field changes If Special Characters or Blank Exact duplicate of last transaction for this claim (Use all DN's for comparison) Field changes Blank Not Numeric FEIN not in our system All numbers the same (e.g.111111111) Field changes Blank Blank Field changes Blank or shows "Unknown" Field changes Field changes Blank or shows "Unknown" Field changes Blank State Code Invalid Field changes 58 1 58 1 58 58 1 58 58 30 57 58 1 28 39 40 58 1 1 58 1 58 58 1 58 1 58 58 Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Must be A-Z, 0-9, or spaces Duplicate Transmission Transaction Code/ID Invalid Mandatory Field Not Present Must be Numeric (0-9) FEIN Number not found (No match on database) All digits cannot be the same Code/ID Invalid Mandatory Field Not Present Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Blank Exact duplicate of last transaction for this claim (Use all DN's for comparison) Not = 00, 02 or CO CO' and no warning fields were changed CO' and no previous warnings for Mnt Type Code Dt (DN 02) Blank Invalid Date Blank Not = MO If blank, do not process rest of transaction If Special Characters Claim has already been filed for Agency Claim Number. An active case resolution for the Agency Claim Nbr exists. Match on Agcy Clm Nbr, but not on two of following: Dt of Injury, Employee SSN, Clm Admin Clm Nbr, Emplyr Fein If no previous transaction found Claim has been combined with another Injury Number. Blank Cannot be all Zeros Does not exist in our Employer Fein File All numbers the same e.g.111111111 Insurer Fein = TPA Fein Insurer Fein = Employer Fein, SI Ind = ' ' or 'N' Field changes If blank, all characters the same (e.g. XXXXX), shows "Self Insured" or "Unknown" Field changes If = spaces or zeroes & TPA Name > spaces Not Numeric Fein Number not in our database. All digits the same (e.g.111111111) Field changes Blank Field changes Blank Field changes Blank Exact duplicate of last transaction for this claim (Use all DN's for comparison) Not = 148 CONDITION CAUSING ERROR ELEM ERR# 1 57 58 64 1 57 58 58 58 1 29 1 58 1 30 42 42 42 53 58 ERROR MESSAGE Mandatory Field Not Present Duplicate Transmission Transaction Code/ID Invalid Invalid Data Sequence Relationship Mandatory Field Not Present Duplicate Transmission Transaction Code/ID Invalid Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Must be a valid date (CCYYMMDD) Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present Must be A-Z, 0-9, or spaces Not Statutorily Valid Not Statutorily Valid Not Statutorily Valid No matching FROI Code/ID Invalid Mandatory Field Not Present Must be Numeric (0-9) FEIN Number not found (No match on database) All digits cannot be the same Code/ID Invalid Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present Must be Numeric (0-9) FEIN Number not found (No match on database) All digits cannot be the same Code/ID Invalid Mandatory Field Not Present. Code/ID Invalid Mandatory Field Not Present Code/ID Invalid ACK CDE CONDITION/PROCESSING NOTES/ FREE FORM TEXT (FFT) MESSAGES

TR Should always be equal to 148. TR TR TR TR TR TR TR FFT: Maint Type Code = "CO"; can only chg warning fields TR FFT: No previous warnings for Maint Type Code Date TR Date transaction flagged for transmission. TR TR TR TR TR TR TR TR TR TR TR TR TR TR TR FFT: Insurer and SCO Fein cannot be the same FFT: Employer not listed as Authorized Self insured in TR database TE FFT: Insurer fields changed. TR If ER is an Authorized Self Insured, SI ER name goes here TE FFT: Insurer fields changed. TR TR Required if Claim Administrator is used on Case. TR TR TE FFT: TPA Fields changed TR Required if Claim Administrator Fein (DN 08) is entered. TE FFT: TPA Fields changed TR Will be Claims Admin Address line 1 when Claims Admin FEIN is entered, otherwise will be Carrier Address Line 1. Will be Claims Admin Address line 2 when the Claims Line 2. another Injury # Mandatory when Missouri accepts all Maintenance Type Codes other than 00. 02, CO - If invalid characters, do not process rest of transaction.of transaction will be processed . Remainder FFT: Cannot change after Claim has been Transaction will be processed, but will be rejected. filed. If two matches areFFT:found, has resolution for insurer will not Case remainder of transaction not be processed. FFT: Case found, but no match on Remainder of transaction will not be processed. additional fields Remainder of transaction FFT: No previous 00 transaction will be processed FFT: Case has been combined into Code = 00(Orig), 01(Cncl), 02(Chg), 04(Dnl), AU (Acqd/Unallocated), CO (Corr)

1
28 39 40 58 58 58 1 58 1 28 39 40 58 1 58 1 58

TE FFT: TPA Fields changed

TE Admin FEIN is entered, otherwise will be Carrier Address
TE FFT: TPA Fields changed Will be Claims Admin City when Claims Admin FEIN is TR entered, otherwise will be Carrier City. TE FFT: TPA Fields changed Will be Claims Admin State when Claims Admin FEIN is entered, otherwise will be Carrier State. TR TR TE FFT: TPA Fields changed Will be Claims Admin Zip Code when Claims Admin FEIN is entered, otherwise will be Carrier Zip If State = MO, Must be range 63000-65899, TR Other States = range 00601-99950 TE FFT: TPA Fields changed TR TR TR FFT: FRI Submitted more than once in this submission TE TR TR TR TR TE FFT: Employer Fields changed TR TR TE FFT: Employer Fields changed TR TE FFT: Employer Fields changed TE FFT: Employer Fields changed TR TE FFT: Employer Fields changed TR TR Must be valid 2-char state code TE FFT: Employer Fields changed FFT: Clm Admin Clm # changed & Ins or TPA Fein/Name didn't

02/11/2008 0023 Employer Postal Code M 00,02,CO 00,02,CO 02,CO 0024 Self Insured Indicator M 00,02, CO 00,02,CO 00,02,CO 0025 0026 0027 POLICY 0028 0029 0030 0031 Industry Code Insured Report Number Insured Location Number Policy Number Policy Effective Date Policy Expiration Date Date of Injury M O O C C C M 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO ACCIDENT 00,02,CO 00,02,CO 00,02,CO 02,CO 02,CO 0032 0033 Time of Injury Postal Code of Injury Site O M 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 0034 0035 Employers Premises Indicator Nature of Injury Code M M 00,02,CO 00,02,CO 00,02,CO 02,CO 0036 Part of Body Injured Code M 00,02,CO 00,02,CO 02,CO 0037 Cause of Injury Code M 00,02,CO 00,02,CO 02,CO 0038 0039 0040 Accident Description/Cause Initial Treatment Date Reported to Employer M M M 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 02,CO 0041 Date Reported to Claim Administrator M 00,02,CO 00,02,CO 00,02,CO 00,02,CO 02,CO 042 Social Security Number M 00,02,CO 00,02,CO 00,02,CO 00,02,CO 02,CO 00,02,CO 0043 0044 0045 0046 0047 0048 0049 Employee Last Name Employee First Name Employee Middle Initial Employee Address Line 1 Employee Address Line 2 Employee City Employee State M M O M O M M 00,02,CO 02,CO 00,02,CO 02,CO 00 02,CO 00,02,CO 02,CO 00 02,CO 00,02,CO 02,CO 00,02,CO 00,02,CO 02,CO 0050 Employee Postal Code M 00,02,CO 00,02,CO 02,CO 0051 Employee Phone O 00,02,CO 02,CO Field changes Blank or "Unknown" Field changes Blank Invalid State Code Field changes Blank First 5 digits the same, or not in valid ranges Field changes Not Numeric / Special Characters Field changes 58 1 58 1 58 58 1 58 58 28 58 Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Must be numeric (0-9) Code/ID Invalid Field changes Blank or "Unknown" Field changes 58 1 58 Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Cannot find venue for this zip Not = Y or N Blank Invalid Code (not numeric; cannot be zeroes) Field changes Blank Invalid Code Field changes Blank Invalid Code Field changes Blank Blank Invalid Code Blank Invalid Date < Date of Injury > Maintenance Type Code Date Field changes but Date of Injury not changed Blank Invalid Date < Date of Injury > Maintenance Type Code Date Field changes but Date of Injury not changed Blank Not Numeric First digit = 8 or 9, All numbers the same (e.g.111111111) First 3 digits = '000', Field changes First 3 digits > 772 Digits are sequential numbers (I.e. 1234567) Blank Field changes Blank Field changes Shows "Unknown" or Ind Applicable" Blank, (if Self Insured "Not= 'N' or blank) Invalid Date Blank, (if Self Insured Ind = 'N' or blank) Invalid Date Blank Invalid Date > Maintenance Type Code Date Claim has already been filed for Agency Claim Number. Year changes and has passed all edits Invalid Time Data is blank or partially blank Blank First 5 digits the same, or not in valid ranges Case is already on a docket/tickler Is Special Characterssame (e.g. 1111111111), Blank, All digits the 30 1 1 29 1 29 1 29 37 42 58 31 58 1 58 58 58 58 1 58 58 1 58 58 1 58 58 1 1 58 1 29 34 37 58 1 29 34 37 58 1 28 40 58 58 64 1 58 1 58 Must be A-Z, 0-9, or spaces Mandatory Field Not Present Mandatory Field Not Present Must be a valid date (CCYYMMDD) Mandatory Field Not Present Must be a valid date (CCYYMMDD) Mandatory Field Not Present Must be a valid date (CCYYMMDD) Must be <= Maint Type Cd Dt (DN 0003) Not Statutorily Valid Code/ID Invalid Must be a valid Time (HHMM) Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Mandatory Field Not Present Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present. Must be a valid date (CCYYMMDD) Must be >= Date of Injury Must be <= Maintenance Type Code Date Code/ID Invalid Mandatory Field Not Present Must be a valid date (CCYYMMDD) Must be >= Date of Injury Must be <= Maintenance Type Code Date Code/ID Invalid Mandatory Field Not Present Must be numeric (0-9) All digits cannot be the same Code/ID Invalid Code/ID Invalid Invalid Data Sequence/Relationship Mandatory Field Not Present Code/ID Invalid Mandatory Field Not Present Code/ID Invalid Blank First 5 digits the same, or not in valid ranges Field changes Not = Y, N or blank "Y" and the Employer is not listed as an Authorized Self Insured when the injury occurred Employer is listed as an "N" and the Authorized Self Insured when the injury occurred Invalid Code 1 58 58 58 58 58 Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Code/ID Invalid Code/ID Invalid Code/ID Invalid TR TR

1730539.xls, FROI Requirements If State = MO, Must be range 63000-65899,

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Other States = range 00601-99950 TE FFT: Employer Fields changed Must be "Y" if Employer is an Authorized Self-Insured

58

Code/ID Invalid

ER not listed as SELF INSURED (DN 0024) FFT: Employer not listed as an Authorized self insured in database FFT: Employer is listed as an Authorized self insured in TR database. If SIC Code - pos 5-6 MUST = "SC"; otherwise it is assumed TR to be NAICS Code. TR

TR

TR
TE TR Required if Self Ins Ind (DN 0024) = N.

Number assigned by Ins Co, not SCO. TR Required if Self Ins Ind (DN 0024) = N. TR TR Required if Self Ins Ind (DN 0024) = N. TR TR TR TR TR FFT: Cannot change after claim has been filed TE FFT: Injury Year changed TE TE TR TR TR FFT: Case is on docket so venue not changed TR FFT: Could not find venue for zip code TR TR TR TE FFT: Field changed TR TR Must be numeric and Code in our database TE FFT: Field changed TR TR Must be numeric and Code in our database TE FFT: Field changed TR TR TR *** See special notes. TR TR TR TR TR FFT: Cannot change unless Date of Injury changes TR TR TR TR TR FFT: Cannot change unless Dt of Injury changes TR TR TR TR Must be valid SSN. TE FFT: Employee field changed TR TR TE FFT: Employee field changed TR TE FFT: Employee field changed TE

TE FFT: Employee field changed
TR

TE FFT: Employee field changed TE TE FFT: Employee field changed
TR

TE FFT: Employee field changed
TR TR Must be valid 2-digit state code.

TE FFT: Employee field changed
TR TR If State = MO, Must be range 63000-65899, Other States = range 00601-99950

TE FFT: Employee field changed
TE

TE FFT: Employee field changed

02/11/2008 0052 Employee Date of Birth M 00,02,CO 00,02,CO 00,02,CO 00,02,CO 0053 0054 0055 Gender Code Marital Status Code Number of Dependents M O C 00,02,CO 00,02,CO 00,02,CO 00,02,CO 02,CO 0056 Date Disability Began C 00,02,CO 00,02,CO 00,02,CO 02,CO 0057 Employee Date of Death C 00,02,CO 00,02,CO 00,02,CO 02,CO EMPLOYMENT 0058 Employment Status Code O 02,CO 00,02,CO 0059 0060 0061 Class Code Occupation Description Date of Hire M O O 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 0062 Wage M 00,02,CO 00,02,CO 00,02,CO 02,CO 0063 Wage Period M 00,02,CO 00,02,CO 02,CO 0064 0065 Number of Days Worked Date Last Day Worked O O 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 02,CO 0066 0067 0068 Full Wages Paid for Date of Injury Indicator Salary Continued Indicator Date of Return to Work O O C 00,02,CO 00,02,CO 00,02,CO 00,02,CO 00,02,CO 02,CO Invalid Date > Date of Injury > Maintenance Type Code Date Blank Not Numeric Wage < or = $1.00 Form-2 (Lost Time) record has been received Blank Invalid Code Form-2 (Lost Time) record has been received >7 Not numeric Invalid Date If > spaces, but < Date of Injury > Maintenance Type Code Date Form-2 (Lost Time) record has been received Invalid Code Invalid Code Invalid Date < Date Disability Began > Maintenance Type Code Date Form-2 (Lost Time) record has been received 29 33 37 1 28 45 42 1 58 42 18 28 29 34 37 42 58 58 29 35 37 42 Must be a valid date (CCYYMMDD) Must be <= Date of Injury Must be <= Maintenance Type Code Date (Data Element 0003 Mandatory Field Not Present Must be Numeric (0-9) Value is < Required by Jurisdiction Not Statutorily Valid Mandatory Field Not Present Code/ID Invalid Not Statutorily Valid Number of days worked must be 0-7 Must be numeric (0-9) Must be a valid date (CCYYMMDD) Must be >= Date of Injury Must be <= Maintenance Type Code Date Not Statutorily Valid Code/ID Invalid Code/ID Invalid Must be a valid date (CCYYMMDD) Must be >= Date Disability Began (DN 0056) Must be <= Maintenance Type Code Date Not Statutorily Valid Invalid Date, Blank Employee less than 14 years old, > Date of Injury Employee greater than 85 years old > Maintenance Type Code Date Blank Invalid Code Invalid Code Not Numeric Form-2 (Lost Time) record has been received Invalid Date >Maintenance Type Code Date <= Date of Injury Form-2 (Lost Time) record has been received Invalid Date < Date of Injury > Maintenance Type Code Date Field changes Valid code but Form-2 (Lost Time) has been received Invalid Code Blank Not Numeric or not valid code 1 29 33 37 1 58 58 28 58 29 37 45 58 29 34 37 58 42 58 1 58 Mandatory Field Not Present Must be a valid date (CCYYMMDD) Must be <= Date of Injury Must be <= Maintenance Type Code Date Mandatory Field Not Present Code/ID Invalid Code/ID Invalid Must be Numeric (0-9) Code/ID Invalid Must be a valid date (CCYYMMDD) Must be <= Maintenance Type Code Date Value is < Required by Jurisdiction Code/ID Invalid Must be a valid date (CCYYMMDD) Must be >= Date of Injury Must be <= Maintenance Type Code Date Code/ID Invalid Not Statutorily Valid Code/ID Invalid Mandatory Field Not Present Code/ID Invalid TR TR TR TR TR

1730539.xls, FROI Requirements FFT: Employee less than 14 yrs old. FFT: Employee > 85 years of age

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TR Must be M=Male, F=Female, U=Unknown TE *** See special notes. TR Required if Date of Death (DN 0057) is entered.

TE FFT: Lost Time (Form-2) record exists
TR TR TR Must be entered if EE doesn't ret to work DOI + 1

TE FFT: Lost Time (Form-2) record exists
TR TR TR Must be entered if accident was fatal.

TE FFT: Employee field changed
TE FFT: Cannot change since Form-2 has been filed. TE *** See special notes. TR TR Must be valid NCCI Class Code.

TR
TE TE TE TR TR FFT: Wage contains spaces TR TR FFT: Cannot change since form-2 has been filed. TR TR 1=Weekly, 2=Bi-Weekly, 4=Monthly, 6=Daily TR FFT: Cannot change since form-2 has been filed. TE TE TE TE TE TE FFT: Cannot change since form-2 has been filed. TE N=No, Y=Yes, U=Unknown TE TE TE TE TE FFT: Cannot change since form-2 has been filed. ** See special notes. Required if EE has returned to work

02/11/2008

1730539.xls, FROI Special Notes

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Special Notes:
* When Initial Treatment Code (Data Element 0039) is reported as equal to 00, 01 or 02, the worker’s compensation case will be considered a medical only case. If the time period between the Date Disability Began (Data Element 0056) and the Date Returned to Work (Data Element 0068) is three days or less, the case will be classified as a medical only case. You will receive a letter requesting the cost of medical treatment and the date returned to work, if not supplied. After all required information has been filed and there is no further activity in a case for six months, the case may be administratively closed. When the Initial Treatment Code (Data Element 0039) is reported as equal to 03, 04 or 05, the workers’ compensation case will be considered as an indemnity case. You will receive a letter requesting the cost of medical treatment, the date returned to work, and the total amount of temporary total disability benefits paid to the employee. ** When the Date Returned to Work (Data Element 0068) is more than three days from the Date Disability Began (Data Element 0056), the workers’ compensation case will be considered an indemnity case. You will receive a letter requesting the cost of medical treatment, the date returned to work, and the total amount of temporary total disability benefits paid to the employee. *** Codes Initial Treatment Codes 00 = No Medical Treatment 01 = Minor on-site remedies by employer 02 = Minor clinic/hospital medical remedies 03 = Emergency Evaluation 04 = Hospitalization > 24 hours 05 = Future Major Medical/Lost Time

Marital Status Codes M=Married S=Separated K=Unknown U=Widowed, Divorced, Single, Unmarried

Employment Status Codes Description Piece Worker Volunteer Worker

Flat File C

ANSI File PW

9 VO 8 SL Seasonal A AD Apprenticeship Full Time B AP Apprenticeship Part Time 1 FT Regular Employee 2 PT Part-Time Employee 3 NE Unemployed 6 RT Retired 4 PS On Strike 5 DS Disabled 7 AA or UK Other FFT - Free Form Text - This is a special custom error message that will appear in the free form text portion of the Acknowledgement record. M – Mandatory Error - Cases having fatal errors will NOT be accepted in the Missouri Division of Workers’ Compensation system. These cases will be returned in the Acknowledgment File as Acknowledgment Code “TR”. These cases can then be resubmitted as MTC 00 once the fatal errors have been corrected. C – Conditional – Data Elements with Conditional errors indicate a value is required based on another Data Element or pre-existing condition. Conditional errors can cause rejection of the Case (Acknowledgment Code “TR”), or the Case may be accepted with errors (Acknowledgement Code “TE”) based on the value entered in the Data Element. O – Optional - Data elements identified as Optional may be entered but are not required.

02/11/2008

1730539.xls, Acknowledgment Format

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IAIABC RELEASE 1 ACKNOWLEDGMENT RECORD (AK1)
IAIABC GROUPING TRANSACTION IAIABC DN 0001 0107 0108 0109 0006 0014 0008 0110 0111 0026 0015 0005 0002 0003 IAIABC DATA ELEMENT NAME Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer FEIN Claim Administrator Postal Code Third Party Administrator FEIN Acknowledgment Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Agency Claim Number Maintenance Type Code Maintenance Type Date IAIABC FORMAT 3 A/N 9N DATE HHMMSS 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 BEG POS END POS 1 3 4 12 13 20 21 26 27 35 36 44 45 53 54 56 57 58 59 83 84 108 109 133 134 135 136 144 147 207 143 146 206 208

VARIABLE SEGMENT ERROR CODE

0112 Request Code (Purpose) 0113 Free Form Text 0114 Number of Errors Error Code = Occurs Number of Error Times (Up to 99 Times) 0115 0116 0117 Element Number Element Error Number Variable Segment Number

4N 3N 2N

209 213 216

212 215 217

02/11/2008

1730539.xls, Acknowledgment Requirements

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IAIABC RELEASE 1 ACKNOWLEDGMENT RECORD (AK1)
IAIABC GROUPING TRANSACTION IAIABC DN 0001 0107 0108 0109 0006 0014 0008 0110 0111 0026 0015 0005 0002 0003 IAIABC DATA ELEMENT NAME Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer FEIN Claim Administrator Postal Code Third Party Administrator FEIN Acknowledgment Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Agency Claim Number Maintenance Type Code Maintenance Type Date REQ CDE M M M M C C C M M C C C C C 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO None = 0, Contact Sender = 1 MTC 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO 00, 02,CO CONDITION CAUSING ERROR ELEM ERR# ERROR MESSAGE ACK CDE CONDITION/ PROCESSING NOTES Acknowledgement Detail Record AK1 Header Error = 000000000 Trailer Error =999999999

1st Report of Injury = 148· Transmission Rejected = HD Transaction Accepted = TA Transaction Rejected = TR Transaction Accepted with Errors = TE

Example: Original

98 000001 00

VARIABLE SEGMENT ERROR CODE

0112 Request Code (Purpose) O 0113 Free Form Text O 0114 Number of Errors M Error Code = Occurs Number of Error Times (Up to 99 Times) 0115 0116 0117 Element Number Element Error Number Variable Segment Number M M M

00, 02,CO 00, 02,CO 00, 02,CO

02/11/2008

1730539.xls, Header Format

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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 (future use) Sender Postal Code Receiver ID Receiver FEIN Filler (rsvd for poss. future use) Receiver Postal Code Date Transmission Sent Time Transmission Sent Original Transmission Date Original Transmission Time Test/Production Indicator Interchange Version ID Transmission Type Code Release Number 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 HHMMSS DATE HHMMSS 1 A/N 5 A/N 3 A/N 2 A/N BEG POS END POS 1 3 4 28

0099

29

53

0100 0101 0102 0103 0104 0105

54 62 68 76 82 83

61 67 75 81 82 87

02/11/2008

1730539.xls, Header Requirements

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IAIABC RELEASE 1 HEADER RECORD (HD1)
IAIABC GROUPING IAIABC DN 0000 0001 IAIABC DATA ELEMENT NAME Transaction Set ID REQ CDE M Duplicate Batch 0098 Sender ID Sender FEIN M Blank Not in our Trading Partner Table Filler (future use) Sender Postal Code Receiver ID Receiver FEIN Filler (rsvd for poss. future use) Receiver Postal Code Date Transmission Sent 39 39 No Match on Database No Match on Database TR TR FFT: Header Record - Sender Fein is blank FFT: Trading Partner not valid or not in system 57 Duplicate Transmission/Transaction TR MTC CONDITION CAUSING ERROR Header without Transaction records ELEM ERR# 61 ERROR MESSAGE Event Criteria not met ACK CDE TR CONDITION/ PROCESSING NOTES FFT:Header Record without transactions Transmission Header Record HD1 FFT: Duplicate EDI Batch

TRANSACTION

0099

0100

M Invalid Greater than Current date

29 41 31

Must be a valid date (CCYYMMDD) Must be <= Current date Must be a valid time (HHMMSS)

TR TR TR

FFT: Header Record - Date Transmission Sent invalid

0101 0102 0103 0104 0105

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

M C C M M

Time is invalid

FFT: Hdr Time is not correct

Not valid or not set this way in our system Not equal "HD1", "148" or "TR1"

39 58

No Match on Database Code/ID Invalid

TR TR

Test = T, Production = P Header indicated test file

FFT:

1st Report of Injury Release Number

148 · 1·

· Only value possible for Missouri

02/11/2008

1730539.xls, Trailer Format

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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 BEG POS END POS 1 3 4 12

02/11/2008

1730539.xls, Trailer Requirements

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IAIABC RELEASE 1 TRAILER RECORD (TR1)
IAIABC GROUPING TRANSACTION IAIABC DN 0001 0106 IAIABC DATA ELEMENT NAME Transaction Set ID Detail Record Count REQ CDE M N umber of transactions does not equal Detail Record Count MTC CONDITION CAUSING ERROR ELEM ERR# 56 Detail Record count not equal nbr records recvd ERROR MESSAGE ACK CDE M M CONDITION/ PROCESSING NOTES Transmission Trailer Record TR1 Sequential Nbr. 000000001 FFT: Records in batch do not equal Detail Record Cnt