IAIABC EDI IMPLEMENTATION GUIDE

for
First, Subsequent, Acknowledgment Detail, Header, & Trailer Records

Release 1 February 15, 2002
Includes Flat File, Hard Copy and ANSI Formats
International Association of Industrial Accident Boards and Commissions

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TABLE OF CONTENTS
FOREWORD Introduction .......................................................................................................................... 3 Data Collection Objectives.................................................................................................... 5 Entities Responsible for Workplace Data.............................................................................. 7 Current Data Initiatives....................................................................................................... 11 ANSI ASC X12 Alliance ....................................................................................................... 13 IAIABC Electronic Data Interchange (EDI) Project .............................................................. 15 SECTION 1: THE EDI PROJECT Introduction .......................................................................................................................... 1-3 EDI Philosophy ..................................................................................................................... 1-5 IAIABC Project Mission Statement........................................................................................ 1-7 Antitrust Statement............................................................................................................... 1-7 IAIABC EDI Committees........................................................................................................ 1-9 SECTION 2: EDI CONTACTS Contacts List ......................................................................................................................... 2-3 SECTION 3: SYSTEMS IMPLEMENTATION GUIDE (Including Forms and Tables) Systems Guide...................................................................................................................... 3-3 Process Model Record Layouts............................................................................................ 3-35 Electronic Data Interchange Partnering Agreement.............................................................. 3-47 Master Trading Partner Profile.............................................................................................. 3-51 Transmission Profile – Receiver’s Specifications................................................................. 3-53 Transmission Profile – Sender’s Response .......................................................................... 3-55 Event Table........................................................................................................................... 3-57 Element Requirement Table (Part I ....................................................................................... 3-61 Element Requirement Table (Part II)..................................................................................... 3-65 Payment/Adjustment Element Requirement Table................................................................ 3-69 Edit Matrix Table................................................................................................................... 3-71 SECTION 4: TRANSACTION STANDARDS Hard Copy Form and Instructions......................................................................................... 4-5 IAIABC Flat File Record Layouts Acknowledgment Record (AK1)..................................................................................... 4-11 First Report of Injury (148)............................................................................................. 4-13 Subsequent Report of Injury (A49) ................................................................................ 4-15 Trailer Record (TR1) ...................................................................................................... 4-17 Header Record (HD1) ..................................................................................................... 4-19 ANSI X12 N Formats ............................................................................................................. 4-23 SECTION 5: ELECTRONIC SCENARIOS Release 1 Limitations............................................................................................................ 5-3 Scenarios.............................................................................................................................. 5-7 SECTION 6: DEFINITIONS, GLOSSARY, AND CODE LISTS Data Format.......................................................................................................................... 6-5 Definitions ............................................................................................................................ 6-6 Glossary ............................................................................................................................... 6-47 Appendix – Code Lists Part of Body Codes....................................................................................................... 6-63 Nature of Injury Codes................................................................................................... 6-65 Cause of Injury Codes................................................................................................... 6-67 FIPS Codes.................................................................................................................... 6-71

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FOREWORD

Foreword

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INTRODUCTION
Welcome and thank you for participating in the IAIABC Electronic Data Interchange (EDI) Project. This manual has been created to help your organization implement the IAIABC EDI Standards. It should be noted as states implement the standard, systems and reporting environments may vary between trading partners which could limit the ability to process some transactions as originally designed. It contains sections of documents that target your management, technical, and information systems staff. The Foreword provides an in-depth background on Workers’ Compensation data collection activities, and provides the rationale for developing National Standards and EDI. Section 1, the EDI Project, provides project philosophy, and organizational documents that will provide assurance and confidence in the project’s direction. Section 2, EDI Contacts, provides jurisdiction and EDI committee participant information from which opinions, assistance, and EDI partners can be found. Information is also provided to enable you to access the IAIABC website to provide you with a host of project and continual updates information. Section 3, Systems Implementation Guide, will assist you through the implementation process. It contains a brief implementation primer. It also contains an EDI Partnering Agreement, Trading Partner and Transmission Profiles, Event Tables, Element Requirement Tables and Edit Matrix Tables. Section 4, Transaction Standards, includes IAIABC Release 1 data requirements as expressed in hard copy, flat file and ANSI ASC X12 formats. These documents identify the technical positioning of the data in the data vehicle. ANSI ASC X12 format transactions provide both X12 and IAIABC data names. Section 5, Electronic Scenarios, contains scenarios that define the approved usage and scope/limitations of this report. Expansions or alterations are not authorized unless coordinated through the appropriate IAIABC EDI Committee Work Group by willing participants for the intent of pre-release testing, or developing enhancements of interest to our participants. Section 6, Definitions, Glossary & Codes Lists, provides definitions and formats for all data referenced in the transactions and scenarios. Together these documents should provide the initiative and information necessary to get started in IAIABC Workers’ Compensation EDI. Thank you for joining us in our effort to improve Workers’ Compensation.

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DATA COLLECTION OBJECTIVES

The need for reliable information regarding workers’ compensation has been recognized virtually since the birth of the system. In 1914 the Commission on Workmen’s Compensation Laws stated that: “No real knowledge of the operation of Workmen’s Compensation Acts can be acquired until complete statistics have been gathered . . . injustices that may exist through the law cannot be remedied until the facts are known, and the facts cannot be known until complete statistics have been compiled.” Later the drafters of the 1970 Occupational Safety and Health Act (OSHA) recognized the lack of suitable data and called for the effective compilation and analysis of injury statistics. Subsequently, the National Commission on State Workmen’s Compensation Laws noted the deficiencies of the current level of data and stated that such failings handicapped the effective evaluation and administration of state programs. The passage of time has not alleviated the need for uniform and reliable information regarding the operation of the workers’ compensation program. Time has, however, served to solidify the objectives of any effort to expand data collection. These objectives include: • • • • • • Measure aggregate system costs, Establish a uniform means to identify the causes of workplace injury/illness, Develop management information to measure the effectiveness of benefit delivery systems, Provide information for comparing experience across jurisdictional lines, Identify cost drivers in the system, and Measure the impact of legislative and regulatory change.

As the objectives for collecting workers’ compensation data have become more focused, there has been a corresponding recognition for the two forms of statistical data being requested most frequently. • RATE-SETTING DATA — This data is collected by rating organizations and insurance departments for purposes of setting rates and allocating costs to policy, class, etc. While utilized primarily for that purpose, this type of data is also collected by program administrators to monitor payments by injury type and establish the amounts paid or incurred for medical and vocational rehabilitation services. MANAGEMENT DATA — Management data is comprised of those data elements which demonstrate proof of coverage, ascertain the type of claims being compensated, and measure the effectiveness of the program in terms of the timeliness in delivering benefits.

While the two forms of data furnish unique perspectives of what is occurring within the system, in combination they furnish a complete description of both the efficiency and the cost of the benefit delivery system program. There is considerable redundancy in these two forms of data. While some redundancy is unavoidable, it should be eliminated wherever possible to reduce costs and improve data reliability and consistency. Notwithstanding the objectives of an expanded data collection capability, it is important to reaffirm the goal of achieving the collection of necessary and accurate data through the most cost effective means possible. Any effort to enhance the data collection process must weigh the need for the data versus the anticipated cost of collecting the data and ensuring that its accuracy is sufficient to meet the intended purposes.

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ENTITIES RESPONSIBLE FOR WORKPLACE DATA

While there is frequent reference to the lack of adequate and credible workers’ compensation data, there is no question that data is being gathered by various entities for select purposes. Each of these entities collect data for unique purposes with a focus toward either management or financial data. The following identifies the major entities engaged in the collection of workplace data and includes an abbreviated review of the purpose of the effort and the type of data being collected.

A. OCCUPATIONAL SAFETY AND HEALTH (FEDERAL AND STATE)
The principal facility identified at the federal level for collecting statistics on workplace injuries or illnesses was established by the Occupational Safety and Health Act (OSHA) of 1970. OSHA requires covered employers to prepare and maintain records of occupational injuries and illnesses. Covered employers include all employers except those with fewer than 5 employees, or employers in low hazard industries (e.g. retail trade, finance, insurance and real estate). The Bureau of Labor Statistics (BLS), through a sample of employers, conducts an annual occupational injury and illness survey. This survey is used to develop national occupational injury and illness estimates by the 4-digit Standard Industrial Classification (SIC) codes in most industries and at the 2digit code in most non-industrial industries. Annually published exhibits illustrate experience by nature of injury, part of body affected and injury source, and include the number of lost workday cases and the number of lost workdays. Recordable injuries and illnesses are occupational fatalities, non-fatal occupational illnesses, or nonfatal occupational injuries which involve loss of consciousness, restriction of work or motion, transfer to another job, or medical treatment other than first-aid. State OSHA facilities compile individual state experience for state reporting purposes, and submit the same data to the federal organization for compilation of national statistics. Data is used at both the state and federal level to target safety programs.

B. WORKERS’ COMPENSATION INSURANCE ORGANIZATIONS (WCIO)
The WCIO is a voluntary association of statutorily authorized or licensed rating, advisory or data service organizations collection workers' compensation insurance information in or more states. Members of the WCIO include the independent rating bureaus, NCCI, Inc. and Insurance Services Office (ISO). The members of these organizations are the insurers writing workers' compensation in their respective jurisdictions. Carriers and insurers provide the rating bureaus and/or advisory organizations with policy, premium and claim information as well as specific data needs in their respective states. The information collected is used for a variety of purposes such as ratemaking, experience rating, lost cost analysis, etc. Additionally, many of these organizations provide proof of coverage information to state jurisdictions. The WCIO has developed standards for the electronic transmission of information between insurance carriers and rating/advisory organizations. These specifications are available for policy information, unit statistical reporting, experience modifications, detailed claim information and individual case reports. A subcommittee of WCIO maintains the specifications manual.

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ENTITIES RESPONSIBLE FOR WORKPLACE DATA (cont.)

C. STATE WORKERS’ COMPENSATION ADMINISTRATIVE AGENCIES
Many state workers’ compensation agencies — identified as industrial commissions, accident boards, divisions, etc. — have extended their role beyond that of dispute resolution to include monitoring the benefit delivery process, assisting injured workers in understanding their rights and obligations under the law and collecting statistical data regarding the program’s operation. State agencies require employers, insurers and medical providers to file reports containing claim and payment activity information. This generally originates with the Employers First Report of Injury. This report provides information regarding the identification of the employer and injured worker, the time and location of the accident, and details relative to how the injury occurred, the part of body involved, and the extent of the injury. Many states require the filing of subsequent reports which detail the time when indemnity benefits begin, the type of benefits being paid, and the amount of prior earnings subject to replacement. A number of states collect payment information on a periodic basis and a summary of payments by type of benefit when the claim is concluded. A few states also collect detailed data on medical treatment expenses and amounts paid and outcomes of vocational rehabilitation. State agencies use this information to monitor the benefit delivery process and informally assist workers by explaining rights and entitlements under the law. Separate information is generally tracked internally to monitor the status of adjudication and dispute outcomes. Many states compile detailed data on lost-time injuries and publish annual statistical reports on claim experience. Often times, they cooperate through the network established by the IAIABC to publish national and multi-national reports on claim experience.

D. OTHER SOURCES OF WORKPLACE DATA
In addition to data collection that takes place by those entities previously described, independent efforts exist to collect workplace injury data. Two of the more prominent efforts include individual employer or insurer data systems, and independent claim surveys. Individual employers and insurers have developed sophisticated computer systems to retrieve information in order to monitor claim experience and cost development. This data begins with the coverage information entered when the policy is issued and is supplemented with loss information filed at the time the claim is reported. This loss information is designed to capture payment data with detail at the level of benefits paid by injury type, the medical paid by procedure code, and litigation status. Additionally, these systems track development and compare experience over time. The second source, used frequently at the state level, involves the compilation of information through survey forms. Frequently, in response to proposed legislative activity, claim surveys are conducted to elicit specific information in order to document the extent of a perceived problem. Such surveys generally focus on cases closed during a specific period of time or on claims involving select injury type claims (e.g. permanent partial disability cases). Surveys are usually conducted through a sample of cases. Data collected both through individual employer and carrier claim files, and claim survey forms, is utilized by research organizations such as the Workers’ Compensation Research Institute (WCRI) or the California Workers’ Compensation Institute (CWCI). These research organizations identify system characteristics and develop information that assists legislators and program reformers to focus on specific problems and issues. Claim surveys are also used by regulators and statistical agencies to augment the data collected through other mechanisms.

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ENTITIES RESPONSIBLE FOR WORKPLACE DATA (cont.)

SUMMARY
The foregoing demonstrates in an abbreviated fashion the types and purposes of the data collected by the major entities involved including governmental entities as well as other interest groups. While each entity may be collecting data for distinct purposes, there is a significant amount of overlap in information collected during the life of the claim or period of program coverage. In similar fashion, there is the potential for these different entities to develop jurisdictional unique terms or definitions for purposes of describing certain benefit types. As these entities develop the capability to transmit information electronically, there also exists the possibility of developing multiple data formats for the same data element. All of these entities are interested in collecting complete and accurate data in a timely manner. The most efficient and accurate form in which to collect this information requires uniformity and standardization. Where possible, duplicate collection should be eliminated and the data needs should be analyzed to ensure that the information can be used to compare experience across jurisdictional lines.

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CURRENT DATA INITIATIVES

Recognizing the multiple purposes for which data is being collected, a number of efforts have been undertaken to refine and improve this collection capability. The International Association of Industrial Accident Boards and Commissions (IAIABC), the National Association of Insurance Commissioners (NAIC), the National Council on Compensation Insurance Inc. (NCCI), the independent rating bureaus, the Bureau of Labor Statistics (BLS), and the United States Department of Health and Human Services are the principal organizations engaged in these data collection efforts. Through efforts that began independently, working groups from each of these organizations now work jointly to recommend the collection of certain basic data elements in order to understand and monitor developments in the workers’ compensation arena.

A. THE INTERNATIONAL ASSOCIATION OF INDUSTRIAL ACCIDENT BOARDS AND COMMISSIONS (IAIABC)
The IAIABC is an association of administrators from state workers’ compensation agencies. One of their objectives is to develop and recommend standards for improving and strengthening workers’ compensation laws and their administration. Since 1914, the IAIABC has been examining appropriate collection and use of industrial accident data. As a result of an effort that began in 1987, the Statistics Committee of the IAIABC compiled a listing of recommended management and payment data elements for state administrators to collect on each losttime claim. This proposal was adopted by the IAIABC membership in 1990. Subsequent to that activity, the IAIABC has embarked on a project to develop standards for communicating data electronically between providers, payers, and state administrators through Electronic Data Interchange (EDI). Common formats and data reporting specifications are being developed for the First Report of Injury, the subsequent payment reports, medical information, vocational rehabilitation, litigation activity, and proof of coverage. The IAIABC EDI project includes representation from state administrative agencies, insurance carriers, rating bureaus, research organizations, self-insured employers, standards organizations and vendors. The background and current status of the EDI project will be more fully described in the following section.

B. WORKGROUP FOR ELECTRONIC DATA INTERCHANGE (WEDI)
A committee under the direction of the Secretary of the United States Department of Health and Human Services is examining standardization of medical reports and the electronic transfer of medical information for all lines of health insurance. The IAIABC EDI working group has entered into discussions with the WEDI task force in order to ensure that the efforts are coordinated and that the concerns for workers’ compensation are recognized.

C. WORKERS’ COMPENSATION INSURANCE ORGANIZATIONS (WCIO)
The WCIO is an organization comprised of the managers of the various boards and bureaus. Their objective is to provide to their members, standards for the exchange of informations. One of their major publications is the WCIO Workers’ Compensation Data Specifications Manual. This manual contains magnetic tape specifications for reporting policy (WCPOLS), unit statistical information (WCSTAT), and claim information (WCCDCI), in addition to other products. Recently, the WCPOLS segment was revised to include the IAIABC Proof of Coverage (POC) data elements. This permits the organizations’ members to submit their POC data using WCPOLS, which could then be reformatted, if necessary, and provided to the industrial accident boards and commissions.

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CURRENT DATA INITIATIVES (cont.)

D. NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS (NAIC)
The NAIC is an association of state insurance commissioners responsible for all lines of insurance including workers’ compensation. The NAIC established a working group of the Workers’ Compensation Statistical (D) Task Force to examine the subject of workers’ compensation data collection. Utilizing the listing of data elements developed through a series of meetings, the NAIC adopted a Workers’ Compensation Insurance Data Reporting Model Regulation at their December 1989 meeting. The model regulation provides that insurance carriers, state funds and self-insured employers are to report their statistical experience to at least one of the statistical agents designated by the Commissioner. The model regulation calls for an annual data report to be completed on a selected sample of workers’ compensation claims.

E. INSURANCE DATA MANAGEMENT ASSOCIATION WORKGROUP (IDMA)
A working group, sponsored by the Insurance Data Management Association (IDMA) is currently reviewing the different injury coding schemes that have evolved over time with the goal of devising a standard injury coding format. This group is composed of representatives from OSHA, the Bureau of Labor Statistics (BLS), state workers’ compensation administrators, the IAIABC, the workers’ compensation rating bureaus and member insurance companies. This effort will permit a better interface between industry and federal data.

SUMMARY
This overview of ongoing data collection activities clearly demonstrates that there is both a tremendous amount of interest and activity directed to the collection of credible, accurate data in a timely manner. This activity speaks to the need for coordination in the area of workers’ compensation data collection.

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ANSI ASC X12 ALLIANCE

AMERICAN NATIONAL STANDARDS INSTITUTE
Accredited Standards Committee for Electronic Data Interchange Insurance (ANSI ASC X12N) The IAIABC EDI Committee has been working with ANSI ASC X12N since June 1991. Both organizations provide different qualities that are helpful. Currently, there are ANSI compatible versions of Release 1 First and Subsequent Reports, Proof of Coverage and the Medical Bill/Payment Report. ANSI accredits national standard setting bodies in the United States. Traditionally these standards have been used to set product design and safety standards. These standards provide both manufacturer and consumer with confidence and thus improve commerce. Working with ANSI ASC X12 provides the following benefits: Standards: Standards provide vendors with confidence that will attract them to produce products and services that enhance EDI. The involvement of vendors reduces the individual effort required by companies and ultimately lowers implementation and operation costs.

Translators: Are used to map sender and receiver data to ANSI designed transactions. This can simplify revisions and coordination of trading partner differences. Connectivity: Provides compatibility with Trading Partners and intermediaries who offer data storage, forwarding, and inter-operability services. Software: Off the shelf solutions often cost less. Because ANSI is used for other business requirements, i.e. purchase orders, the software may be readily available or easily adapted.

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IAIABC ELECTRONIC DATA INTERCHANGE (EDI) PROJECT

INTRODUCTION
Over the past decade, many developments in computer technology have had extensive articles written about them. In recent years a technology topic that has grown in popularity and usage is EDI. It seems to be the acronym or “buzz” word of choice in many technology and insurance magazines. EDI, short for Electronic Data Interchange, represents the electronic exchange of information, without the element of human intervention. EDI has grown out of the need to pass data quickly between trading partners and had its genesis as far back as the 1960s when magnetic media was the most effective choice available. However, due to recent improved computer and data communication technology, it has helped speed the trend toward EDI solutions. The expanded usage of EDI has resulted in greatly increased transfer of information and reduced clerical and data entry costs. Electronic Data Interface (EDI) in Workers’ Compensation represents an extension of an earlier International Association of Industrial Accident Boards and Commissions (IAIABC) project which focused on the identification of data elements for Workers’ Compensation system participants to collect. This listing of recommended data elements was compiled over a period of time during which insurance regulators, state program administrators, insurance carriers, and self-insured employers, identified those articles of information that would develop a core of data elements in order to provide credible management and financial information. The EDI stage of that project simply moves the discussion on data collection to the next natural level. After establishing a listing of recommended data elements for collection, the next issue to address is the identification of the most cost efficient and accurate manner in which to collect that data. EDI represents that next natural phase. State workers’ compensation agencies, responsible for monitoring the benefit delivery process, represent the most practical location for collecting that data. Those agencies presently utilize paper forms to monitor the claim process on each lost-time claim. Rather than utilizing those various forms (e.g. first injury reports, memorandum of payment, case progress reports, closed claim information, etc.) the EDI effort is intended to replace such forms through an electronic link whereby a standardized listing of data elements can be communicated electronically. EDI simply represents the use of current capabilities to effectively transmit data deemed appropriate.

POINTS FAVORING EDI
When proposing EDI for Workers’ Compensation, it is beneficial to first identify those features which favor its adoption. Those features have application whether we are discussing the employers, the carriers, or the perspective of the state agency and include the following: • The principal reason in support of EDI is the cost efficiencies associated with the same. Reduced cost can be realized through the elimination of data entry at the state agency level when the state system is directly linked to an external data source. While state agencies realize an immediate benefit through accepting First Reports of Injury electronically, subsequent payment reports filed via electronic means represent significant savings for employers and carriers. Additional savings are connected with reduced filing space requirements and reductions in the expenditures for postage and mail sorting and delivery time. Along with savings associated with the direct transfer of data through electronic means, there is the separate issue of improved data accuracy. Information entered or “keypunched” a number of times is subject to error. The fewer times it is necessary to enter information, the greater will be the degree of accuracy. There is little value in collecting and utilizing data unless there is a strong assurance that the data is accurate. The ongoing collection of appropriate financial data in a timely fashion provides the opportunity to continually monitor and measure changes in the workers’ compensation environment. The electronic submission of data on all claims can permit comparison of experience at different points in time and across jurisdictional lines. This will afford the opportunity to identify systemic problems.
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IAIABC EDI PROJECT (cont.)

A concluding reason to support EDI is that it will culminate in the creation of comprehensive data bases at the state level that are standardized among states in the type and format of data being collected. Standardized formats assist benefit providers to manage one standard rather than fifty systems to respond to the needs of fifty different states.

The potential for cost savings through the elimination of duplicative entry processes and the efficiencies associated with a single standard for data transfer make this project a key to controlling expenses in the workers compensation cost environment.

STATUS OF THE EDI PROJECT
The EDI project grew out of the work of the IAIABC’s Statistic’s Committee initiatives. On April 26, 1916, the Chair of the IAIABC’s Committee on Statistics and Compensation Insurance Cost introduced a plan to promote uniform practices in collecting and utilizing administrative information. In 1932, the IAIABC began to consider the usefulness of standard forms. The IAIABC’s standard version of the Employer’s First Report of Injury was approved in 1956. The IAIABC began promoting computerized databases with the introduction of the Basic Administrative Information System (BAIS) in the 1970’s. The IAIABC’s cummulative work in this area is sometimes referred to as the “universal data set” initiative. The term reflects the ideal of having a single plan for collecting data that will work in every jurisdiction. As in all previous projects, the EDI Project brings all the stakeholders under one roof to develop an agreed upon and useful standard. In March of 1991, a group within the IAIABC proceeded with the concept of moving the national data collection project into a design phase. At the same time, a technical working group was established and focused on the detail of defining the data elements and developing the data formats to be used for electronic data transfer. This group, after reviewing all the various forms presently filed with state agencies, identified distinct phases that the project would follow. These phases reflect the various generic categories within which the various state reporting forms fall. These categories include: 1. First Report of Injury (Release I completed 8/95, Release II completed 7/97) The initial report designed to notify the parties of the occurrence of an injury or illness. Contains basic claim information regarding the who, what, when and how of an occupational injury or illness. 2. Subsequent Payment Reports (Release I completed 8/95, Release II completed 7/97) Consists of forms that gather information when benefit payments begin, case progress information and paid amounts by benefit type when the claim is concluded. 3. Medical Data (Release I completed 3/01) Develops more refined data pertinent to the dates of service, diagnostic and procedures codes, and costs associated with providing of such care. 4. Proof of Coverage (Release I completed 8/97) Information filed with the majority of state administrative agencies that verifies the name of the insured employer and the provider of coverage. Each of these categories represents a separate project phase for the technical working group. Variations in the way the state statutes are constructed will present unique problems to the collection of certain data elements. However, even with recognition for these difficulties, the intent is to utilize EDI to the degree possible while seeking greater uniformity in order to make comparisons across jurisdictional lines. Check our website at http://www.IAIABC.org/EDI for up-to-date project status.

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SECTION 1

1.
The EDI Project

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INTRODUCTION
The term Electronic Data Interchange tends to conjure up visions of added technical complexity. It is difficult, if not impossible, to envision how technology could improve an environment currently buried in paper and apparently intent on generating more paper and additional requirements. Technology will not help that. Technology can only provide us with the capability to exchange data efficiently. It will not eradicate the necessity for us as business partners to exchange data, or make simple that which we have made complicated. It does however, provide us with a golden opportunity to simplify our business processes and exchange data for our mutual benefit. The first objective of the EDI Development Group is to educate Workers' Compensation System participants, i.e. employers, claim administrators, jurisdictions, and service providers, of the business advantages gained from exchanging information efficiently, cost effectively and with reduced human assistance. Once this is accomplished, our objective is for the system participants to jointly develop new business processes that meet today's and tomorrow's requirements in the simplest and most beneficial way possible. Together, these objectives will reduce our overhead and focus our attention on our primary business: administrating Workers' Compensation claims, providing services and monitoring compliance to insure that our Workers' Compensation Systems function effectively and efficiently. To accomplish this, IAIABC project participants, with either business or information science backgrounds, work together to analyze our current processes and develop simpler standard processes. From this work, data transactions and supporting processes are created.

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EDI PHILOSPHY
The philosophy of the IAIABC EDI Committee is to simplify and improve the way we do business. To meet this objective, the IAIABC EDI Committee maintains several goals: 1. Standardize All Data Elements: Terminology and definitions often differ from jurisdiction to jurisdiction. Our objective is to create common definitions that will allow cross jurisdictional data comparisons. Such comparisons will be useful in identifying beneficial legislation and administrative rules. 2. Do Not Re-invent The Wheel: It is not efficient to redesign what already works. Whenever we find that an existing standard meets our criteria and may be employed by many system participants, we adopt that standard. 3. Use Codes Where Possible: The Workers' Compensation industry captures more data than most industries, yet it provides little benefit. Our goal is to use the data we capture to improve the interaction of the system participants, and to use this data to its best advantage. Although common terminology will improve that, most of the data we capture is textual, and textual data requires human interpretation. Accordingly, our philosophy is to use codes wherever possible and minimize textual data. The use of codes also allows immediate analysis of the data. 4. Plan for Change: As our work continues, we will become aware of new business requirements that are certain to arise from legislation, administrative rules, customer requirements, and our own business needs. Constant change could make EDI costly and difficult to manage. Our objective is to manage change by designing transactions and processes and using codes to provide flexibility of use. This approach allows our designs to accommodate many enhancements without redesigning the transaction. Transaction revisions will be scheduled to reduce and regulate their frequency. 5. Simplify The Reporting Requirements: Workers' Compensation data reporting requirements appear to be unique to each jurisdiction and customer. After analysis, we found that all the reporting requirements had basic commonalties. By arranging these common elements, we developed a menu format that provides unique reporting requirements for any trading partner in a manner that simplifies the reporting process. 6. A Partnership Approach: Electronic Data Interchange requires that trading partners interact and exchange data so that the business processes of both are improved. It also implies that data quality is an important joint responsibility. To meet this requirement, a data edit process and an Acknowledgment Transaction have been designed. The acknowledgment reports acceptance or rejection of the transaction, errors, and business information for each report. This process assists Trading Partners by reporting problems promptly and insuring data quality.

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IAIABC PROJECT MISSION STATEMENT
To improve the exchange of information between all Workers' Compensation participants, for the purpose of effecting improvements in all aspects of the Workers' Compensation System, to benefit those receiving or providing benefits or services, or monitoring, researching, administrating and legislating our Workers' Compensation Systems.

ANTITRUST STATEMENT
As an association, the function of the IAIABC is to reflect the interests of participants in the Workers' Compensation program and state administrative agencies. In any meeting associated with the IAIABC, insurance companies shall not disclose an individual company's rates or loss costs. Companies should avoid any discussions intended to increase or stabilize rates, or raise any complaints about companies that may be charging low or inadequate rates. No discussion will be permitted which attempts to pressure companies to raise rates, or use particular rates, or establish factors as a "benchmark" in setting rates. There should be no discussion of how changes in state regulation might affect a company's presence in a particular state or a company's underwriting standards. In particular, there should be no suggestion that companies withdraw from a particular market or stop underwriting particular classes of customers in order to induce, deter or retaliate against government action.

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EDI COMMITTEES
PURPOSE: To promote the advantages of exchanging data between participant systems. To promote/recommend business & data interchange objectives. To assist participants in identifying business data requirements. To establish data interchange standards. To provide a structure to accomplish these purposes. OBJECTIVES: To unify/motivate participants to improve the Workers' Compensation environment. To identify Workers' Compensation opportunities: a. To improve working relationships. b. To standardize data definitions. c. To improve the reliability/timeliness of data. d. To reduce operation expenses. e. To improve customer service. f. To improve management of the environment. To establish a network: a. To discuss/determine data interchange objectives. b. To organize activities for efficiency and prioritization of resources by participant interest. c. To present/request/analyze environment data interchange and process requirements. d. To develop data interchange solutions. e. To institute solutions by consensus opinion. f. To influence environmental change. To establish standard for: a. Elements. b. Transactions. c. Communication. d. Edits. e. Acknowledgment. f. Management of data interchange. SCOPE: Data exchanged between Workers' Compensation environment participants. Data exchanged via electronic means, or alternate methods that support the exchange of data electronically, or provide comparable benefit.

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2.
EDI Contacts

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Contact List
The list of contacts previously included in the manuals has proven to be of limited use. The contact persons and phone numbers change too frequently to be included in the static format of a manual release, which is updated with much less frequency than needed to maintain a good working list of contacts. Thus, the material formerly included in the manuals is now available on the International Association of Industrial Accident Boards and Commissions web page at: http://www.iaiabc.org/html/edi.htm Those wishing to suggest updates to the list should contact Faith Howe, EDI Manager, IAIABC, by e-mail at fhowe@iaiabc.org.

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3.
Systems Implementation Guide
Including Trading Partner Implementation Planning, Agreements, and System Tables

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SECTION 3 IAIABC RELEASE 1 SYSTEMS IMPLEMENTATION GUIDE The System Implementation Guide has been created as an aid to assist you in developing an EDI reporting systems. This should be used in conjunction with the EDI Implementation guide published by the IAIABC, and may be complemented with an addendum describing Jurisdiction specific rules. The following is a summary of the sections included in this guide: TRADING PARTNER TABLES Electronic Data Interchange Partnering Agreement – This form is a set of expectations, responses, between two entities exchanging data electronically. Trading Partner Profile - This form will uniquely identify a trading partner and provide contact information. Members of the partnership will fill out the information as it pertains to them. The completed forms are then exchanged between partners. Transmission Profile - This form is used to communicate all allowable options the receiver of Workers Compensation data will provide to an originator (or sender). Event Table - This table is used to describe the conditions which trigger creation of EDI transactions. Element Requirement Table - A matrix the receiver uses to define the level of reporting (e.g. mandatory, optional, etc.) for each data element within an EDI transaction. Payment/Adjustment Element Requirement Table - A separate table has been included for defining the reporting requirements of the Subsequent Report Payment Adjustments variable length segments. This table was intended to allow for differences in reporting requirements based on payment type. Edit Matrix - Describes the recommended edits the receiver may perform on each data element. If errors are found the edit matrix provides a standard numbering methodology to communicate inaccuracies to the sender via the acknowledgment transaction.

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SECTION 3 PROCESS MODELS These models include all the activities necessary for processing and are intended to be used only as a guide. Included are process models considering two perspectives. Claim Administrator - Describes how a Claim Administrator receives data from an employer, returns acknowledgments, and creates injury transactions to be sent to a jurisdiction. It also describes how the Claim Administrator processes acknowledgment data from the jurisdiction. Jurisdiction - Describes how the jurisdiction processes injury data from the claims administrator and creates acknowledgment transactions back to the Claims Administrator.

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SECTION 3 Instructions for Completing Trading Partner Forms The Trading Partner tables are a set of tables designed to provide information integral to controlling the extraction and transmission process for successful EDI of Workers Compensation data. The data contained in these tables are originally established by the “primary” trading partner (jurisdiction) to reflect their reporting requirements and environment. SPECIAL NOTE: Careful consideration of both demonstrated business need as well as data availability must be given when establishing data element requirements between trading partners. It is recommended that data requesters meet with data providers to develop a consensus regarding which data elements should be collected/reported. MASTER TRADING PARTNER PROFILE This form will uniquely identify a trading partner and contact information. Each member in a partnership will fill out the information as it pertains to them and then exchange it with their trading partner(s). TRADING PARTNER TYPE - The business function a given trading partner performs within a given agreement. If other, please specify. MASTER TRADING PARTNER INFORMATION: Name - The name of your business entity corresponding with the Master FEIN. Master FEIN - The Federal Employer's Identification Number of your business entity. This, along with the 9-position postal code (Zip+4) in the trading partner address field will be used to identify a unique trading partner. Address - The street address of the physical location of your business entity. It will represent where materials may be received regarding this trading partner agreement if using a delivery service other then the U.S. Postal Service. City - The city portion of the street address of your business entity. State - The 2-character standard state abbreviation of the state portion of the street address of your business entity. Postal Code - The 9-position postal code of the street address of your business entity. This field, along with Trading Partner FEIN will be used to uniquely identify a trading partner.

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SECTION 3 Mailing Address/City/State/Postal Code - The mailing address used to receive deliveries via the U.S. Postal Service for your business entity. This should be the mailing address that would be used to receive materials pertaining to this trading partner agreement. If this address is the same as the aforementioned street address, indicate “Same as above”. CONTACT INFORMATION This section provides the ability to identify individuals within your business entity, which can be used as contacts for this trading partner agreement. Room has been provided for two contacts business and technical. The BUSINESS CONTACT should be the individual most familiar with the overall extract and transmission process within your business entity. He/she may be the project manager, business systems analyst, etc. This individual should be able to track down the answers to any issues, which may arise from your trading partner that the technical contact cannot address. The TECHNICAL CONTACT is the individual that should be contacted if issues regarding the actual transmission process arise. This individual may be a telecommunications specialist, computer operator, etc. BUSINESS/TECHNICAL CONTACT NAME: - The name of the contact. BUSINESS/TECHNICAL CONTACT TITLE: - The title of the contact or the role that contact performs within a given trading partner agreement. BUSINESS/TECHNICAL CONTACT PHONE: - The telephone number at which that contact can be reached. BUSINESS/TECHNICAL CONTACT FAX: - If FAX facilities are available, the telephone number of the FAX machine to use for the contact is provided in this space. EMAIL INFORMATION If the contact can be reached via electronic mail, all Email addresses that may be used to send messages to this contact are provided in this section. EMAIL INFORMATION: Network - The name of the Email network or service through which the contact can be reached. EMAIL INFORMATION: ID - The Email correspondent identifier of the contact.

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TRANSMISSION PROFILE - RECEIVER'S SPECIFICATIONS This form is used to communicate all allowable options the receiver of Workers' Compensation data will provide to a sender. The receiver is responsible for providing the information on the first page of this form, indicating all their requirements, and where applicable, the supported options form, which a sender can select. The sender will then complete page 2 of this form providing their data in the allotted spaces, and indicating their selections where the receiver provides choices. This information is then returned to the receiver. One profile should be completed for each set of transactions with common transmission requirements. For example, one form may be used for 148 and A49 transmission because a given receiver can only accept Flat-File format for these report types and can only accept them via VAN "A", while a second form will provide requirements and options that will relate to MED reports, which can only be accepted in ANSI format and via VAN "B" or "C". Although one profile will satisfy most needs, it should be noted that if transmission parameters vary by transaction types, you could specify those difference by providing more then one profile. Ideally, the receiver will customize the first page of the form, removing those selections and options that do not apply to their environment. RECEIVER NAME - The name of your business entity corresponding with the Master FEIN. DATE - Date this form completed. TRADING PARTNER TYPE - Check the appropriate category reflecting the receiver's business type. RECEIVER IDENTIFIER - This is unique identifier consisting of the Receiver’s FEIN and Receiver’s Postal Code. RECEIVER FEIN - The FEIN of the trading partner, which will receive Workers' Compensation data. This must match the FEIN supplied on that entity s Trading Partner Profile. This entity will be the first to fill in this form. RECEIVER POSTAL CODE - The 9-position postal code associated with the receiving trading partner’s street address, which together with the Receiver FEIN will be used as the identifier of this trading partner.

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SECTION 3 PROFILE ID - This profile ID is a Free-Form Field used to uniquely identify a given profile between any given pair of trading partners. This field becomes critical when more than one profile exists between a given pair of trading partners. It is used for reference purposes. TRANSACTION SETS This section identifies all the transaction sets/report types described within the profile along with any options the receiver can provide to the sender for each transaction set. Both the IAIABC and ANSI designators and Transaction Sets are provided (e.g. POC/271, where "POC" is the IAIABC designator and "271" is the ANSI designator). TRANSACTION SET ID IAIABC/ANSI - Indicates the type of EDI documents the receiving trading partner will support with parameters. FLAT FILE RELEASES - If a Flat File can be accepted for a given transaction set by the receiving trading partner, the release number(s) supported by the receiver is/are specified here. Note that multiple releases may be supported per transaction set with a receiver’s environment. The sender will specify a single release per transaction set on the return form. ANSI VERSION # - If an ANSI transmission can be accepted for a given transaction set by the receiving trading partner, the version number(s) supported by the receiver are specified here. Note that multiple versions may be supported per transaction set with a receiver’s environment. The sender will specify a single version per transaction set on the return form. ACKNOWLEDGMENT INFORMATION This section provides acknowledgment options the receiver provides. ACKNOWLEDGMENT INFORMATION: Mode - For any given transaction set, the receiver will indicate whether they can support electronic, paper or no acknowledgments. Any unsupported option should be removed/crossed-off by the receiving trading partner. ACKNOWLEDGMENT INFORMATION: Resp. Period - The receiving trading partner will indicate the maximum period of elapsed time within which an sending trading partner may expect to receive an acknowledgment for the given transaction set.

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ACKNOWLEDGMENT INFORMATION: Level - For a given transaction set, the receiving trading partner will specify whether they can support acknowledgments for all transactions, only transactions with errors, and/or only transactions that are rejected. It should be noted that providing multiple options indicates that the receiving Trading Partner is capable of supporting "Filtered" acknowledgments. Options not supported must be removed/crossed off. FREQUENCY - All frequencies the receiving trading partner will accept transmission for the transaction sets identified within this profile are specified here. Frequencies that cannot be supported by the receiving trading partner should be removed/crossed-off the list. DAY OF WEEK - If the receiving trading partner supports weekly or biweekly options, all days of the week that the receiver will accept transmission will be specified here. Remove/cross-off any day of the week that cannot be used to accept transmission data. DAY OF MONTH - For frequencies other than daily, weekly, and bi-weekly all calendar days of the month that the receiving trading partner will accept transmission will be specified here. MONTH OF YEAR - If frequencies of bi-monthly, quarterly, semi-annually or annually are supported frequencies by the receiving trading partner, the month(s) of the year that can be used to receive transmission are specified here. TRANSMISSION PAYMENTS - The receiving trading partner will specify which payment arrangement for transmission costs are acceptable. If each MEMBER of the trading partner agreement will pay for their own transmission cost, specify EACH. If all transmission cost will be paid by the RECEIVING trading partner, for both their transmissions and those of their trading partner within this agreement, specify ALL. If all transmission cost will be paid by the ORIGINATING trading partner, for both their transmissions and those of their trading partner within this agreement, specify NONE. TRANSMISSION CUT-OFF TIME - The receiving trading partner will specify the time up until which the transmission will be accepted for that processing cycle.

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SECTION 3 ELECTRONIC MAILBOX AVAILABLE - If one or more Value Added Networks (VANS) can be used to exchange data, the receiving trading partner will specify all available electronic mailboxes to which data can be transmitted. Separate mailbox information may be provided for transmitting production versus test data. NETWORK - The name of the value added network service on which the mailbox can be accessed. NETWORK: Mailbox Acct ID - The name of the receiver's mailbox on the specified VAN. NETWORK: User ID - This is the identifier of the receiver entity to the VAN. NETWORK: Message Class - If this VAN allows for "slots" in their mailbox (classification of message), this field will contain the message class to be used when transmitting information to the receiving entity. SPECIAL NOTE: Message Class is not recommended fo r usage. If the Receiver allows usage, this information must be coordinated between both trading partners. DIRECT CONNECT OR FILE TRANSFER PROTOCOL (FTP) AVAILABLE - If data can be transmitted directly to the receiving trading partner's computer, or via File Transfer Protocol (FTP), the receiving trading partner must provide (or have available upon request) the technical specifications needed to support these media types. All pertinent technical information must be available for the sender to develop the send process if either of these options is selected. FLAT FILE RECORD DELIMITER - If the receiving trading partner supports a Flat File format, the character used to physically indicate end of record is specified here (e.g. carriage return, line feed (CR/LF)).

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SECTION 3 COMPLETE IF USING ANSI This section provides information needed to exchange ANSI formatted transmission data. ANSI SEGMENT TERMINATOR – If the receiving trading partner supports ANSI transmissions, the character used as a segment terminator is specified here. ANSI DATA ELEMENT SEPARATOR – If the receiving trading partner supports ANSI transmissions, the character used as a data element separator is specified here. SUB-ELEMENT SEPARATOR – If the receiving trading partner supports ANSI transmissions, the character used as a sub-element separator is specified here. ANSI SENDER/RECEIVER QUALIFIER - If you can accept ANSI transmissions, this will be your ANSI ID Code Qualifier as specified in an ISA segment. Separate Qualifiers are provided to exchange Production and Test data, if different identifiers are needed. ANSI SENDER/RECEIVER ID - If you can accept ANSI transmissions, this will be the ID Code that corresponds with the ANSI Sender/Receiver Qualifier (ANSI ID Code Qualifier) as specified in an ISA segment. Separate/Sender/Receiver ID’s are provided to exchange Production and Test data, if different identifiers are needed. ACKNOWLEDGMENT INFORMATION: Functional Acknowledgment for AK-1 - The receiving trading partner can specify if they wish to receive a functional acknowledgment when an ANSI detailed acknowledgment has been transmitted back to the sender. This does not apply if the receiving trading partner cannot support ANSI electronic acknowledgments.

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SECTION 3 TRANSMISSION PROFILE - SENDER'S RESPONSE Receiver Name, Receiver Identifier, Profile ID and Description are information transferred from the Receiver's portion of the Transmission Profile. SENDER SELECTIONS/INFORMATION Once the sender has an opportunity to investigate all available options for transmitting data to the receiving trading partner, their selected media option and related information is specified in this section. MASTER TRADING PARTNER INFORMATION: NAME - The primary trading partner name of the receiver. The trading partner receiving transmissions should provide this information in preprinted form. FEIN - The primary FEIN of the receiving trading partner. The trading partner receiving transmissions should provide this information in preprinted form. SENDER NAME - The name of the business entity that will be extracting and transmitting detailed Workers Compensation information to their trading partner. This should be the name that appears on the TRADING PARTNER PROFILE. TRADING PARTNER TYPE - Check the appropriate category reflecting the sender’s business type. SENDER FEIN - the FEIN of the trading partner, which will transmit Workers' Compensation data. This must match the FEIN supplied on the entity s Trading Partner Profile. SENDER POSTAL CODE - The 9 position postal code associated with the sending trading partner's street address which together with the Sender FEIN will be used as the identifier of this trading partner. FOR EACH TRANSACTION SET THE SENDER WILL BE ORIGINATING: The sender will indicate the format of each transaction set for which an agreement is being made - Flat File or ANSI. The format and Release/Version number that the sender wants to receive electronic detailed acknowledgments is specified on the line indicated by “AKI/824”.

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RELEASE/VERSION - If Flat file was selected, the IAIABC Release Number this trading partner will use to format the respective report is specified in this space; if ANSI format was selected, the ANSI Version Number is specified in this space. It is recommended that the latest release that can be commonly supported by both sender and receiver be selected. PROJECTED # PER TRANSMISSION - The sending trading partner will specify the projected average number of detail records for a given Transaction Set Id that will be sent to the receiving trading partner per transmission. This will be used for planning purposes. MODE - The sending trading partner will select their preferred mode (electronic/paper/none) of acknowledgments for that transaction set from the options provided by the receiving trading partner. LEVEL - The sending trading partner will select their preferred level (all/errors/rejected) of acknowledgments for that transaction set from the options provided by the receiving trading partner. TRANSMISSION FREQUENCY The sending trading partner will specify which one frequency they will use to transmit data from the choices provided by the receiving trading partner. SELECTED MEDIA - The sender will place an "X" in front of the option, which they have selected to transmit information. If "DIRECT CONNECT", the receiver must have provided any technical specifications that the sending trading partner may need for successful data exchange. If "ELECTRONIC MAILBOX" is selected, the selected VAN will be specified by providing network information in the fields provided in this section. NETWORK - The sender specifies the VAN they will use to transmit data to the receiving trading partner. Separate mailbox information is provided for production versus test transmissions. NETWORK: Mailbox Acct ID - The name of the sender's mailbox on this VAN where acknowledgments can be routed from the receiver back to the sender. NETWORK: User ID - This is the identifier of the sender entity to the VAN. NETWORK: Message Class - If this VAN allows for slots in their mailbox (classification of messages), this field will contain the message class to be used when transmitting information back to the sending entity.

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SECTION 3 EVENT TABLE USAGE INSTRUCTIONS This table was designed to provide information integral for a sender to understand the receivers EDI reporting requirements. It relates EDI information to events and under what circumstances they are initiated. This includes legislative mandates affecting different reporting requirements based on various criteria (i.e., dates of injury after a certain period). It is used and controlled by the receiver of EDI transactions to convey the level of EDI reporting that they currently accept. It is also used by each trading partner to record an individual trading partner's production level by MTC, and implementation dates. For a sender of EDI information, at least one Event Table must be completed. If there are any exceptions within clients of a sender, then an Event Table must be completed for each exception. TRADING PARTNER ID: A composite Field containing a trading partner's FEIN and nine position postal code. This is a generic term that can identify either the sender or receiver. TRANSACTION SET ID: The code that identifies the transaction being sent/received (i.e. 148, A49, POC). An entry for each transaction set that a trading partner is using should be included along with each MTC. MTC: The Maintenance Type Code defines the specific purpose (event) for which the transaction is being sent (triggered). MTC DESCRIPTION: Text describing the Maintenance Type Code. PRODUCTION LEVEL IND: Reflects an EDI participation status for a specific transaction. It indicates whether the transaction being sent is being targeted to a receivers "production" or "test" system. Transactions performed while under "parallel" status should have the "test" indicator set. TECHNICAL NOTE: This flag is set at the transmission (batch) header level in the HD1. Therefore, all transactions with a batch must be at the same production level. IMPLEMENTATION DATE FROM/THRU: These are the effective dates of the production level indicator for a trading partner. REPORT TRIGGER CRITERIA: This is a list of events that trigger a specific report and cause it to be submitted. If there are multiple events for a given MTC, then each event must be listed separately. REPORT TRIGGER VALUE: A value that is used to modify or define a Report Trigger Criteria.
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PERIODIC QUALIFIER: These are code values that describe the types of claims that are required to be reported periodically (e.g. open claims, closed claims). NOTE: See periodic Qualifier Code Table appendix to system dictionary. REPORT LIMIT NUMBER: When present, this value reflects the maximum number of periodic reports required. REPORT REQUIREMENT CRITERIA: The criteria that defines the claim event date. This will be compared to the effective form and thru dates. This reflects statutory requirements that affect report submission. EFFECTIVE DATE FROM: The first date that a claim meeting the Report Requirement Criteria will be reported for a specific report trigger. EFFECTIVE DATE THRU: The last date that a claim meeting the Report Requirement Criteria will e reported for a specific report trigger. REPORT DUE CRITERIA: The criteria that determine the latest date that a report must be completed and submitted for a specific trigger to be considered timely. REPORT DUE VALUE: A value that is used to modify or define a Report Due Criteria. FOLLOW UP FORM: The hard copy Form, or Form number, that is required to be sent out at the time of an EDI transaction is submitted. RECEIVER: A code (From a valid code list) to identify the receiver of the Form/Pamphlet being sent.

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SECTION 3 ELEMENT REQUIREMENT TABLE USAGE INSTRUCTIONS This table was designed to provide a tool to communicate a Receiver's business data element requirements for each of its trading partners. This allows for element requirements to be defined to a Transaction Set ID and down to the level of each Maintenance Type Code. Further, it provides for element requirements to differ based on Report Requirement Criteria established on the Event Table. NOTE: This table should be completed after the Event Table as it relates to events described on that table. The data element numbers and element descriptions are listed down the left column while the Maintenance Type Codes are listed across the top of the table. On each coordinate, the receiver should note the requirement for each element: M - Element is mandatory C - Element is mandatory when certain conditions exist (receiver will need to specify the condition(s)) O - Element is optional R - Restricted, receiver does not accept this element.

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SECTION 3 EDIT MATRIX USAGE INSTRUCTIONS The Edit Matrix is designed to convey which data elements have edits applied to them and to provide standard error messages to use in association with these edits. Error messages are communicated in the Acknowledgment records in the Form of data element number and error message. NOTE: All error messages and data element numbers must be assigned by the EDI Systems group to ensure standardization across jurisdictions. Those elements with ‘X’ on the coordinate are suggested or recommended edits. Trading Partners should review these recommendations and may want to include/exclude edits, as they feel appropriate, within the framework of the matrix. The Edit Matrix includes all transaction set edits established by the IAIABC EDI Development committee. The data element numbers and element descriptions are listed down the left column while the error message numbers and associated text are listed across the top of the table. Some trading partners have found it useful to establish an additional table that contains more specific, data element-related, and error messages. This can be useful, especially for error messages that are more generic. Once they are tied to a data element, they can be made more specific and reduce the need for followup phone calls from receivers.

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SECTION 3 CLAIM ADMINISTRATOR PROCESSING 2.1 RETRIEVE INCOMING DATA 2.1.1 SCHEDULE RECEIVE PROCESS Using the Transmission Profile - Receiver's Options, the receiver identifies frequencies to the communications system. This process accommodates automated scheduling of the receive process. 2.1.2 CONNECT/RECEIVE All communications processes are executed to receive data from the identified Electronic Mailboxes and/or the Direct Connect listed on the Receiver's Options. Both X12 and IAIABC flat files are received during this process. The X12 files are routed to the Translate (2.1.3) process and the flat file data is either held pending processing of the X12 files or immediately passed to the next process. 2.1.3 TRANSLATE X12 FILE This process can be implemented in many different ways depending on whether the receiver is using commercial translation software or has built a translator internally. Processes that may take place during translation are: Verify trading partner relationship Convert file from variable to fixed length removing delimiters Syntactical error checking for X12 compliance Generation of 997 Functional Acknowledgment 2.1.4 MAP TRANSLATED FILE The mapping process converts the X12 data to transactions to be processed (e.g. IAIABC flat file). This process assumes that the X12 transmission is mapped to the IAIABC flat file. Mapping to a flat file allows the application interface to process a single file type. 2.2 PROCESS BATCHES 2.2.1 VALIDATE HEADER RECORD (HD1) Each transmission batch contains a header record (HD1), transaction record(s) and a trailer record (TR1). Begin the processing of a transmission batch by validating the header. The header record is used to identify the trading partner transmitting the transmission batch, the receiver, the interchange version ID, the date and time the transmission was sent, and the test/production indicator.
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SECTION 3 The transmission profile, element requirements table and the edit matrix are used to edit the data elements in the header record. Any errors in these data elements would create edit errors that would cause the transmission batch to be rejected at the header level. The audit file is used to determine a duplicate transmission batch. Header rejects and duplicate transmissions are acknowledged with one AK1 transaction containing Record Sequence Number 0000. The first step in this process is to validate the sender ID. If the sender ID is invalid, manual verification of trading partner tables and/or communications will be required. No further processing of this transmission batch will be done. The next step in this process is to perform edits on the remaining HD1 data elements and to check for a duplicate transmission batch. A transmission batch is considered to be a duplicate when the combination of sender ID, date transmission sent, time transmission sent and interchange version ID already exist in the audit file. If a transmission batch is rejected at the header level, a new record is posted to the audit file with a batch processing status of rejected, an appended AK1outbound is written. The individual transactions within the batch are not processed. The process continues with the next transmission batch. If a transmission batch is accepted, a new record is posted to the audit file and the process continues to validate detail records. The audit ID number should be a unique sequential number assigned by the receiver. 2.2.2 VALIDATE BATCH INTEGRITY Examine detail transaction records checking to ensure that each contains a transaction set ID that corresponds to the transmission type code indicated within the interchange version ID of the HD1. If a transaction within the batch does not match the HD1 transaction type code, the entire batch will be rejected, the batch processing status in the audit record will be set to rejected, and an appended AK1-outbound is written. This will be indicated by a "HD" in the application acknowledgment code, 'all zeros' in the record sequence number, '0105' in the element number and '064' in the element error number. Processing of that batch will cease and will resume with the next HD1 record. The entire transmission batch will not be processed. The process continues with the next transmission batch. As each transaction within a batch is processed, the receiver must assign a record sequence number to uniquely identify each transaction and maintain the order in which it was received. The record sequence number, along with the audit ID number, will be appended to each transaction. The record sequence number is reset for each batch.

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SECTION 3 2.2.3 VALIDATE TRAILER RECORD (TR1) The trailer record contains the count of the number of detail records within a transmission batch. The trailer record detail record count for the transmission batch is edited to make sure the number of transactions is the same as the detail record count in the trailer. The edit matrix table is read to apply the edits to the trailer record. If the trailer record is accepted, meaning it passed the edits, the audit file is updated with the number of records in the transmission. If the trailer record is rejected, the transmission batch is rejected, the batch processing status in the audit record will be set to rejected, and an appended AK1-outbound is written. 2.2.4 BUILD APPENDED TRANSACTIONS Append the Audit ID number to each incoming injury transaction. This can be used to associate detail transactions with their corresponding header record information. 2.3 PROCESS ACKNOWLEDGMENT TRANSACTIONS 2.3.1 RECONCILE EDI ACTIVITY LOG Each time a transmission is sent to a trading partner, the sender will retain information about each transaction in the EDI Activity Log. The EDI Activity Log uniquely identifies each transaction. As appended acknowledgment transactions are processed, Audit File entries are reconciled with the EDI Activity Log. The Audit record is created from the injury batch's HD1 (Header) information in 2.2.1 (Validate Header Record). As the appended acknowledgment transactions are matched, AK1 data is added to the EDI Activity Log: EDI status, date acknowledgment transmission sent, processed and received. The reconciled acknowledgments will then serve as input into 2.3.2 (Interpret Acknowledgment Transactions). Any acknowledgment transactions not reconciled will be used to create the Reconciliation Error Report and manual intervention will be required. 2.3.2 INTERPRET ACKNOWLEDGMENT TRANSACTIONS Reconciled acknowledgment transactions have an Application Acknowledgment Code (status). The action needed will depend on the code: Transmission Rejected: This means that every record in the transmission batch (header record + detail records + trailer record) was rejected. The reason for the batch rejection will be contained in the error code segment of the acknowledgment transaction. The sender will determine the cause of the rejection and respond appropriately.
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SECTION 3 Transaction Accepted with no errors (TA): There will be information contained in the acknowledgment transactions which will need to be conveyed (e.g., Agency Claim Number). Transaction Rejected (TR): The reason for the rejection is contained in the Error Code segment(s) of the AK1. The element number and element error number will need to be compared to the Edit Matrix in order to determine the reason for the rejection. Transaction Accepted with Errors (TE): The element number and element error number will need to be compared to the Edit Matrix in order to determine the reasons for the error. Once the error has been fixed, appropriate action should be taken by the sender (e.g., A correction transaction ("CO") or the next transaction due will be sent to correct the error). 2.4 PROCESS INJURY TRANSACTIONS 2.4.1 SORT INCOMING TRANSACTIONS Incoming transactions may be sorted for more efficiency during the edit process and to run in the MTC sequence required by the receiver. 2.4.2 EDIT INCOMING INJURY TRANSACTIONS Each data element in a transaction is edited according to the edit matrix and element requirement table. The element requirement table specifies whether the element is mandatory, conditional or optional for the corresponding transaction set ID and maintenance type code. The edit matrix is used to determine which edits to apply to each data element. Mandatory data elements with edit errors will cause the transaction to be rejected. A conditional data element is treated as optional until trading partner specific conditions are met, at which time it may be treated as mandatory. Optional data elements with edit errors will allow the transaction to be accepted with errors and will not be loaded to the database. Transmission Profile Access by using Trading Partner ID. Verify that media and format specified in the profile match with actual media and format. Event Table Access using Trading Partner ID, Transaction Set ID and MTC. Verify that trigger and due date criteria are met.

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SECTION 3 Element Requirement Table Access by using Transaction Set ID and MTC. Retrieve requirement codes for the transaction, to be used in conjunction with the Edit matrix. Payment Adjustment Element Requirement Table This table is used for SROI, to access the Payment Adjustment Code. Retrieve requirement codes for the transaction, to be used in conjunction with the Edit Matrix. Edit Matrix The cells marked on the edit matrix represent the minimum edits to be applied. The receiver may perform additional edits to those indicated as long as a standard element error code is returned to the sender. Any issue with a mandatory field will cause rejection of the transaction. All fields must be edited so that all possible errors are returned in the appended AK1-out. Optional fields with errors are reset to blanks or zeros. Edited Incoming Transactions will be used to update the Receiver Computer System. 2.4.3 CREATE EDI TRANSACTIONS 2.4.3.1 COMPARE EVENT TABLE

Internal System Identify updates made since the last transmission. These updates will be analyzed against the Event Table. Update the Internal Application as needed to indicate the last update has been EDI processed. Event Table Compare updates from the Internal Application to determine whether a new EDI transaction must be initiated. Compare against the EDI Activity Log to verify sequence of filing. EDI Activity Log Analyze transactions already sent to verify that any potential new transaction is appropriate.

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SECTION 3 2.4.3.2 EXAMINE ELEMENT REQUIREMENT TABLE

Element Requirement Table Access by using the Trading Partner ID, Transaction Set ID and Maintenance Type Code. Retrieve Requirement Codes for the transaction, to be used in conjunction with the Edit Matrix. Payment Adjustment Element Requirement Table Used for SROI, access using the Payment Adjustment Code. Retrieve Requirement Codes for the transaction, to be used in conjunction with the Edit Matrix. 2.4.3.3 Edit Matrix Apply edits to each element according to the matrix. Any issue will cause the transaction to be written to the Application Data Errors file. All elements must be edited so that all possible errors are communicated to resolution. Valid Code Table Used during the edits process. Access by data element number and code value to verify that a value is valid. Some validation tables will be Trading Partner specific. Transactions with no errors are written to the EDI Transaction file. 2.4.4 BUILD EDI BATCH Obtain detail records from the appended AK1-out and EDI Transaction files. Add header and trailer records for each batch and write to AK1-out and EDI Injury Batch. FROI and SROI should be included in separate batches, one batch for each report type. Create a new entry in the EDI Activity Log for each transaction included with an EDI Injury Batch. 2.5 RECONCILE 997-INBOUND EDIT TRANSACTIONS

The 997 Functional Acknowledgment can be used to determine several business issues. The 997 should be inspected for syntactical errors in the X12 transmission being functionally acknowledged.
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SECTION 3 The 997 can be matched to the appropriate outbound X12 to confirm that the original transmission was received. This will allow you to identify transmissions that have not been functionally acknowledged. 2.6 SEND FILES

2.6.1 MAP/TRANSLATE OUTBOUND FILE The mapping process converts the IAIABC flat file to X12 data. The translation process can be implemented in many different ways depending on whether the receiver is using commercial translation software or have built a translator internally. Processes that may take place during translation are: Verify trading partner relationship Syntactical error checking for X12 compliance 2.6.2 CONNECT/SEND All communications processes are executed to send data to the identified Electronic Mailboxes and/or the Direct Connect listed on the Receiver's Options. Both X12 and IAIABC flat files are sent during this process.

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SECTION 3 JURISDICTION PROCESS 3.1 RETRIEVE INCOMING DATA 3.1.1 SCHEDULE RECEIVE PROCESS Using the Transmission Profile - Receiver's Options, the receiver identifies frequencies to the communications system. This process accommodates automated scheduling of the receive process. 3.1.2 CONNECT/RECEIVE All communications processes are executed to receive data from the identified Electronic Mailboxes and/or the Direct Connect Listed on the Receiver's Options. Both X12 and IAIABC flat files are received during this process. The X12 files are routed to the Translate (3.1.3) process and the flat file data is either held pending processing of the X12 files or immediately passed to the next process. 3.1.3 TRANSLATE X12 FILE This process can be implemented in many different ways depending on whether the receiver is using commercial translation software or has built a translator internally. Processes that may take place during translation are: Verify trading partner relationship Convert file from variable to fixed length removing delimiters Syntactical error checking for X12 compliance Generation of 997 Functional Acknowledgment 3.1.4 MAP TRANSLATED FILE The mapping process converts the X12 data to transactions to be processed (e.g. IAIABC flat file). This process assumes that the X12 transmission is mapped to the IAIABC flat file. Mapping to a flat file allows the application interface to process a single file type. 3.2 PROCESS BATCHES 3.2.1 VALIDATE HEADER RECORD (HD1) Each transmission batch contains a header record (HD1), transaction record(s) and a trailer record (TR1). Begin the processing of a transmission batch by validating the header. The header record is used to identify the trading partner transmitting the transmission batch, the receiver, the interchange version ID, the date and time the transmission was sent, and the test/production indicator.
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SECTION 3 The transmission profile, element requirements table and the edit matrix are used to edit the data elements in the header record. Any errors in these data elements would create edit errors which would cause the transmission batch to be rejected at the header level. The audit file is used to determine a duplicate transmission batch. Header rejects and duplicate transmissions are acknowledged with one AK1 transaction containing Record Sequence Number 0000. The first step in this process is to validate the sender ID. If the sender ID is invalid, manual verification of trading partner tables and/or communications will be required. No further processing of this transmission batch will be done. The next step in this process is to perform edits on the remaining HD1 data elements and to check for a duplicate transmission batch. A transmission batch is considered to be a duplicate when the combination of sender ID, date transmission sent, time transmission sent and interchange version ID already exist in the audit file. If a transmission batch is rejected at the header level, a new record is posted to the audit file with a batch processing status of rejected, an appended AK1outbound is written. The individual transactions within the batch are not processed. The process continues with the next transmission batch. If a transmission batch is accepted, a new record is posted to the audit file and the process continues to validate detail records. The audit ID number should be a unique sequential number assigned by the receiver. 3.2.2 VALIDATE BATCH INTEGRITY Examine detail transaction records checking to ensure that each contains a transaction set ID that corresponds to the transmission type code indicated within the interchange version ID of the HD1. If a transaction within the batch does not match the HD1 transaction type code, the entire batch will be rejected, the batch processing status in the audit record will be set to rejected, and an appended AK1-outbound is written. This will be indicated by a 'HD' in the application acknowledgment code, 'all zeros' in the record sequence number, '0105' in the element number and '064' in the element error number. Processing of that batch will cease and will resume with the next HD1 records. The entire transmission batch will not be processed. The process continues with the next transmission batch. As each transaction within a batch is processed, the receiver must assign a record sequence number to uniquely identify each transaction and maintain the order in which it was received. The record sequence number, along with the audit ID number, will be appended to each transaction. The record sequence number is reset for each batch.

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SECTION 3 3.2.3 VALIDATE TRAILER RECORDS (TR1) The trailer record contains the count of the number of detail records within a transmission batch. The trailer record detail record count for the transmission batch is edited to make sure the number of transactions is the same as the detail record count in the trailer. The edit matrix table is read to apply the edits to the trailer record. If the trailer record is accepted, meaning it passed the edits, the audit file is updated with the number of records in the transmission. If the trailer record is rejected, the transmission batch is rejected, the batch processing status in the audit record will be set to rejected, and an appended AK1-outbound is written. 3.2.4 BUILD APPENDED TRANSACTIONS Append the Audit ID number to each incoming injury transaction. This can be used to associate detail transactions with their corresponding header record information. 3.3 PROCESS INJURY TRANSACTIONS 3.3.1 SORT APPENDED INCOMING INJURY TRANSACTIONS Incoming transactions may be sorted for more efficiency during the edit process and to run in the MTC sequence required by the Receiver. 3.3.2 EDIT INCOMING INJURY TRANSACTIONS Each data element in a transaction is edited according to the edit matrix and element requirement table. The element requirement table specifies whether the element is mandatory, conditional or optional for the corresponding transaction set ID and maintenance type code. The edit matrix is used to determine which edits to apply to each data element. Mandatory data elements with edit errors will cause the transaction to be rejected. A conditional data element is treated as optional until trading partner specific conditions are met, at which time it may be treated as mandatory. Optional data elements with edit errors will allow the transaction to be accepted with errors and will not be loaded to the database. Transmission Profile Access by using Trading Partner ID. Verify that media and format specified in the profile match with actual media and format. Event Table Access using Trading Partner ID, Transaction set ID and MTC. Verify that trigger and due date criteria are met.
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SECTION 3 Element Requirement Table Access by using Transaction Set ID and MTC. Retrieve requirement codes for the transaction, to be used in conjunction with the Edit Matrix. Payment Adjustment Element Requirement Table This table is used for SROI, to access the Payment Adjustment Code. Retrieve requirement codes for the transaction, to be used in conjunction with the Edit Matrix. Edit Matrix The cells marked on the edit matrix represent the minimum edits to be applied. The receiver may perform additional edits to those indicated as long as a standard element error code is returned to the sender. Any issue with a mandatory field will cause rejection of the transaction. All fields must be edited so that all possible errors are returned in the appended AK1-out. Optional fields with errors are reset to blanks or zeros. Edited Incoming Transactions will be used to update the Receiver Computer System. 3.3.3 BUILD EDI BATCH Obtain detail records from the appended AK1-out and EDI Transaction files. Add header and trailer records for each batch and write to AK1-out and EDI Injury Batch. FROI and SROI should be included in separate batches, one batch for each report type. 3.4 RECONCILE 997-INBOUND

The 997 Functional Acknowledgment can be used to determine several business issues. The 997 should be inspected for syntactical errors in the X12 transmission being functionally acknowledged. The 997 can be matched to the appropriate outbound X12 to confirm that the original transmission was received. This will allow you to identify transmissions that have not been functionally acknowledged. 3.5 SEND FILES

3.5.1 MAP/TRANSLATE OUTBOUND FILE The mapping process converts the IAIABC flat file to X12 data.

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SECTION 3 The translation process can be implemented in many different ways depending on whether the receiver is using the commercial translation software or have built a translator internally. Processes that may take place during translation are: Verify trading partner relationship Syntactical error checking for X12 compliance 3.5.2 CONNECT/SEND All communications processes are executed to send data to the identified Electronic Mailboxes and/or the Direct Connect listed on the Receiver's Options. Both X12 and IAIABC flat files are sent during this process.

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Process Model Record Layouts
AUDIT RECORD HD1 Received Audit ID #: Receiver assigned sequential unique number Batch Received DATE Batch Received TIME Batch Processing Status: Accepted/Rejected Acknowledgment Mode: Electronic/Paper/Both/None Acknowledgment Format: X12/Flat File Acknowledgment Media: VAN/Direct Connect/etc. Acknowledgment DATE Acknowledgment TIME Number of Transactions Received Number of Transactions Accepted (TA) Number of Transactions Accepted with Errors (TE) Number of Transactions Rejected (TR) AK1-IN AK1 Audit ID # AK1-OUT AK1 Audit ID # EDI ACTIVITY LOG Claim Administrator Claim Number MTC Record Sequence Number EDI Status Transaction Set ID Original Date Sent Original Time Sent

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148 824 997 ANSI BATCHES 2.1 RETRIEVE INCOMING DATA

FLAT FILE BATCHES FROI SROI AK1 TRANSMISSION PROFILE FROI SROI AKI

EDI ACTIVITY LOG

RECONCILIATION ERROR REPORT

EDIT MATRIX 2.3 PROCESS ACKNOWLEDGEMENT TRANSACTIONS

FLAT FILE BATCHES FROI SROI AK1 NETWORK FREQUENCY

ELEM REQ TABLE FUNCTIONAL 997-OUT FUNCTIONAL 997-IN 997-OUTBOUND

2.2 PROCESS BATCHES

APPENDED AK1 TRANSACTION

AUDIT FILE

AK1 ERROR MSG DATA ELEMENT

TRANSMISSION PROFILE

INJURY TRANSACTION

HD1 ERROR FILE 2.5 RECONCILE FUNCTIONAL 997-INBOUND

Internal System

HEADER REJECT

EMPLOYER ACK BATCH

2.4 PROCESS INJURY TRANSACTIONS

INJURY BATCH
2.6 SEND FILES

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TRANSMISSION PROFILE

NETWORK FREQUENCY

2.1.3 TRANSLATE ANSI FILE

FUNCTIONAL 997 OUT

FUNCTIONAL 997-OUT

2.1.1 SCHEDULE RECEIVE PROCESS

ANSI 148 ANSI 824

ANSI FILE(S) ANSI 148 ANSI 824

FIXED LENGTH ANSI

ANSI DATA FROM MAILBOX

ANSI 148 ANSI 824 ANSI 997

2.1.2 CONNECT/RECEIVE

2.1.4 MAP TRANSLATED FILE

ANSI 997 IN 997-INBOUND FROI SROI AK1

FROI SROI AK1 FLAT FILE(S)

FROI SROI AK1

FLATFILE DATA FROM MAILBOX

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XMISSION PROFILE EDIT MATRIX SENDER FEIN POSTAL CODE XMISSION TYPE CODE REL # T-P INDICATOR FLATFILE

FLATFILE BATCH 2.2.2 VALIDATE BATCH INTEGRITY

ELEMENT REQ

HD1 ELEMENTS

2.2.1 VALIDATE HEADER RECORD

FLATFILE BATCH

FLATFILE BATCH

2.2.3 VALIDATE TRAILER RECORD

BATCH PROCESSING STATUS HD1 ELEMENTS EDIT MATRIX HD1 AUDIT INFO RECORD AUDIT FILE FLA FILE BATCH APPENDED AK1 OUTBOUND AUDIT ID # HD1 RECEPTION DATE NBR RECORDS APPENDED-AK1 INBOUND BATCH PROCESSING STATUS

APPENDED AK1 OUTBOUND

2.2.4 BUILD APPENDED TRANSACTIONS APPENDED AK1 OUTBOUND

APPENDED AK1 INBOUND APPENDED FROI APPENDED SROI

INJ TRANS

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RECONCILIATION ERROR REPORT AUDIT FILE ORG TRANS DATE ORG TRANS TIME DATE TRANS SENT 2.3.1 RECONCILE EDI ACTIVITY LOG APPENDED AK1 TRANSACTION APPENDED AK1 DATE ORG TRANSMISSION SENT TIME ORG TRANSMISSION SENT RECORD SEQUENCE NBR EDI STATUS DATE ACK TRANSMISSION SENT DATE PROCESSED DATE RECEIVED AK1

EDIT MATRIX

ERROR MSG DATA ELEMENT

AK1

RECONCILED ACK TRANSACTION

AK1

2.3.2 INTERPRET ACKNOWLEDGEMENT TRANSACTIONS

AK1 ERROR MSG DATA ELEMENT AGENCY CLAIM NBR

EDI ACTIVITY LOG

Internal System

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EVENT TABLE MTC T/P IND FROI BATCH SROI BATCH

ELEM REQ TABLE MTC TRANS SET ID ELEMENTS REQUIRED RPT REQ BEGIN DATE RPT REQ END DATE

PAY ADJ ELEM REQ TABLE PAYMENT ADJ CODE ELEMENTS REQUIRED RPT REQ BEGIN DATE RPT REQ END DATE EDIT MATRIX DATA NBR ERROR MSG NBR EDITED INCOMING TRANSACTIONS

2.4.1 SORT INCOMING TRANSACTIONS

SORTED FROI SORTED SROI

2.4.2 EDIT INCOMING INJURY TRANSACTIONS

IA-1

APPENDED AK1 OUTBOUND APPENDED AK1 OUTBOUND APPENDED AK1 OUTBOUND

TP ID

EXISTING CLAIMS DATA

EDI ACTIVITY LOG

TRANSMISSION PROFILE AUDIT FILE PAY ADJ ELEM REQ TABLE ELEM REQ TABLE

Claim Admin Legacy System

CA CLAIM # MTC RECORD SEQUENCE # EDI STATUS TRANSACTION SET ID ORIGINAL DATE SENT ORIGINAL TIME SENT

INJURY DATA EDI ACTIVITY LOG

2.4.4 BUILD EDI BATCH

AUDIT ID # ORIGINAL DATE SENT ORIGINAL TIME SENT

EDI TRANSACTION AK1 OUT BATCH INJURY BATCH

FROI SROI

2.4.3 CREATE EDI TRANSACTIONS

EDI HISTORY

AK1 OUT BATCH

INJURY BATCH

EVENT TABLE

EDIT MATRIX

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EDIT MATRIX EVENT TABLE ALL ELEMENTS APPLICATION DATA ERRORS ALL ELEMENTS 2.4.3.3 EDIT TRANSACTIONS CLAIM ADM CLAIM # MAINTENANCE TYPE CODE EDI STATUS DATE TRANSMISSION SENT TRANSACTION SET ID 2.4.3.1 COMPARE EVENT TABLE

EDI ACTIVITY LOG

TP ID RPT TRIGGER CRITERIA RPT REQMNT CRITERIA

TRANSACTION SET ID MAINTENANCE TYPE CODE REPORT DUE CRITERIA REPORT DUE VALUE TEST/PROD INDICATOR

FROI SROI

VALID CODE TABLE

EDI INJURY TRANSACTION

Internal System

EXISTING CLAIMS DATA

2.4.3.2 EXAMINE ELEMENT REQ TABLE

ALL ELEMENTS

ALL ELEMENTS

ELEMENT REQ TABLE

PAYMENT ADJ ELEMENT REQ TABLE

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FLATFILES

997-OUTBOUND

EMPLOYER ACKNOWLEDGEMENT BATCH INJURY BATCH

Text 2.6.2 Text CONNECT/SEND

2.6.1 MAP/TRANSLATE OUTBOUND FILES 148 824 148 824 EMPLOYER ACKNOWLEDGEMENT BATCH INJURY BATCH

X12 FILE(S)

FLATFILE DATA TO MAILBOX

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148 997-IN ANSI BATCHES FLATFILE BATCHES FROI SROI NETWORK FREQUENCY FUNCTIONAL 997-IN 3.1 RETRIEVE INCOMING DATA

FROI SROI

FLATFILE BATCHES TRANSMISSION PROFILE FROI SROI EDIT MATRIX

ELEM REQ TABLE FUNCTIONAL 997 OUT

3.2 PROCESS BATCHES

AUDIT FILE

TRANSMISSION PROFILE

997-OUTBOUND

INJURY TRANSACTION

Internal System

3.4 RECONCILE FUNCTIONAL 997-INBOUND

AK1 OUTBOUND

APPENDED AK1 OUTBOUND

3.3 PROCESS INJURY TRANSACTIONS

INJURY BATCH 3.5 SEND FILES

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TRANSMISSION PROFILE

NETWORK FREQUENCY

3.1.3 TRANSLATE ANSI FILE

FUNCTIONAL 997 OUT

FUNCTIONAL 997-OUT

3.1.1 SCHEDULE RECEIVE PROCESS

ANSI 148 FIXED LENGTH ANSI DOWNLOADED ANSI BATCHES

ANSI 148

3.1.4 MAP TRANSLATED FILE

ANSI BATCHES

ANSI 148 ANSI 997

3.1.2 CONNECT/RECEIVE

ANSI 997 IN FROI SROI 997-INBOUND

FROI SROI

FROI SROI

FLATFILE BATCHES

DOWNLOADED FLATFILE BATCHES

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FLATFILE XMISSION PROFILE SNDR FEIN & POSTAL CODE XMISSION TYPE CODE REL # T/P INDICATOR EDIT MATRIX

FLATFILE BATCH

ELEMENT REQ HD1 ELEMENTS 3.2.1 VALIDATE HEADER RECORD

FLATEFILE BATCH

3.2.2 VALIDATE BATCH INTEGRITY FLATFILE BATCH 3.2.3 VALIDATE TRAILER RECORD

BATCH PROCESSING STATUS HD1 INFO BATCH PROCESSING STATUS

HD1 ELEMENTS

AUDIT RECORD AUDIT FILE FLATFILE BATCH APPENDED AK1 OUTBOUND

EDIT MATRIX AUDIT ID # HD1 RECEPTION DATE NBR RECORDS 3.2.4 BUILD APPENDED TRANSACTIONS APPENDED AK1 OUTBOUND INJ TRANS

APPENDED AK1 OUTBOUND

APPENDED FROI APPENDED SROI

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ELEM REQ TABLE EVENT TABLE MTC TRANS SET ID ELEMENTS REQUIRED RPT REQ BEGIN DATE RPT REQ END DATE

PAY ADJ ELE REQ TABLE PAYMENT ADJ CODE ELEMENTS REQUIRED RPT REQ BEGIN DATE RPT REQ END DATE

Paper Form
EDIT MATRIX

MTC T/P IND

DATA NBR ERROR MSG NBR EDITED INCOMING TRANSACTIONS

FROI BATCH

SROI BATCH SORTED FROI SORTED SROI

3.3.2 EDIT INCOMING INJURY TRANSACTIONS

EXISTING CLAIMS DATA

Internal System

3.3.1 SORT APPENDED INCOMING INJURY TRANSACTIONS

TP ID APPENDED AK1 OUTBOUND

APPENDED AK1 OUTBOUND APPENDED AK1 OUTBOUND AUDIT FILE 3.3.3 BUILD EDI BATCH AUDIT ID # ORIGINAL DATE SENT ORIGINAL TIME SENT

TRANSMISSION PROFILE

AK1 OUT BATCH EDI TRANSACTION AK1 OUT BATCH

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FLATFILES

997-OUTBOUND

OUTBOUND ACKNOWLEDGEMENT BATCH

CONNECT/SEND 3.5.1 MAP/TRANSLATE OUTBOUND FILE

Text Text 3.5.2

824

OUTBOUND ACKNOWLEDGEMENT BATCH

824 FLATFILE DATA TO MAILBOX X12 FILE(S)

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Electronic Data Interchange Partnering Agreement
This is an agreement between the parties named below to use Electronic Data Interchange (EDI) technologies and techniques for the purpose(s) and objective(s) set out below or as amended from time to time in writing by mutual agreement and such further purposes and objectives as the parties may agree in writing from time to time with reference to this Agreement.
1. Parties. The parties to this agreement are: State of ________________________________ (State Name) Workers' Compensation Commission (hereafter WCC); and ______________________________________ (Partner – Insurer, Third Party Administrator, etc.) and all other Companies within the (Company) authorized to write WC insurance or provide insurance related services (hereafter Reporter.) Purpose. Reporter is either required to file or may be allowed by law or regulation to file for itself or on behalf of customers or clients a First Report of Injury or Illness and Subsequent Reports to the (State Name) Workers' Compensation Commission. The Objective is to initiate, implement and maintain First Reports and Subsequent Reports through electronic filing. Both agree that the Objective is lawful and performance hereunder shall be deemed complete p erformance of the parties obligations under any law or regulation governing the Objective. This document shall be deemed to fulfill any requirement on the part of the Reporter to apply to WCC or any related governmental entity for permission to file information electronically. Exhibit A which is annexed and incorporated in this Agreement sets forth the following mutually agreed elements of the arrangement between the parties: A. The schedule, form, including data element definitions, and format of data transmissions from the Reporter, including original submissions and corrections or re-submissions as needed (data transmissions). The test and implementation plan and schedule under which the parties will prepare to send and receive data from each other. The schedule, form, including data element definitions, and format of data transmissions from the WCC, including acknowledgments, notices of error or notices of acceptance as applicable (data transmissions). The Value Added Network (VAN) or other data transmission method that will be used to transmit and receive data transmissions. The allocation of data transmission costs between the parties.

2.

3.

4.

B. C.

D. E. 5.

Each party shall retain the content of data transmissions in confidence to the extent required by law.

Agreed this ____ (Write out date) day of _______________(Write out Month), ______(Numerical Year) for the parties by their duly authorized or lawfully empowered representatives. (signature) (name) (title) (signature) (name) (title)

(REPORTER)

(WCC)

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State Of (State Name) Workers' Compensation Commission
Exhibit A
A.1. Reporter and WCC agree to use the American National Standards Institute X12N Standards established by the International Association of Industrial Accident Boards and Commissions, where applicable, or the flat file equivalent. The Project will commence upon the transmission of the version of the First Report of Injury defined per paragraph C3 below on _(Date)____. During the testing phase, the Reporter will be required to file paper forms in addition to the electronic transmission of records. Once testing requirements are met, the Reporter will no longer be required to file paper forms. If the Reporter's customers are required to file a paper copy of the First Report, the WCC agrees to waive the requirement for all reports made to the WCC by the Reporter on behalf of its customers. The parties will perform a test of the reporting system. The test will determine whether the transmission mechanism is acceptable. Acceptance will occur when the parties agree that 90% of all electronic first reports (a) meet or pass all technical requirements; and (b) match or are more accurate than the paper forms filed for a period of 4 consecutive weeks. The term of the test will not exceed 90 days unless an extension is agreed to between the parties. The format of data elements and definitions will conform to the International Association of Industrial Accident Boards and Commissions (I.A.I.A.B.C.) Release 1 data dictionary as it is today and as amended from time to time and approved by the I.A.I.A.B.C.'s EDI Working Group, and EDI Council or as otherwise agreed between the parties in writing. The transmission of data will occur on (Day of Week ) of each week from the Reporter or as otherwise agreed, and will be received by the WCC within the following business week. The data elements for the First and Subsequent Reports and their priority are found on the attached trading partner table. (Attachment 1) Additional tables for other reports and forms can become part of this agreement by mutual agreement between the parties. Any error in transmission will be timely identified by the WCC, but not greater than five ( 5) business days. Transmissions will be accomplished via a Value Added Network or File Transfer Protocol (FTP) as agreed between the parties from time to time. The Reporter shall pay transmission costs for all reports being sent to the WCC. WCC shall bear the costs of any transmission to the Reporter.

B.1.

B.2.

C.1.

C.2. C.3.

C.4 D.1. E.1.

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SECTION 3 MASTER TRADING PARTNER PROFILE TRADING PARTNER TYPE: __ Jurisdiction __ Service Bureau __ Employer __ Claims Administrator __ Other (specify):

MASTER TRADING PARTNER INFORMATION: Name: Master FEIN: Phy Address: City: State: Mail Address: City: State: CONTACT INFORMATION: Business Contact: Name: Title: Phone: FAX: Email Information: Network: ID: Network ID: Network: ID Technical Contact: Name: Title: Phone: FAX: Email Information: Network: ID: Network: ID: Network: ID: Postal Code: Postal Code: -

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SECTION 3 TRANSMISSION PROFILE -- RECEIVER'S SPECIFICATIONS
RECEIVER NAME: TRADING PARTNER TYPE: RECEIVER IDENTIFIER: PROFILE ID: __ Jurisdiction Receiver FEIN: DESCRIPTION: __ Claims Admin DATE: __ Employer __ Service Bureau __ Other

Receiver Postal Code

TRANSACTION SETS FOR THIS PROFILE: TRANSACTION INFORMATION Transaction Flat File ANSI IAIABC/ANSI Release Version 148/148 A49/148 POC/271 MED 837 AKI/824 TRANSMISSION FREQUENCIES FOR THIS PROFILE: Daily __ Weekly __ Bi-Weekly Semi-Monthly Quarterly DAY OF WEEK: DAY OF MONTH: MONTH OF YEAR: TRANSMISSION PAYMENTS: __Monthly __Semi-Annually __Bi-Monthly __Annually __Other ACKNOWLEDGMENT INFORMATION Mode Production Level (EDI/Paper/None) Response Period (All/ Err/ Rejects)

SUN MON TUE WED THU FRI SAT ALL Select Day (1-31): ____ JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC ALL ____Each ____All ____None

Transmission Cut-off Time: ELECTRONIC MAILBOX(es) FOR THIS PROFILE: Network: TEST PROD Mailbox Acct ID: User ID: * Message Class: * See special note in Trading Partner instructions. DIRECT CONNECT AVAILABLE:____ NO FLAT FILE RECORD DELIMITER: ANSI INFORMATION: Segment Terminator Data Elements Separator Sub-Element Separator Acknowledge 824 Transmissions? Yes/No
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Network: TEST Mailbox Acct ID: User ID: * Message Class: PROD

YES

FTP AVAILABLE: ____NO ____YES -- Specifications attached.

ISA Information: Sender/Receiver Qualifier Sender/Receiver ID:
3-53

TEST

PROD

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Return this page to:

TRANSMISSION PROFILE -- SENDER'S RESPONSE

RECEIVER NAME: RECEIVER IDENTIFIER: Receiver FEIN: PROFILE ID: SENDER SELECTIONS/INFORMATION: MASTER TRADING PARTNER INFORMATION: Name: SENDER NAME: TRADING PARTNER TYPE: __ Jurisdiction SENDER IDENTIFIER: Sender FEIN: Transaction IAIABC/ANSI 148/148 A49/148 POC/271 MED 837 AKI/824 ANSI __ Claims Admin __ Employer __ Service Bureau __ Other FEIN: DESCRIPTION: Receiver Postal Code:

Sender Postal Code : ACKNOWLEDGMENT INFORMATION Mode Level

TRANSACTION INFORMATION Release/ Projected Number Format Version per Transaction

TRANSMISSION FREQUENCY (select only one from Receiver's options): Daily Monthly Quarterly Annually Other: SELECTED MEDIA: Weekly -- SUN MON TUE WED THU FRI SAT Day (1-31): ____ Month(s): JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Day (1-31): ____ Month: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Day (1-31): ____ Electronic Mailbox Direct Connect

ELECTRONIC MAILBOX INFORMATION: Network: TEST Mailbox Acct ID: User ID: Message Class: PROD

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SECTION 3 IAIABC Release 1 Systems Event Table
TRANS SET ID MTC MTC DESCRIPTION Original PROD IMPL. DATE LEVEL IND. FROM THRU REPORT TRIGGER CRITERIA A = New Clm B = Cuml Med $ C = Lost Time D = Cuml Wage Repl E = Days Open F = Formula L = Detrm of Comp Dth N = Cuml Indemnity $ Q= Employee Death O = Maintenance Type Event O = Maintenance Type Event RPT TRIG PRD REP LMT VALUE QUAL NUM N/A > $$$ > # days > $$$ # Days Fn # > $$$ RPT REQUIREMENT CRITERIA A = Dt of Injury B = Dt Disab Began C = Dt Emp. Not. D = Dt Admin. Not. E = Dt Juris Not. F = Date of Initial Payment L = Detrm of Comp Dth G = Dt of Dth H = Date Report Trigger I = Calendar Date EFFECTIVE DATE FROM THRU REPORT DUE CRITERIA A = Days frm Dt Acc/Inj B = Days frm Dt. Disab C = Days frm Emp. Not. D = Days from Admin. Not. E = Days frm Juris Not. G = Days frm IP H = Immediate I = Days frm Dt. Of Dth J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger A = Days frm Dt Acc/Inj B = Days frm Dt. Disab C = Days frm Emp. Not. D = Days from Admin. Not. E = Days frm Juris Not. H = Immediate J = Days frm Rpt Trigger AU Acq/Unallocated O = Maintenance Type Event N/A D = Days from Admin. Not. H = Immediate J = Days frm Rpt Trigger CO Correction O = Maintenance Type Event N/A H = Immediate J = Days frm Rpt Trigger VALUE FOLLOW-UP RECEIVER FORM # Days # Days # Days # Days # Days # Days 0 Days # Days # Days 0 Days # Days 0 Days # Days # Days # Days # Days # Days # Days 0 Days # Days # Days 0 Days # Days 0 Days # Days

FROI (148) 00

01 02

Cancel Change

N/A DN =

04

Denial

O = Maintenance Type Event

N/A

SROI(A49) 02 04

Change Denial

O = Maintenance Type Event O = Maintenance Type Event

DN = N/A

H = Immediate J = Days frm Rpt Trigger A = Days frm Dt Acc/Inj B = Days frm Dt. Disab C = Days frm Emp. Not. D = Days from Admin. Not. E = Days frm Juris Not. H = Immediate J = Days frm Rpt Trigger A = Days frm Dt Acc/Inj B = Days frm Dt. Disab C = Days frm Emp. Not. D = Days from Admin. Not. E = Days frm Juris Not. H = Immediate J = Days frm Rpt Trigger

0 Days # Days # Days # Days # Days # Days # Days 0 Days # Days # Days # Days # Days # Days # Days 0 Days # Days

4P

Partial Denial

O = Maintenance Type Event

N/A

AP

Acq/Payment

O = Maintenance Type Event

IAIABC First Report and Subsequent Report of Injury © Release 1

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Revised February 15, 2002

SECTION 3 IAIABC Release 1 Systems Event Table
TRANS SET ID MTC MTC DESCRIPTION Change in Ben Amt Change in Ben Type Compensable DeathNo Dep/Payees PROD IMPL. DATE LEVEL IND. FROM THRU REPORT TRIGGER CRITERIA O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event RPT TRIG PRD REP LMT VALUE QUAL NUM DN87 DN85 RPT REQUIREMENT CRITERIA EFFECTIVE DATE FROM THRU REPORT DUE CRITERIA H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger C = Days frm Emp. Not. D = Days from Admin. Not. H = Immediate I = Days frm Dt. Of Dth J = Days frm Rpt Trigger N/A # Days N/A H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger D = Days from Admin. Not. H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger VALUE FOLLOW-UP RECEIVER FORM 0 Days # Days 0 Days # Days # Days # Days 0 Days # Days # Days 0 Days # Days 0 Days # Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days

CA CB CD

CO FN FS

Correction Final Full Salary

O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event

IP P1 P2 P3 P4 P5 P6 P7

Initial Payment PSusp-RTRTW PSusp-Med Non Cmp PSusp-Adm Non Cmp PSusp-Dth Non Cmp PSusp-Incarceration PSusp-Clmt Missing PSusp-Bens Exhaust

O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event

> $$$ N/A N/A N/A N/A N/A N/A N/A

P8 P9 PJ PY

PSusp-Juris Change PSusp-Setlmnt Aprv PSusp-Apl/Jud Rev Payment Report

O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event B = Cuml Med $ D = Cuml Wage Repl F = Formula H = Chg in Elem Value

N/A N/A N/A > $$$ > $$$ Fn # N/A

H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger

0 Days # Days 0 Days # Days 0 Days # Days

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Revised February 15, 2002

SECTION 3 IAIABC Release 1 Systems Event Table
TRANS SET ID MTC MTC DESCRIPTION PROD IMPL. DATE LEVEL IND. FROM THRU REPORT TRIGGER CRITERIA N = Cuml Indemnity $ O = Maintenance Type Event RPT TRIG PRD REP LMT VALUE QUAL NUM > $$$ N/A RPT REQUIREMENT CRITERIA EFFECTIVE DATE FROM THRU REPORT DUE CRITERIA VALUE FOLLOW-UP RECEIVER FORM

RB RE S1 S2 S3 S4 S5 S6 S7 S8 S9 SJ UR VE

Reinstmnt of Bens Reduced Earnings Susp-RTRTW Susp-Med Non Cmp Susp-Adm Non Cmp Susp-Dth Non Cmp Susp-Incarceration Susp-Clmt Missing Susp-Bens Exhaust Susp-Juris Change Susp-Setlmnt Aprv Susp-Apl/Jud Rev Upon Request Volunteer

H = Immediate J = Days frm Rpt Trigger

0 Days # Days

O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger H = Immediate J = Days frm Rpt Trigger

0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days 0 Days # Days

D = Days from Admin. Not. H = Immediate J = Days frm Rpt Trigger

# Days 0 Days # Days

BM BW MN QT SA AN

Bi-Monthly Bi-Weekly Monthly Quarterly Semi-Annually Annual

O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event O = Maintenance Type Event

N/A N/A N/A N/A N/A MM/DD

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SECTION 3
IAIABC RELEASE I

ELEMENT CRITERIA CODES:
C = CONDITIONAL M = MANDATORY O = OPTIONAL R = RESTRICTED

ELEMENT REQUIREMENT TABLE
(Part I)

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

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 Policy Effective Date Policy Expiration Date

ELEMENT 148/ A49/ HD1/AK1/TR1 148/A49 148/A49 148/A49 148/A49 148/A49 148 148/A49 148 148 148 148 148 148/A49 148/A49 148 148 148 148 148 148 148 148 148 148 148/A49 148 148 148 148

HD1/AK1/TR:

148 MTC's:

A49 MTC's:

LOCATED ON HD1 AK1 TR1 00 01 02 04 CO AU 02 04 4P AP CA CB CD CO FN FS IP RB RE UR VE AN BM BW MN QT SA M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M

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Revised February 15, 2002

SECTION 3
IAIABC RELEASE I

ELEMENT CRITERIA CODES:
C = CONDITIONAL M = MANDATORY O = OPTIONAL R = RESTRICTED

ELEMENT REQUIREMENT TABLE
(Part I)

IAIABC DN 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 Date of Injury Time of Injury

IAIABC DATA ELEMENT NAME

ELEMENT 148/A49 148 148 148 148 148 148 148 148 148 148 148/A49 148 148 148 148 148 148 148 148 148 148 148 148 148/A49 148/A49 148/A49 148 148 148 148

HD1/AK1/TR:

148 MTC's:

A49 MTC's:

LOCATED ON HD1 AK1 TR1 00 01 02 04 CO AU 02 04 4P AP CA CB CD CO FN FS IP RB RE UR VE AN BM BW MN QT SA

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 Claims 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

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Revised February 15, 2002

SECTION 3
IAIABC RELEASE I

ELEMENT CRITERIA CODES:
C = CONDITIONAL M = MANDATORY O = OPTIONAL R = RESTRICTED

ELEMENT REQUIREMENT TABLE
(Part I)

IAIABC DN 0062 0063 0064 0065 0066 0067 0068 0069 0070 0071 0072 0073 0074 0075 0076 0077 0078 0079 0080 0081 0082 0083 0084 0085 0086 0087 0088 0089 0090 0091 0092 Wage Wage Period

IAIABC DATA ELEMENT NAME

ELEMENT 148/A49 148/A49 148/A49 148 148 148/A49 148 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49

HD1/AK1/TR:

148 MTC's:

A49 MTC's:

LOCATED ON HD1 AK1 TR1 00 01 02 04 CO AU 02 04 4P AP CA CB CD CO FN FS IP RB RE UR VE AN BM BW MN QT SA

Number of Days Worked Date Last Day Worked Full Wages Paid for Date of Injury Indicator Salary Continued Indicator Date of Return to Work Pre-Existing Disability Dt of Maximum Medical Improvement Return to Work Qualifier Date of Return/Release to Work Claim Status Claim Type Agreement to Compensate Code Date of Representation Late Reason Code Number of Permanent Impairments Number of Payments/Adjustments Number of Benefit Adjustments Number of Paid to Dates/Red.Earnings/Rec. Number of Death Dep./Payee Relationships Permanent Impairment Body Part Code Permanent Impairment Percent Payment/Adjustment Code Payment/Adjustment Paid to Date Payment/Adjustment Weekly Amount Payment/Adjustment Start Date Payment/Adjustment End Date Payment/Adjustment Weeks Paid Payment/Adjustment Days Paid Benefit Adjustment Code

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

M M M M M

See P/A Requirement Table

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Revised February 15, 2002

SECTION 3
IAIABC RELEASE I

ELEMENT CRITERIA CODES:
C = CONDITIONAL M = MANDATORY O = OPTIONAL R = RESTRICTED

ELEMENT REQUIREMENT TABLE
(Part I)

IAIABC DN 0093 0094 0095 0096 0097 0098 0099 0100 0101 0102 0103 0104 0105 0106 0107 0108 0109 0110 0111 0112 0113 0114 0115 0116 0117

IAIABC DATA ELEMENT NAME Benefit Adjustment Weekly Amount Benefit Adjustment Start Date Paid to Date/Red.Earnings/Rec.Code Paid to Date/Red. Earnings/Rec. Amt Dependent/Payee Relationship Sender ID Receiver ID Date Transmission Sent Time Transmission Sent Original Transmission Date Original Transmission Time Test/Production Indicator Interchange Version ID Detail Record Count Record Sequence Number Date Processed Time Processed Acknowledgment Transaction Set ID Application Acknowledgement Code Request Code (Purpose) Free Form Text Number of Errors Element Number Element Error Number Variable Segment Number

ELEMENT A49 A49 A49 A49 A49 HD1 HD1 HD1 HD1 HD1 HD1 HD1 HD1 TR1 AK1 AK1 AK1 AK1 AK1 AK1 AK1 AK1 AK1 AK1 AK1

HD1/AK1/TR:

148 MTC's:

A49 MTC's:

LOCATED ON HD1 AK1 TR1 00 01 02 04 CO AU 02 04 4P AP CA CB CD CO FN FS IP RB RE UR VE AN BM BW MN QT SA

M M M M * * M M M M M M M M

M C C C

* M on HD1 of AK1

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Revised February 15, 2002

SECTION 3
IAIABC RELEASE I

ELEMENT CRITERIA CODES:
C = CONDITIONAL M = MANDATORY O = OPTIONAL R = RESTRICTED

ELEMENT REQUIREMENT TABLE
(Part II)

IAIABC DN 0001 0002 0003 0004 0005 0006 0008 0014 0015 0026 0031 0042 0055 0056 0057 0062 0063 0064 0067 0069 0070 0071 0072 0073 0074 0075 0076 0077 0078

IAIABC DATA ELEMENT NAME Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Agency Claim Number Insurer FEIN Third Party Administrator FEIN Claim Administrator Postal Code Claim Administrator Claim Number Insured Report Number Date of Injury Social Security Number Number of Dependents Date Disability Began Employee Date of Death Wage Wage Period Number of Days Worked Salary Continued Indicator Pre-Existing Disability Dt of Maximum Medical Improvement Return to Work Qualifier Date of Return/Release to Work Claim Status Claim Type Agreement to Compensate Code Date of Representation Late Reason Code Number of Permanent Impairments

ELEMENT

A49 MTC's (continued):

LOCATED ON S1 S2 S3 S4 S5 S6 S7 S8 S9 SJ P1 P2 P3 P4 P5 P7 P9 PJ PY 148/ A49/ HD1/AK1/TR1 M M M M M M M M M M M M M M M M M M M 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 148/A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M

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SECTION 3
IAIABC RELEASE I

ELEMENT CRITERIA CODES:
C = CONDITIONAL M = MANDATORY O = OPTIONAL R = RESTRICTED

ELEMENT REQUIREMENT TABLE
(Part II)

IAIABC DN 0079 0080 0081 0082 0083 0084 0085 0086 0087 0088 0089 0090 0091 0092 0093 0094 0095 0096 0097 0098 0099 0100 0101 0102 0103 0104 0105 0106 0107

IAIABC DATA ELEMENT NAME Number of Payments/Adjustments Number of Benefit Adjustments Number of Paid to Dates/Red.Earnings/Rec. Number of Death Dep./Payee Relationships Permanent Impairment Body Part Code Permanent Impairment Percent Payment/Adjustment Code Payment/Adjustment Paid to Date Payment/Adjustment Weekly Amount Payment/Adjustment Start Date Payment/Adjustment End Date Payment/Adjustment Weeks Paid Payment/Adjustment Days Paid Benefit Adjustment Code Benefit Adjustment Weekly Amount Benefit Adjustment Start Date Paid to Date/Red.Earnings/Rec.Code Paid to Date/Red. Earnings/Rec. Amt Dependent/Payee Relationship Sender ID Receiver ID Date Transmission Sent Time Transmission Sent Original Transmission Date Original Transmission Time Test/Production Indicator Interchange Version ID Detail Record Count Record Sequence Number

ELEMENT A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 A49 HD1 HD1 HD1 HD1 HD1 HD1 HD1 HD1 TR1 AK1 M M M M M M M M M M M M M M M M M M M M M M M M

A49 MTC's (continued): M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M

LOCATED ON S1 S2 S3 S4 S5 S6 S7 S8 S9 SJ P1 P2 P3 P4 P5 P7 P9 PJ PY

SEE P/A ELEMENT REQUIREMENT TABLE

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SECTION 3
IAIABC RELEASE I

ELEMENT CRITERIA CODES:
C = CONDITIONAL M = MANDATORY O = OPTIONAL R = RESTRICTED

ELEMENT REQUIREMENT TABLE
(Part II)

IAIABC DN 0108 0109 0110 0111 0112 0113 0114 0115 0116 0117 Date Processed Time Processed

IAIABC DATA ELEMENT NAME

ELEMENT AK1 AK1 AK1 AK1 AK1 AK1 AK1 AK1 AK1 AK1

A49 MTC's (continued):

LOCATED ON S1 S2 S3 S4 S5 S6 S7 S8 S9 SJ P1 P2 P3 P4 P5 P7 P9 PJ PY

Acknowledgment Transaction Set ID Application Acknowledgement Code Request Code (Purpose) Free Form Text Number of Errors Element Number Element Error Number Variable Segment Number

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SECTION 3
ELEMENT CRITERIA CODES: M = MANDATORY C = CONDITIONAL- Trading Partner must specify applicable P/A Codes and required segment conditions O = OPTIONAL R = RESTRICTED * = If Value Changed, Send It

IAIABC RELEASE 1 - PAYMENT/ADJUSTMENT ELEMENT REQUIREMENT TABLE

CRITERIA - Begin or End Dates

Example: For Dates of Acc < 1-1-94

Fatal PermTotal PermTotal Supplemental Perm Partial/Scheduled Perm Partial/Unscheduled Temporary Total Temp Total Catastrophic Temporary Partial Perm Partial Disfigurement Employer Paid Vocational Rehab Compromised Unspecified (lump sum) Compromised Medical Compromised Fatal Compromised Permanent Total Compromised Permanent Total Supplemental Compromised Employer Paid Compromised Permanent Partial Scheduled Compromised Permanent Partial Unscheduled Compromised Vocational Rehab Compromised Temporary Total Compromised Temporary Total Catastrophic Compromised Temporary Partial Compromised Permanent Partial Disfigurement

P/A DESCRIPTION

P/A Code 010 020 021 030 040 050 051 070 090 240 410 500 501 510 520 521 524 530 540 541 550 551 570 590

P/A PTD C

P/A AMNT C

P/A START DATE C

P/A END DATE C

P/A WEEKS PAID C

P/A DAYS PAID C

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February 15, 2002

DN

IAIABC

0030
Jurisdiction Insurer FEIN Insurer Name Industry Code Insured Name Employer City Policy Number Employer FEIN Employer State Employer Name Entire Transaction Transaction Set ID Policy Effective Date IAIABC DATA ELEMENT NAME Self Insured Indicator Policy Expiration Date Employer Postal Code Agency Claim Number Insured Report Number Claim Administrator City Maintenance Type Code Employer Address Line 2 Insured Location Number Employer Address Line 1 Claim Administrator State Maintenance Type Code Date Third Party Administrator FEIN Claim Administrator Addr Line 2 Third Party Administrator Name Claim Administrator Addr Line 1 Claim Administrator Postal Code Claim Administrator Claim Number

0029

0028

0027

0026

0025

0024

0023

0022

0021

0020

0019

0018

0017

0016

0015

0014

0013

0012

0011

0010

0009

0008

0007

0006

0005

0004

0003

0002

0001

0000

ERROR MESSAGE
001 002 Mandatory field not present Transaction Set ID Invalid MTC invalid for '148' MTC invalid for 'A49' State Code Invalid NCCI Nature Code Invalid NCCI Part of Body Code Invalid NCCI Cause of Injury Code Invalid 008 009 010 011 Gender Code Invalid Marital Status Code Invalid Wage Period Code Invalid 012 013 014 Indicator Invalid Employment Status Code Invalid Class Code (NCCI or State Spec) Invalid 015 016 017 018 019 020 021 022 023 024 025 026 027 Industry Code (SIC or NAICS) Invalid Initial Treatment Code Invalid Claim Status Code Invalid Number of Days worked must be 0-7 Days must be 0-6 Return to Work Qualifier Code invalid Claim Type Code Invalid Agreement to Compensate Code Invalid Late Reason Code Invalid Payment/Adjustment Code Invalid Benefit/Adjustment Code Invalid PTD/RE/Recovery Code Invalid Dep/Payee Relationship Code invalid

X X X 003 004 005 006 007 X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

IAIABC First Report and Subsequent Report of Injury © Release 1
X X X X 028 X 029 030 031 X X 032 033 034 035 036 037 038 X X 039 X 040 X 041 042 043 044 045 046 X 047 X 048 X 049 X 050 X 051 X 052 053 X 054 055 056 X X 057 X X X X X X X X X X 058 X 059 060 060 061 062 063 064 065 066 067 068 X X 100 Must be numeric (0-9) Must be a valid date (CCYYMMDD) Must be A-Z, 0-9, or spaces Must be a valid time (HHMMSS) Must be valid on Zip Code Table Must be <= Date of Injury Must be >= Date of Injury Must be >= Date Disability Began Must be <= Date of Death Must be <= Maintenance Type Code date Must be >= Start date No match on database All digits cannot be the same Must be <= Current date Not statutorily valid Receiver ID Invalid Value is > than required by jurisdiction Value is < than required by jurisdiction Interchange Version ID invalid Reinstated but not suspended Duplicate First Report (148) Duplicate Initial Payment (A49) No matching Subsequent report (A49) Reduced Earnings prior to Initial Payment Suspension prior to Initial Payment No matching FROI (148) Must be valid occurence for segment Must be <= Date of Hire Detail Record Count not = # records recv'd Duplicate transmission/transaction Code/ID invalid Value not consistent w/ value prev reported Previous supporting docs not received Previous supporting docs not recv'd Event Criteria not met Required segment not present Invalid event sequence/relationship Invalid data sequence/relationship Corresponding report/data not found Invalid record count Must be >= Policy Effective Date Must be <= Policy Expiration Date No Leading/Embedded Spaces X X X X X

SECTION 3

IAIABC Release 1 Edit Matrix Table

3-71
Revised February 15, 2002

DN

IAIABC

0061
Class Code Date of Hire IAIABC DATA ELEMENT NAME Gender Code Date of Injury Time of Injury Employee City Employee State Initial Treatment Employee Phone Marital Status Code Cause of Injury Code Date Disability Began Nature of Injury Code Employee Last Name Employee First Name Employee Middle Initial Employee Postal Code Occupation Description Number of Dependents Employee Date of Birth Social Security Number Employee Date of Death Employee Address Line 2 Employee Address Line 1 Postal Code of Injury Site Employment Status Code Part of Body Injured Code Accident Description/Cause Date Reported to Employer Employers Premises Indicator Date Reported to Claim Admin

0060

0059

0058

0057

0056

0055

0054

0053

0052

0051

0050

0049

0048

0047

0046

0045

0044

0043

0042

0041

0040

0039

0038

0037

0036

0035

0034

0033

0032

0031

ERROR MESSAGE
001 002 003 004 005 MTC invalid for '148' MTC invalid for 'A49' State Code Invalid NCCI Nature Code Invalid NCCI Part of Body Code Invalid NCCI Cause of Injury Code Invalid 008 009 010 011 Gender Code Invalid Marital Status Code Invalid Wage Period Code Invalid 012 013 014 015 Indicator Invalid Employment Status Code Invalid Class Code (NCCI or State Spec) Invalid Industry Code (SIC or NAICS) Invalid 016 017 018 019 020 021 022 023 024 025 026 027 Initial Treatment Code Invalid Claim Status Code Invalid Number of Days worked must be 0-7 Days must be 0-6 Return to Work Qualifier Code invalid Claim Type Code Invalid Agreement to Compensate Code Invalid Late Reason Code Invalid Payment/Adjustment Code Invalid Benefit/Adjustment Code Invalid PTD/RE/Recovery Code Invalid Dep/Payee Relationship Code invalid Mandatory field not present Transaction Set ID Invalid

X X 006 007 X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

IAIABC First Report and Subsequent Report of Injury © Release 1
X X X X X X X X X 028 X X X 029 030 X 031 X 032 033 X X 034 035 036 X X X X X X 037 038 039 X 040 041 042 043 044 045 046 047 048 049 050 051 052 053 054 X 055 056 057 X X X X X X X X X X X X X X X 058 X X X 059 060 060 061 062 063 064 065 066 067 068 100 Must be numeric (0-9) Must be a valid date (CCYYMMDD) Must be A-Z, 0-9, or spaces Must be a valid time (HHMMSS) Must be valid on Zip Code Table Must be <= Date of Injury Must be >= Date of Injury Must be >= Date Disability Began Must be <= Date of Death Must be <= Maintenance Type Code date Must be >= Start date No match on database All digits cannot be the same Must be <= Current date Not statutorily valid Receiver ID Invalid Value is > than required by jurisdiction Value is < than required by jurisdiction Interchange Version ID invalid Reinstated but not suspended Duplicate First Report (148) Duplicate Initial Payment (A49) No matching Subsequent report (A49) Reduced Earnings prior to Initial Payment Suspension prior to Initial Payment No matching FROI (148) Must be valid occurence for segment Must be <= Date of Hire Detail Record Count not = # records recv'd Duplicate transmission/transaction Code/ID invalid Value not consistent w/ value prev reported Previous supporting docs not received Previous supporting docs not recv'd Event Criteria not met Required segment not present Invalid event sequence/relationship Invalid data sequence/relationship Corresponding report/data not found Invalid record count Must be >= Policy Effective Date Must be <= Policy Expiration Date No Leading/Embedded Spaces X X X X X X X X X

SECTION 3

IAIABC Release 1 Edit Matrix Table

3-72
Revised February 15, 2002

DN

IAIABC

0092
Wage Claim Type Wage Period Date of MMI Claim Status RTW Qualifer Late Reason Code Pre-Existing Disability Number Days Worked Date Last Day Worked Date of Representation Date of Return to Work Payment/Adj. End Date Payment/Adj. Days Paid IAIABC DATA ELEMENT NAME Benefit/Adjustment Code Payment/Adj. Start Date Salary Continued Indicator Num. Benefit/Adjustments Payment/Adj. Weeks Paid Payment/Adjustment Code Agreement to Comp. Code Payment/Adj. Paid to Date Num. Death Dep/Payee Rel Num. Payment/Adjustments Perm. Impairment Body Part Payment/Adjustment Amount Date Release/Return to Work Num. PTD/Reduced Earnings Perm. Impairment Percentage Num. Permanent Impairments Full Wages Paid for Date of Inj Ind

0091

0090

0089

0088

0087

0086

0085

0084

0083

0082

0081

0080

0079

0078

0077

0076

0075

0074

0073

0072

0071

0070

0069

0068

0067

0066

0065

0064

0063

0062

ERROR MESSAGE
001 002 003 004 005 006 007 008 009 010 MTC invalid for '148' MTC invalid for 'A49' State Code Invalid NCCI Nature Code Invalid NCCI Part of Body Code Invalid NCCI Cause of Injury Code Invalid Gender Code Invalid Marital Status Code Invalid 011 012 013 014 015 016 Wage Period Code Invalid Indicator Invalid Employment Status Code Invalid Class Code (NCCI or State Spec) Invalid Industry Code (SIC or NAICS) Invalid Initial Treatment Code Invalid 017 Claim Status Code Invalid Mandatory field not present Transaction Set ID Invalid

X

X

IAIABC First Report and Subsequent Report of Injury © Release 1
X X X X X X 018 019 020 X 021 022 023 024 025 026 027 X X X X X X X X X X X X X 028 X X X X X 029 030 031 032 033 X X X X X X X 034 X X X X 035 036 X X X X 037 038 039 040 041 042 043 044 045 046 047 048 049 050 051 052 053 X X X X X 054 055 056 057 X X X X X X X X X X X X 058 059 060 060 061 062 063 064 065 066 067 068 100 Number of Days worked must be 0-7 Days must be 0-6 Return to Work Qualifier Code invalid Claim Type Code Invalid Agreement to Compensate Code Invalid Late Reason Code Invalid Payment/Adjustment Code Invalid Benefit/Adjustment Code Invalid PTD/RE/Recovery Code Invalid Dep/Payee Relationship Code invalid Must be numeric (0-9) Must be a valid date (CCYYMMDD) Must be A-Z, 0-9, or spaces Must be a valid time (HHMMSS) Must be valid on Zip Code Table Must be <= Date of Injury Must be >= Date of Injury Must be >= Date Disability Began Must be <= Date of Death Must be <= Maintenance Type Code date Must be >= Start date No match on database All digits cannot be the same Must be <= Current date Not statutorily valid Receiver ID Invalid Value is > than required by jurisdiction Value is < than required by jurisdiction Interchange Version ID invalid Reinstated but not suspended Duplicate First Report (148) Duplicate Initial Payment (A49) No matching Subsequent report (A49) Reduced Earnings prior to Initial Payment Suspension prior to Initial Payment No matching FROI (148) Must be valid occurence for segment Must be <= Date of Hire Detail Record Count not = # records recv'd Duplicate transmission/transaction Code/ID invalid Value not consistent w/ value prev reported Previous supporting docs not received Previous supporting docs not recv'd Event Criteria not met Required segment not present Invalid event sequence/relationship Invalid data sequence/relationship Corresponding report/data not found Invalid record count Must be >= Policy Effective Date Must be <= Policy Expiration Date No Leading/Embedded Spaces X X X X X

SECTION 3

IAIABC Release 1 Edit Matrix Table

3-73
X X X

Revised February 15, 2002

DN

IAIABC

0117
Sender ID Receiver ID Date Processed Free Form Text Time Processed Element Number Number of Errors Detail Record Count Element Error Number IAIABC DATA ELEMENT NAME Interchange Version ID Benefit/Adj. Start Date PTD/RE/Recovery Amnt Time Transmission Sent PTD/RE/Recovery Code Request Code (Purpose) Date Transmission Sent Test/Production Indicator Variable Segment Number Record Sequence Number Original Transmission Date Benefit/Adjustment Amount Original Transmission Time Dependent Payee Relationship Application Acknowledgement Code Acknowledgment Transaction Set ID

0116

0115

0114

0113

0112

0111

0110

0109

0108

0107

0106

0105

0104

0103

0102

0101

0100

0099

0098

0097

0096

0095

0094

0093

ERROR MESSAGE
001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 MTC invalid for '148' MTC invalid for 'A49' State Code Invalid NCCI Nature Code Invalid NCCI Part of Body Code Invalid NCCI Cause of Injury Code Invalid Gender Code Invalid Marital Status Code Invalid Wage Period Code Invalid Indicator Invalid Employment Status Code Invalid Class Code (NCCI or State Spec) Invalid Industry Code (SIC or NAICS) Invalid Initial Treatment Code Invalid Claim Status Code Invalid Number of Days worked must be 0-7 Days must be 0-6 Return to Work Qualifier Code invalid Claim Type Code Invalid Agreement to Compensate Code Invalid Late Reason Code Invalid Payment/Adjustment Code Invalid Benefit/Adjustment Code Invalid Mandatory field not present Transaction Set ID Invalid

X

X

X

X

X

X

X

X

X

X

X

X

X

IAIABC First Report and Subsequent Report of Injury © Release 1
X 026 X 027 X X X 028 X X X X 029 X 030 X X X 031 032 033 X 034 X 035 036 037 038 X 039 040 X 041 042 X 043 044 045 X 046 047 048 049 050 051 052 053 054 055 X 056 057 X X X X X X X 058 PTD/RE/Recovery Code Invalid Dep/Payee Relationship Code invalid Must be numeric (0-9) Must be a valid date (CCYYMMDD) Must be A-Z, 0-9, or spaces Must be a valid time (HHMMSS) Must be valid on Zip Code Table Must be <= Date of Injury Must be >= Date of Injury Must be >= Date Disability Began Must be <= Date of Death Must be <= Maintenance Type Code date Must be >= Start date No match on database All digits cannot be the same Must be <= Current date Not statutorily valid Receiver ID Invalid Value is > than required by jurisdiction Value is < than required by jurisdiction Interchange Version ID invalid Reinstated but not suspended Duplicate First Report (148) Duplicate Initial Payment (A49) No matching Subsequent report (A49) Reduced Earnings prior to Initial Payment Suspension prior to Initial Payment No matching FROI (148) Must be valid occurence for segment Must be <= Date of Hire Detail Record Count not = # records recv'd Duplicate transmission/transaction X X

X

X

SECTION 3

IAIABC Release 1 Edit Matrix Table

3-74
X X

Code/ID invalid 059 060 060 061 062 063 064 065 X 066 067 068 100 Value not consistent w/ value prev reported Previous supporting docs not received Previous supporting docs not recv'd Event Criteria not met Required segment not present Invalid event sequence/relationship Invalid data sequence/relationship Corresponding report/data not found Invalid record count Must be >= Policy Effective Date Must be <= Policy Expiration Date No Leading/Embedded Spaces

Revised February 15, 2002

SECTION 4

4.
Transaction Standards

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Release 1 Hard Copy Form

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February 15, 2002

WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER JURISDICTION INSURED REPORT NUMBER EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT) INDUSTRY CODE EMPLOYER FEIN LOCATION # PHONE # OSHA LOG NUMBER REPORT PURPOSE CODE JURISDICTION CLAIM NUMBER

CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #) POLICY PERIOD TO
CHECK IF APPROPRIATE SELF INSURANCE

CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)

CARRIER FEIN

POLICY/SELF-INSURED NUMBER

ADMINISTRATOR FEIN

EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE) ADDRESS (INCL ZIP) DATE OF BIRTH SEX
M MALE

SOCIAL SECURITY NUMBER MARITAL STATUS U
M S K
UNMARRIED SINGLE/DIVORCED

DATE HIRED

STATE OF HIRE

OCCUPATION/JOB TITLE
EMPLOYMENT STATUS

PHONE

FEMALE F U UNKNOWN # OF DEPENDENTS

MARRIED SEPARATED UNKNOWN

NCCI CLASS CODE YES YES NO NO

RATE PER:

DAY WEEK

MONTH
OTHER:

DAYS WORKED/WEEK

FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE?

OCCURRENCE/TREATMENT
TIME EMPLOYEE BEGAN WORK AM PM CONTACT NAME/PHONE NUMBER DATE OF INJURY/ILLNESS TIME OF OCCURRENCE ( ) CANNOT BE DETERMINED TYPE OF INJURY/ILLNESS AM PM PART OF BODY AFFECTED LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN

DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE PREMISES? YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS OCCURRED EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE

DATE RETURN(ED) TO WORK

IF FATAL, GIVE DATE OF DEATH

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)

YES

NO

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)

NO YES INITIAL TREATMENT 0 1 2 3 4 5 NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSP EMERGENCY CARE HOSPITALIZED > 24 HOURS
FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

OTHER
WITNESSES (NAME & PHONE #)

DATE ADMINISTRATOR NOTIFIED

DATE PREPARED

PREPARER’S NAME & TITLE

PHONE NUMBER

FORM IA-1(r 1-1-02)

SEE BACK FOR IMPORTANT INFORMATION

IAIABC 2002

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

EMPLOYER’S INSTRUCTIONS
DO NOT ENTER DATA IN SHADED FIELDS

DATES: Enter all dates in MM/DD/YY format. INDUSTRY CODE: This is the code which represents the nature of the employer’s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget. CARRIER: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. CLAIMS ADMINISTRATOR: Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim. AGENT NAME & CODE NUMBER: Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy. OCCUPATION/JOB TITLE: This is the primary occupation of the claimant at the time of the accident or exposure. EMPLOYMENT STATUS: Indicate the employee’s work status. The valid choices are: Full-Time On Strike Unknown Part-Time Disabled Apprenticeship Full-Time Not Employed Retired Apprenticeship Part-Time

Volunteer Seasonal Piece Worker

DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute. CONTACT NAME/PHONE NUMBER: Enter the name of the individual at the employer’s premises to be contacted for additional information. TYPE OF INJURY/ILLNESS: Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm). PART OF BODY AFFECTED: Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back). DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210) If the accident or illness exposure did not occur on the employer’s premises, enter address or location. Be specific.

FORM IA-1(r 1-1-02)

IAIABC 2002

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February 15, 2002

EMPLOYER’S INSTRUCTIONS – cont’d
ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Acetylene cutting torch, metal plate) List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush, and paint. Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illness. SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (eg. Cutting metal plate for flooring) Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (eg. walking along a hallway). HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL: (Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.) Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker’s right wrist was broken in the fall. DATE RETURN(ED) TO WORK: Enter the date following to most recent disability period on which the employee returned to work.

FORM IA-1(r 1-1-02)
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IAIABC 2002
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Release 1 Flat File Formats

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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 0112 0113 0114 VARIABLE SEGMENT ERROR CODE 0115 0116 0117 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 END 1 4 13 21 27 36 45 54 57 59 84 109 134 136 144 147 207 3 12 20 26 35 44 53 56 58 83 108 133 135 143 146 206 208

Error Code Occurs Number of Error Times (maximum number of occurrences = 99) Element Number Element Error Number Variable Segment Number 4N 3N 2N 209 213 216 212 215 217

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IAIABC RELEASE 1 FIRST REPORT OF INJURY (148)
IAIABC GROUPING TRANSACTION IAIABC DN 0001 0002 0003 JURISDICTION CLAIM ADMINISTRATOR 0004 0005 0006 0007 0008 0009 0010 0011 0012 0013 0014 0015 INSURED 0016 0017 0018 0019 0020 0021 0022 0023 0024 0025 0026 0027 POLICY 0028 0029 0030 ACCIDENT 0031 0032 0033 0034 0035 0036 0037 0038 0039 0040 0041 EMPLOYEE 0042 0043 0044 0045 0046 0047 0048 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 IAIABC FORMAT 3 A/N 2 A/N DATE 2 A/N 25 A/N 9 A/N 30 A/N 9 A/N 30 A/N 30 A/N 30 A/N 15 A/N 2 A/N 9 A/N 25 A/N 9 A/N 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 9 A/N 30 A/N 15 A/N 1 A/N 30 A/N 30 A/N 15 A/N POSITIONS BEG END 1 4 6 14 16 41 50 80 89 119 149 179 194 196 205 230 239 269 299 329 359 374 376 385 386 392 402 417 435 447 455 463 471 475 484 485 487 489 491 641 643 651 659 668 698 713 714 744 774 3 5 13 15 40 49 79 88 118 148 178 193 195 204 229 238 268 298 328 358 373 375 384 385 391 401 416 434 446 454 462 470 474 483 484 486 488 490 640 642 650 658 667 697 712 713 743 773 788

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Revised February 15,2002

SECTION 4
IAIABC RELEASE 1 FIRST REPORT OF INJURY (148)
IAIABC GROUPING IAIABC DN 0049 0050 0051 0052 0053 0054 0055 0056 0057 EMPLOYMENT 0058 0059 0060 0061 0062 0063 0064 0065 0066 0067 0068 IAIABC DATA ELEMENT NAME 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 Days Worked Date Last Day Worked Full Wages Paid for Date of Injury Indicator Salary Continued Indicator Date of Return to Work IAIABC FORMAT 2 A/N 9 A/N 10 A/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 POSITIONS BEG END 789 791 800 810 818 819 820 822 830 838 840 844 874 882 893 895 896 904 905 906 790 799 809 817 818 819 821 829 837 839 843 873 881 892 894 895 903 904 905 913

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Revised February 15,2002

SECTION 4
IAIABC RELEASE 1 SUBSEQUENT REPORT OF INJURY (A49) DATA ELEMENTS
IAIABC GROUPING TRANSACTION IAIABC DN 0001 0002 0003 JURISDICTION CLAIM ADMINISTRATOR 0004 0006 0008 0014 0042 0055 0069 0056 0070 0071 0072 0057 WAGE 0062 0063 0064 0067 ACCIDENT 0031 0026 0015 0005 CLAIM STATUS 0073 0074 0075 0076 PAYMENTS VARIABLE SEGMENT COUNTERS 0077 0078 0079 0080 0081 0082 VARIABLE SEGMENTS Permanent Impairments Occurs Number of Permanent Impairments times (maximum number of occurences = 6) 0083 0084 Permanent Impairment Body Part Code Permanent Impairment Percentage 3 A/N 3.2 N 1 4 3 8 IAIABC DATA ELEMENT NAME Transaction Set ID Maintenance Type Code Maintenance Type Code Date Jurisdiction Insurer FEIN Third Party Administrator FEIN Claim Administrator Postal Code Social Security Number Number of Dependents Pre-Existing Disability Date Disability Began Date of Maximum Medical Improvement Return to Work Qualifier Date of Return/Release to Work Employee Date of Death Wage Wage Period 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 Payments/Adjustments Number of Benefit Adjustments Number of Paid to Date/Reduced Earnings/Recoveries Number of Death Dependent/Payee Relationships IAIABC FORMAT 3 A/N 2 A/N DATE 2 A/N 9 A/N 9 A/N 9 A/N 9 A/N 2N 1 A/N DATE DATE 1 A/N DATE DATE $9.2 2 A/N 1N 1 A/N DATE 25 A/N 25 A/N 25 A/N 1 A/N 1 A/N 1 A/N DATE 2 A/N 2N 2N 2N 2N 2N POSITIONS BEG END 1 4 6 14 16 25 34 43 52 54 55 63 71 72 80 88 99 101 102 103 111 136 161 186 187 188 189 197 199 201 203 205 207 3 5 13 15 24 33 42 51 53 54 62 70 71 79 87 98 100 101 102 110 135 160 185 186 187 188 196 198 200 202 204 206 208

Payment/Adjustments Occurs Number of Payment/Adjustments times (maximum number of occurences = 10) 0085 0086 0087 0088 0089 0090 0091 Payment/Adjustment Code Payment/Adjustment Paid to Date Payment/Adjustment Weekly Amount Payment/Adjustment Start Date Payment/Adjustment End Date Payment/Adjustment Weeks Paid Payment/Adjustment Days Paid 3 A/N $9.2 $9.2 DATE DATE 4N 1N 1 4 15 26 34 42 46 3 14 25 33 41 45 46

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Revised February 15, 2002

SECTION 4
IAIABC RELEASE 1 SUBSEQUENT REPORT OF INJURY (A49) DATA ELEMENTS
IAIABC GROUPING IAIABC DN IAIABC DATA ELEMENT NAME IAIABC FORMAT POSITIONS BEG END

Benefit Adjustments Occurs Number of Benefit Adjustments times (maximum number of occurrences = 10) 0092 0093 Benefit Adjustment Code Benefit Adjustment Weekly Amount 4 A/N $9.2 1 5 16 4 15 23

0094 Benefit Adjustment Start Date DATE Paid to Date/Reduced Earnings/Recoveries Occurs Number of Paid to Date/Reduced Earning/Recoveries times (maximum number of occurrences = 25) 0095 Paid To Date/Reduced Earnings/Recoveries Code 3 A/N Paid To Date/Reduced Earnings/Recoveries Amount 0096 $9.2 Death Dependent/Payee Relationship Occurs Number of Death Dependent/Payee Relationship times (maximum number of occurrences = 12) 0097 Dependent/Payee Relationship 2 A/N

1 4

3 14

1

2

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Revised February 15, 2002

SECTION 4
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 END 1 4 3 12

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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 Sender Postal Code 0099 Receiver ID Receiver FEIN Filler Receiver Postal Code 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 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 54 62 68 76 82 83 61 67 75 81 82 87 29 53 POSITIONS BEG END 1 4 3 28

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Release 1 ANSI X12N Formats
IAIABC First Report and Subsequent Report of Injury © Release 1 4-21 February 15, 2002

SECTION 4

This page is meant to be blank.

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The Release 1 ANSI X12 N Documentation was not available at the time of publication and will be placed on the IAIABC website in the future, as an addendum to the Release 1 manual dated 2-15-02.

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SECTION 5

5.
Electronic Scenarios

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SECTION 5

RELEASE 1 LIMITATIONS
There are limitations in the ability to use Release 1 of the First Report and Subsequent Report record layouts and coding structures, some of which are listed below. It is recommended that all prospective Trading Partners discuss the limitations and agree on how they might be overcome PRIOR TO attempting to implement any particular part of Release 1. The following are some of the documented limitations. Data Element Limitations: Reporting usage is limited by the data elements currently on the record layouts. There have been additional data elements identified that are needed by some, if not all, of the jurisdictions for complete functionality. This would apply to most of the Maintenance Type Codes. Benefit Adjustment Code Limitations: The usefulness of Benefit Adjustment Codes is limited due to the fact that there is a start date but no end date. Also, quite often a Benefit Adjustment is started on the same transmission as another activity or change. As there is only one Maintenance Type code Date per transaction, it is difficult or impossible to determine what happened when the differing activities occurred on different dates but are included in the same transmission. Thus, Benefit Adjustment Codes should be implemented only after sufficient testing is done to ensure communication of information will occur as needed. Maintenance Type Code Limitations: Some general restrictions for most of the codes are noted as follows: A. Multiple periods of disability for a specific Payment/Adjustment Code are not reportable on a single transmission as the layout is limited to one set of start and end dates. This problem comes into play in two major areas: 1) Single check payments for more than one period of disability. 2) Multiple periods over the life of a claim which causes the dates to be reset each time a new period occurs. B. Effective date: There is only one date field for each Maintenance Type Code Date when multiple date fields are sometimes needed. For instance, the effective date and action date may be different and both need to be reported. In addition, some specific limitations were identified for many of the codes. The following is a list of each code with some of the known limitations that are in addition to data element needs. The (letter) refers to limits noted above in A or B.

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First Report Values: 00 Original 01 02 Cancel – reason needed Change – (B); changes to jurisdiction, date of injury or SSN (if agency claim number not being used), date disability began, wage, date last day worked, date of return to work full salary indicator; reason needed. Denial – (B): reason needed Acquired/Unallocated – data will need to be reviewed carefully by the receiver to ensure previously received data is not improperly overlaid. Correction

04 AU CO

Periodic Values: - (A-2) for all AN Annual BM Bi-Monthly BW MN QT SA UR Bi-Weekly Month Quarterly Semi-Annual Upon Request

Subsequent Report Values: 02 04 4P AP Change – almost the same as 02 First Report plus Maintenance Type Code dates Denial – same as 04 First Report Partial Denial – same as 04, unknown what specific benefit(s) is being denied Acquired/Unallocated Payment – data will need to be reviewed carefully by the receiver to ensure previously received data is not improperly overlaid. CA Change in Benefit Amount – (A-2); (B) CB Change in Benefit Type – (A-2); (B) CD Compensable Death CO Correction FN Final – (A-2) FS Full Salary – (A-1) IP Initial Payment – (A-1) P1–PJ Partial Suspensions – (A-2); (B); unknown which specific benefit(s) is being suspended PY Payment Report RB Reinstatement of Benefit – (A-2) RE Reduced Earnings – (A-2); unknown usage in R-1. S1-SJ Full Suspensions – (A-2); (B) VE Volunteer

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The scenarios in the packet of generic scenarios include some of the limitations noted above in their narratives. In addition, it is suggested by the EDI Technical Development Committee that CA and RE are too limited to be properly used in Release 1. If trading partners agree to attempt to use these codes, they should complete thorough experimentation and testing prior to any permanent implementation. Some of the reasons for this recommendation include: CA: Changes in prior periods for a particular Payment/Adjustment Code are not reportable when a new period of the same code is currently being paid. Changes are quite often caused by an average weekly wage change which might have its own Maintenance Type code Date and thus cause the need to have two dates reported in a single date field. Changes are also quite often associated with the implementation of a Benefit Adjustment Code which might have its own Maintenance Type Code Date and thus cause the need to have two dates reported in a single date field. In some cases all three are happening thus possibly needing three dates in one field. RE: There is no known jurisdiction definitely requesting usage of this in Release 1. Thus, questions on how the cumulative dates, rates, and amounts are to be reported have not been documented sufficiently to create and agree upon a scenario for usage.

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SECTION 5 SCENARIOS TABLE OF CONTENTS
00 – FROI (Original) ..................................................................................................... Page 5-9 01 – FROI (Cancel) ....................................................................................................... Page 5-10 02 – FROI (Change) ...................................................................................................... Page 5-11 04 – FROI (Denial #1 – Instead of 00) ........................................................................... Page 5-12 04 – FROI (Denial #2 – Subsequent to 00).................................................................... Page 5-13 AU – FROI (Acquired/Unallocated)............................................................................... Page 5-14 CO – FROI (Correction)................................................................................................ Page 5-15 AN – PERIODIC (Annual).............................................................................................. Page 5-16 02 – SROI (Change)...................................................................................................... Page 5-18 04 – SROI (Denial #3) ................................................................................................... Page 5-19 4P – SROI (Partial Denial #1 – Initial Lost Time)........................................................... Page 5-21 4P – SROI (Partial Denial #2 – Reoccurrence) .............................................................. Page 5-22 AP – SROI (Acquired Payment).................................................................................... Page 5-25 CB – SROI (Change in Benefit Type)............................................................................ Page 5-26 CD – SROI (Compensable Death No Dependent/Payees) ............................................. Page 5-29 CO – SROI (Correction) ................................................................................................ Page 5-30 FN –SROI (Final) .......................................................................................................... Page 5-31 FS –SROI (Full Salary) ................................................................................................. Page 5-33 IP –SROI (Initial Payment) ............................................................................................ Page 5-34 IP – SROI (Initial Payment - Fatality #1)........................................................................ Page 5-35 IP – SROI (Initial Payment - Fatality #2)........................................................................ Page 5-37 P7 – SROI (Partial Suspension).................................................................................... Page 5-38 PY – SROI (Payment Report #1 - Medical Payment Reporting) .................................... Page 5-40 PY – SROI (Payment Report #2 - Penalty Payment ...................................................... Page 5-41 RB – SROI (Reinstatement of Benefits - #1 Different Benefit Type............................... Page 5-44 RB – SROI (Reinstatement of Benefits - #2 Same Benefit Type ................................... Page 5-47 S1 – SROI (Suspension)............................................................................................... Page 5-50 VE – SROI (Volunteer) .................................................................................................. Page 5-52 Recoveries................................................................................................................... Page 5-53 Multiple Events – 04/IP (Multiple Payments on IP) ....................................................... Page 5-55 Multiple Events – FS/IP #1 (Employer Reimbursed Full Salary) ................................... Page 5-57 Multiple Events – FS/IP #2 (Employer Not Reimbursed Full Salary)............................. Page 5-59 Acknowledgment Scenario 1:Validate Sender ID of Header (HD1) .............................. Page 5- 62 Acknowledgment Scenario 2:Validate Remaining Header Data Elements ................... Page 5-63 Acknowledgment Scenario 3:Validate Header for Duplicate Batch.............................. Page 5-64 Acknowledgment Scenario 4:Validate Trailer Record .................................................. Page 5-65 Acknowledgment Scenario 5:Validate Batch for Transaction Existence ..................... Page 5-66 Acknowledgment Scenario 6:Validate Batch Integrity ................................................. Page 5-67

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SCENARIO: 00 – FROI (Original) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmits the first report of injury on 1/8/93 as the seven days have elapsed. Limitations Known To Date: N/A Sample of “00”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

00 1/8/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

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SCENARIO: 01 – FROI (Cancel) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. No payments have been made on the claim. On 1/11/93 the claim administrator determines that the claim belongs under a different state jurisdiction and sends a cancel report to the original jurisdiction. Limitations Known To Date: The reason for the cancel is needed in order for the jurisdictions to properly process the transmission.

Sample of “00”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

00 1/8/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

Sample of “01”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

01 1/11/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

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SCENARIO: 02 – FROI (Change) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. No payments have been made on the claim. On 01/10/93 the claim administrator is informed that the employment status code was incorrectly reported to them as FT (full- time) when the correct code is AF (apprenticeship full-time). The claim administrator changes the data in their system on 1/11/93 and transmits a change report to the jurisdiction to notify them of the mandatory field that was changed. Limitations Known To Date: Effective date and reason for the change are needed. Changes to jurisdiction, date of injury or SSN (if agency claim number not used or required by the jurisdiction), date disability began, wage, date last day worked, date of return to work, and full salary indicator are not fully supported.

Sample of “00”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

00 1/8/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

Sample of “02”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

02 1/11/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

AF 600.00 1 5 N

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SCENARIO: 04 – FROI (Denial #1 – Instead of 00) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. On 1/8/93 the claim administrator determines that the claim is not compensable and is therefore denying the entire claim. The claim administrator transmits an 04 Denial Report (instead of the 00) to the jurisdiction on 1/8/93 to notify them that the entire claim is denied. Limitations Known To Date: Effective vs. action date and narrative reason for the denial is needed on paper.

Sample of “04”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

04 1/8/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

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SCENARIO: 04 – FROI (Denial #2 – Subsequent to 00) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. No payments have been made on the claim. On 1/13/93 the claim administrator determines that the claim is not compensable and is therefore denying the entire claim. The claim administrator transmits an 04 Denial Report to the jurisdiction on 1/13/93 to notify them that the entire claim is denied. Limitations Known To Date: Effective vs. action date and narrative reason for the denial is needed on paper.

Sample of “00”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

00 1/8/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

Sample of “04”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

04 1/13/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

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SCENARIO: AU – FROI (Acquired/Unallocated) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. All information has been reported on paper or EDI to the jurisdiction as required to date. Weekly wage replacement benefits are currently being paid. On 2/1/94 a new claim administrator takes over administration of the claim. The jurisdiction requires notification of all reportable claims within 14 days of acquisition. The new claim administrator transmits an acquired/unallocated report to the jurisdiction on 2/14/94. Limitations Known To Date: Data will need to be edited carefully by the jurisdiction to ensure that previously received data is not improperly overlaid.

Sample of “00”: FROI Data (from old claim administrator) MTC: 00 Employment Status Code: MTC Date: 1/8/93 Wage: Jurisdiction: XX Wage Period: Date Disability Began: 1/1/93 Number of Days Worked: Date of Return to Work: Salary Continued Indicator: Date of Death: Claim Administrator FEIN

FT 600.00 1 5 N 123456789

Sample of “AU”: FROI Data (from new claim administrator) MTC: AU Employment Status Code: MTC Date: 2/14/94 Wage: Jurisdiction: XX Wage Period: Date Disability Began: 1/1/93 Number of Days Worked: Date of Return to Work: Salary Continued Indicator: Date of Death: Claim Administrator FEIN

FT 600.00 1 5 N 987654321

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SCENARIO: CO – FROI (Correction) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmits the first report of injury on 01/8/93 as the seven days have elapsed. On 1/9/93, the jurisdiction acknowledged the transmission as being accepted with a non-critical error of a missing conditional field – employment status code. On 1/12/93 the claim administrator corrects the error and transmits a correction report to the jurisdiction. Limitations Known To Date: Maintenance Type Code Date of the Correction must be the same date as the transaction it is correcting (see MTC Date Definition, page 6-39). Sample of “00”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

00 1/8/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

600.00 1 5 N

Sample of “CO”: FROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

CO 1/8/93 XX 1/1/93

Employment Status Code: Wage: Wage Period: Number of Days Worked: Salary Continued Indicator:

FT 600.00 1 5 N

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SCENARIO: AN – PERIODIC (Annual – Page 1 of 2) Narrative: Employee was injured on 1/1/92. The jurisdiction requires periodic reporting on an annual basis for all open cases. The claim administrator transmits a periodic report to the jurisdiction on 1/1/94. Note: For this scenario, the Sample of Payment Input Fields does not list each check but only the summary for each Payment Code. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not discernable in a single transmission.

Sample of Payment Input Fields AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 350 360 370 300 050 030 020 010 1/1/92 1/1/92 1/1/92 7/30/93 1/1/92 7/1/92 6/16/93 7/30/93 7/30/93 7/30/93 7/30/93 7/30/93 6/30/92 6/15/93 7/29/93 12/31/93

Weekly Rate: 400.00 Weekly A/D Rate Earning

Gross 36500.00 147000.00 6000.00 5000.00 10400.00 20000.00 2640.00 6660.00

Daily Rate: 80.00 B/A Code Paid 36500.00 147000.00 6000.00 5000.00 10400.00 20000.00 2640.00 6660.00
Continued on next page

26 50 6.6 22.2

400.00 400.00 400.00 300.00

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SECTION 5
SCENARIO: AN – PERIODIC (Annual – Page 2 of 2)

Sample of “AN” Subsequent Data MTC: AN MTC Date: 1/1/94 Jurisdiction: XX Date Disability Began: 1/1/92 Date of Return/Release to Work: RTW Qualifier: Date of Death: 7/30/93
# Occurrences 1 Permanent Impairment Body Part 99 Percent 10.00 # Occurrences 4 Payment Adjustment P/A Code 010 P/A Total 6660.00 P/A Amount 300.00 P/A Start 7/30/93 P/A End 12/31/93 P/A Weeks 22 P/A Days 1 P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days 020 2640.00 400.00 6/16/93 7/29/93 6 3 030 20000.00 400.00 7/1/92 6/15/93 50 0 050 10400.00 400.00 1/1/92 6/30/92 26 0

Wage: Wage Period: Number of Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 Benefit Adjustment # Occurrences 4 Paid to Date/Reduced Earnings/Recoveries PRR Code 300 PRR Amount 5000.00 PRR Code PRR Amount PRR Code PRR Amount PRR Code PRR Amount 350 36500.00 360 147000.00 370 6000.00

600.00 1 5 N 12/31/92 1 0
# Occurrences 1 Death Dependent/ Payee Relationship Relationship 21

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SCENARIO: 02 – SROI (Change) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/20/93, the claim administrator determined that the claim is compensable and initiated payment to the employee. The claim administrator transmitted an initial payment report to the jurisdiction on 1/21/93 to notify them of the initial payment. In that transmission the claim administrator showed a late reason code of L1. On 1/30/93 the claim administrator determines that the late reason code should have been L7. The claim administrator changes the data in their system on 1/31/93 and transmits a change report to the jurisdiction to notify them of the mandatory field that was changed. Limitations Known To Date: Effective date and reason for the change are needed. Changes to jurisdiction, date of injury or SSN (if agency claim number not used or required by the jurisdiction), date disability began, wage, date of return to work, full salary indicator, and MTC code or date are not fully supported.

Sample of “IP”: Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:

IP 1/20/93 XX 1/1/93

Wage: Wage Period: Number of Days Worked: Salary Continued Indicator: MMI: Number of Dependents: Claim Status: Late Reason Code:

600.00 1 5 N

0 L1

Sample of “02”: Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:

02 1/31/93 XX 1/1/93

Wage: Wage Period: Number of Days Worked: Salary Continued Indicator: MMI: Number of Dependents: Claim Status: Late Reason Code:

600.00 1 5 N

0 L7

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SCENARIO: 04 – SROI (Denial #3 – page 1 of 2) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator initially determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not initially paid. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 050 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 400.00

Gross 400.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

Wage: Wage Period: Number of Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O
# Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment

P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days

050 400.00 400.00 1/8/93 1/14/93 1 0

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SCENARIO: 04 – SROI (Denial #3 – page 2 of 2) Narrative: On 1/30/93, the claim administrator determines that the claim is not compensable and is therefore denying the entire claim. The claim administrator transmits a denial report to the jurisdiction on 1/30/93 to notify them that the entire claim is denied. Limitations Known To Date: Effective vs. action date and narrative reason for the denial is needed on paper.

Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 050 1/8/93 1/14/93 1 050 1/1/93 1/7/93 1 050 1/15/93 1/28/93 2 350 1/1/93 1/5/93

Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00

Gross 400.00 400.00 800.00 200.00

Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00 200.00

Sample of “04” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0 Permanent Impairment

04 1/30/93 XX 1/1/93

Wage: Wage Period: Number of Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 Benefit Adjustment # Occurrences 1 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

0
# Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment

P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days

050 1600.00 400.00 1/1/93 1/29/93 4 0

PRR Code PRR Amount

350 200.00

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SCENARIO: 4P – SROI (Partial Denial #1 – Initial Lost Time) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/13/93, the claim administrator determines that the claim is compensable but the lost time from work was not medically authorized. The claim administrator notifies the employee that they are accepting the claim and will pay reasonable medical expenses but are denying payment for the lost time. The claim administrator transmits an 04 partial denial report to the jurisdiction on 1/13/93 to notify them of the partial denial. Limitations Known To Date: Effective vs. action date and narrative reason for the denial is needed on paper. Also, in many circumstances the jurisdiction will be unable to tell what specific benefit type(s) is being denied.

Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 350 1/1/93 1/5/93

Weekly Rate: 400.00 Weekly A/D Rate Earning

Gross 200.00

Daily Rate: 80.00 B/A Code Paid 200.00

Sample of “4P” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0

4P 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 # Occurrences 1

600.00 1 5 N

0
# Occurrences 0

# Occurrences 0

Permanent Impairment

Payment Adjustment

Benefit Adjustment

Paid to Date/Reduced Earnings/Recoveries PRR Code 350 PRR Amount 200.00

Death Dependent/ Payee Relationship

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SCENARIO: 4P – SROI (Partial Denial #2 – Reoccurrence - page 1 of 3) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note: the waiting period is not initially paid. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 050 1/8/93 1/14/93 1

Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00

Gross 400.00

Daily Rate: 80.00 B/A Code Paid 400.00

Sample of “4P” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

Wage: Wage Period: Number Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

0
# Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment

P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days

050 400.00 400.00 1/8/93 1/14/93 1 0

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: 4P – SROI (Partial Denial #2 – Reoccurrence - page 2 of 3) Narrative: On 1/31/93 the claim administrator is notified that the employee returned to work on 1/29/93 with restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to notify them that the indemnity benefits are being suspended effective 1/28/93. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 050 1/8/93 1/14/93 1 050 1/1/93 1/7/93 1 050 1/15/93 1/28/93 2

Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00

Gross 400.00 400.00 800.00

Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00

Sample of “S1” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0

S1 1/28/93 XX 1/1/93 1/29/93 2

Wage: Wage Period: Number Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 # Occurrences 0

600.00 1 5 N

O
# Occurrences 0

# Occurrences 1

Permanent Impairment

Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0

Benefit Adjustment

Paid to Date/Reduced Earnings/Recoveries

Death Dependent/ Payee Relationship

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: 4P – SROI (Partial Denial #2 – Reoccurrence - page 3 of 3) Narrative: On 3/1/93 the claim administrator is notified that the employee began losing time from work again on 2/28/93. The claim administrator investigates and determines that the lost time is not related to the injury. On 3/15/93 the claim administrator sends notification to the employee that they are denying only the additional lost time and reasonable medical payments will continue. The jurisdiction requires a subsequent report for the partial denial. The claim administrator sends a transmission on 3/15/93 to the jurisdiction to notify them of the partial denial. Limitations Known To Date: Effective vs. action date and narrative reason for the denial is needed on paper. Also, in many circumstances the jurisdiction will be unable to tell what specific benefit type(s) is being denied.

Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 050 1/8/93 1/14/93 1 050 1/1/93 1/7/93 1 050 1/15/93 1/28/93 2 350 1/1/93 1/31/93

Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00

Gross 400.00 400.00 800.00 500.00

Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00 500.00

Sample of “4P” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0 Permanent Impairment

4P 3/15/93 XX 1/1/93 1/29/93 1

Wage: Wage Period: Number Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 Benefit Adjustment # Occurrences 1 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

0
# Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment

P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days

050 1600.00 400.00 1/1/93 1/28/93 4 0

PRR Code PRR Amount

350 500.00

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: AP – SROI (Acquired Payment) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The only information reported by the old claim administrator to the jurisdiction to date was the original first report. Weekly wage replacement benefits are currently being paid. On 2/1/94 a new claim administrator takes over administration of the claim. The old administrator can only provide them with a total unallocated indemnity benefits paid to date and a total unallocated medical expense paid to date. On 2/14/94 the new claim administrator makes their initial payment to the employee. The claim administrator transmits an acquired payment report to the jurisdiction on 2/14/94 to notify them of their initial payment. Limitations Known To Date: Data will need to be edited carefully by the jurisdiction to ensure that previously received data is not improperly overlaid. Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 050 2/1/94 2/14/94 2 430 1/1/93 1/31/94 440 1/1/93 1/31/94

Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00

Gross 800.00 10000.00 12500.00

Daily Rate: 80.00 B/A Code Paid 800.00 10000.00 12500.00

Sample of “AP” Subsequent Data MTC: AP MTC Date: 2/14/94 Jurisdiction: XX Date Disability Began: 1/1/93 Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0
Permanent Impairment

Wage: Wage Period: Number Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0
Benefit Adjustment

600.00 1 5 N

O
# Occurrences 2
Paid to Date/Reduced Earnings/Recoveries

# Occurrences 1
Payment Adjustment

# Occurrences 0
Death Dependent/ Payee Relationship

P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days

050 800.00 400.00 2/1/94 2/14/94 2 0

PRR Code PRR Amount PRR Code PRR Amount

430 10000.00 440 12500.00

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: CB – SROI (Change in Benefit Type – page 1 of 3) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note: the waiting period is not initially paid. Limitations Known To Date: N/A Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 050 1/8/93 1/14/93 1

Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00

Gross 400.00

Daily Rate: 80.00 B/A Code Paid 400.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O
# Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment

P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days

050 400.00 400.00 1/8/93 1/14/93 1 0

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: CB – SROI (Change in Benefit Type – page 2 of 3) Narrative: On 2/10/93 the claim administrator is notified that the employee returned to work on 1/29/93 with restrictions earning $450.00 per week. The employee is due temporary partial wage replacement benefits starting on 1/29/93 at a weekly rate of 2/3rds of the difference between the pre-injury weekly wage and the current weekly earnings or 2/3rds of $150.00 = $100.00. On 2/11/93 the claim administrator issues the initial temporary partial check and sends a transmission to the jurisdiction to notify them of the change in benefit type. Note: CB is also used when adding concurrent indemnity benefit payments. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not discernable when reported in a single transmission. Effective vs. action date and reason for the change in benefit are needed. If CA’s or benefit adjustments happen at the same time as the CB, multiple transmissions may come on the same day, therefore, jurisdictions should process the transactions in the same sequence as received to avoid overlaying the most current data. Sample of Payment Input Fields: AWW: 600.00 Days per week: 5 Payment From Thru Weeks Code Date Date Paid 050 1/8/93 1/14/93 1 050 1/1/93 1/7/93 1 050 1/15/93 1/28/93 2 070 1/29/93 2/11/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 A 450.00 Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00 200.00

Gross 400.00 400.00 800.00 200.00

Continued on next page

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: CB – SROI (Change in Benefit Type – page 3 of 3)

Sample of “CB” Subsequent Data: MTC: CB MTC Date: 2/11/93 Jurisdiction: XX Date Disability Began: 1/1/93 Date of Return/Release to Work: 1/29/93 RTW Qualifier: 2 Date of Death:
# Occurrences 0 Permanent Impairment # Occurrences 2 Payment Adjustment

Wage: Wage Period: Number Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 Benefit Adjustment # Occurrences 2 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O
# Occurrences 0 Death Dependent/ Payee Relationship

P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days

050 1600.00 400.00 1/1/93 1/28/93 4 0 070 200.00 100.00 1/29/93 2/11/93 2 0

PRR Code PRR Amount PRR Code PRR Amount

600 450.00 601 450.00

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: CD – SROI (Compensable Death No Dependent/Payees) Narrative: Employee was fatally injured on 1/1/93. The employee’s weekly wage is $600.00. The jurisdiction requires a first report of injury within seven days after the death. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. The claim administrator determines that the claim is compensable. There are no known dependents and no payment is due to the jurisdiction's fund. On 1/14/93 the claim administrator issues a check for $5,000.00 to cover the funeral expense and a check for $1,500.00 for the autopsy expenses. The jurisdiction requires reporting of the compensability determination within 14 days of the death even where no indemnity benefits are currently payable. The claim administrator transmits a compensable death report to the jurisdiction on 1/14/93 to notify them of their determination. Note: When the CD is transmitted, there may not be any paid to dates report. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 370 1/1/93 300 1/1/93 Days per week: 5 Thru Weeks Date Paid 1/1/93 1/1/93 Weekly Rate: 400.00 Weekly A/D Rate Earning Daily Rate: 80.00 B/A Code Paid 1500.00 5000.00

Gross 1500.00 5000.00

Sample of “CD” Subsequent Data MTC: CD MTC Date: 1/14/93 Jurisdiction: XX Date Disability Began: 1/1/93 Date of Return/Release to Work: RTW Qualifier: Date of Death: 1/1/93 # Occurrences 0 Permanent Impairment # Occurrences 0 Payment Adjustment

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 2 Paid to Date/Reduced Earnings/Recoveries PRR Code 300 PRR Amount 5000.00 PRR Code PRR Amount 370 1500.00

600.00 1 5 N 0 0 # Occurrences 0 Death Dependent/ Payee Relationship

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: CO – SROI (Correction) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not initially paid. On 1/15/93 the jurisdiction acknowledged the transmission as being accepted with a non-critical error of a missing conditional field – claim status. On 1/18/93 the claim administrator corrects the error and transmits a correction report to the jurisdiction. Limitations Known To Date: Maintenance Type Code Date of the Correction must be the same date as the transaction it is correcting (see MTC Date Definition, page 6-39).

Sample of “IP”: SROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: RTW Qualifier: Date of Death:

IP 1/14/93 XX 1/1/93

Wage: Wage Period: Number of Days Worked: Salary Continued Indicator: MMI: # of Dependents: Claim Status:

600.00 1 5 N

Sample of “CO”: SROI Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: RTW Qualifier: Date of Death:

CO 1/14/93 XX 1/1/93

Wage: Wage Period: Number of Days Worked: Salary Continued Indicator: MMI: # of Dependents: Claim Status:

600.00 1 5 N O

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: FN –SROI (Final - page 1 of 2) Narrative: Employee was injured on 1/1/93. All reporting required by the jurisdiction has occurred including suspension reports. No indemnity benefits are currently being paid nor are there any additional anticipated to be owed in the future. The last medical treatment by the claimant was more than six months ago and the health care provider has indicated that there is no future medical care anticipated. On 4/1/94 the claim administrator decides to close the claim due to the fact that all payments owed have been made and no future payments are anticipated. The jurisdiction requires notification when the claim administrator closes the claim, therefore the claim administrator transmits a final report on 4/1/94. Note: For this scenario, the Sample of Payment Input Fields does not list each check but only the summary for each Payment Code. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not discernable in a single transmission.

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 350 1/1/93 370 1/1/93 050 1/1/93 Days per week: 5 Thru Weeks Date Paid 7/30/93 7/30/93 4/29/93 17 Weekly Rate: 400.00 Weekly A/D Rate Earning Daily Rate: 80.00 B/A Code Paid 10000.00 2000.00 6800.00

400.00

Gross 10000.00 2000.00 6800.00

Continued on next page

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February 15, 2002

SECTION 5
SCENARIO: FN –SROI (Final – page 2 of 2)

Sample of “FN” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

FN 4/1/94 XX 1/1/93 4/30/93 1

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 2

600.00 1 5 N 8/1/93 C # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 6800.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 4/29/93 P/A Weeks 17 P/A Days 0

Paid to Date/Reduced Earnings/Recoveries PRR Code 350 PRR Amount 10000.00 PRR Code PRR Amount 370 2000.00

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: FS –SROI (Full Salary) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee's weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93 the claim administrator initially determines that the claim is compensable. The employer is paying salary in lieu of compensation. The claim administrator transmits a full salary report to the jurisdiction on 1/14/93 to notify them. The date disability began (1/1/93) is used as the start date, since the employer has continued salary with no break through the disability period to date. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not discernable when reported in a single transmission. Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 240 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 0 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 0.00

Gross 400.00

Sample of “FS” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

FS 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 Y

0 # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 240 P/A Total 0.00 P/A Amount 0.00 P/A Start 1/8/93 P/A End 1/14/93 P/A Weeks 0 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: IP –SROI (Initial Payment) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee's weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury of 1/8/93 as the seven days had elapsed. On 1/14/93 the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not initially paid. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not discernable when reported in a single transmission. Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 050 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 400.00

Gross 400.00

Sample of “IP” Subsequent Data
MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment IP 1/14/93 XX 1/1/93 Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries 600.00 1 5 N

0 # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 400.00 P/A Amount 400.00 P/A Start 1/8/93 P/A End 1/14/93 P/A Weeks 1 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: IP – SROI (Initial Payment - Fatality #1 – page 1 of 2) Narrative: Employee was fatally injured on 1/1/93. The employee’s weekly wage is $600.00. The jurisdiction requires a first report of injury within seven days after the death. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. The claim administrator determines that the claim is compensable. There are no known dependents and a one time payment is due to the jurisdiction's fund. On 1/14/93 the claim administrator issues a check for $5,000.00 to cover the funeral expense, a check for $1,500.00 for the autopsy expenses, and a check for $25,000.00 for a one time payment to the jurisdiction's fund. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not reportable in a single transmission.

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 010 1/1/93 300 1/1/93 370 1/1/93 Days per week: 5 Thru Weeks Date Paid 1/1/93 1/1/93 1/1/93 Weekly Rate: 400.00 Weekly A/D Rate Earning Daily Rate: 80.00 B/A Code Paid 25000.00 5000.00 1500.00

Gross 25000.00 5000.00 1500.00

Continued on next page

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February 15, 2002

SECTION 5
SCENARIO: IP – SROI (Initial Payment - Fatality #1 – page 2 of 2)

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0

IP 1/14/93 XX 1/1/93

1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 # Occurrences 2

600.00 1 5 N 0 C
# Occurrences 1

# Occurrences 1

Permanent Impairment

Payment Adjustment P/A Code 010 P/A Total 25000.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/1/93 P/A Weeks 0 P/A Days 0

Benefit Adjustment

Paid to Date/Reduced Earnings/Recoveries PRR Code 300 PRR Amount 5000.00 PRR Code PRR Amount 370 1500.00

Death Dependent/ Payee Relationship Relationship 81

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: IP – SROI (Initial Payment - Fatality #2) Narrative: Employee was fatally injured on 1/1/93. The employee’s weekly wage is $600.00. The jurisdiction requires a first report of injury within seven days after the death. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. The claim administrator determines that the claim is compensable. There are no known dependents and weekly payments are due to the jurisdiction's fund for 104 weeks. The claim administrator decides to make all the weekly payments in one lump sum. On 1/14/93 the claim administrator issues a check for $5,000.00 to cover the funeral expense, a check for $1,500.00 for the autopsy expenses, and a check for $41,600.00 for a lump sum payment to the jurisdiction's fund. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment.

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 010 1/1/93 300 1/1/93 370 1/1/93 Days per week: 5 Thru Weeks Date Paid 12/29/94 104 1/1/93 1/1/93 Weekly Rate: 400.00 Weekly A/D Rate Earning Daily Rate: 80.00 B/A Code Paid 41,600.00 5000.00 1500.00

Gross 41,600.00 5000.00 1500.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 2 Paid to Date/Reduced Earnings/Recoveries PRR Code 300 PRR Amount 5000.00 PRR Code PRR Amount 370 1500.00

600.00 1 5 N 0 C # Occurrences 1 Death Dependent/ Payee Relationship Relationship 81

# Occurrences 1 Payment Adjustment P/A Code 010 P/A Total 41,600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 12/29/94 P/A Weeks 104 P/A Days 0

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SECTION 5
SCENARIO: P7 – SROI (Partial Suspension - Page 1 of 2) Narrative: Employee was injured on 1/1/92. All information has been reported to the jurisdiction as required to date. Weekly permanent total and permanent total supplemental wage replacement benefits are currently being paid. On 3/1/94 the employee reaches the age of 62, and therefore is not longer eligible for permanent total supplemental. The claim administrator discontinues payment of the permanent total supplemental only as of 3/1/94. The claim administrator transmits a partial suspension report to the jurisdiction on 3/6/94 to notify them of the partial suspension. Note: For this scenario, the Sample of Payment Input Fields does not list each check but only the summary for each Payment Code. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not reportable in a single transmission. Effective vs. action date and reason for the suspension of the benefit is needed. Also, the transmission does not specify which benefit types are being suspended.

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 350 1/1/92 020 1/1/92 021 1/1/92 Days per week: 5 Thru Weeks Date Paid 7/30/93 2/28/94 112 2/28/94 112 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 36500.00 44800.00 2240.00

Gross 36500.00 44800.00 2240.00

Continued on next page

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February 15, 2002

SECTION 5
SCENARIO: P7 – SROI (Partial Suspension - Page 2 of 2)

Sample of “P7” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

P7 3/1/94 XX 1/1/92

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 1

600.00 1 5 N 12/31/92 0 O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 2 Payment Adjustment P/A Code 020 P/A Total 44800.00 P/A Amount 400.00 P/A Start 1/1/92 P/A End 2/28/94 P/A Weeks 112 P/A Days 0 P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days 021 2240.00 20.00 1/1/92 2/28/94 112 0

Paid to Date/Reduced Earnings/Recoveries PRR Code 350 PRR Amount 36500.00

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: PY – SROI (Payment Report #1 - Medical Payment Reporting) Narrative: Employee was injured on 1/1/93. The employee has not lost any time from work due to the injury. The jurisdiction requires a first report of injury within seven days after the injury. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. The claim administrator determines that the claim is compensable. The jurisdiction requires a subsequent report once payment of medical bills reaches $500.00 on medical only claims. As of 1/28/93 the payment of medical bills brought the total paid to date to 500.00. The claim administrator transmits a payment report to the jurisdictions on 1/28/93. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 350 1/1/93 Days per week: 5 Thru Weeks Date Paid 1/21/93 Weekly Rate: 400.00 Weekly A/D Rate Earning Daily Rate: 80.00 B/A Code Paid 500.00

Gross 500.00

Sample of “PY” Subsequent Data MTC: PY MTC Date: 1/28/93 Jurisdiction: XX Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment # Occurrences 0 Payment Adjustment

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 1 Paid to Date/Reduced Earnings/Recoveries PRR Code 350 PRR Amount 500.00

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

IAIABC First Report and Subsequent Report of Injury © Release 1

5-40

February 15, 2002

SECTION 5
SCENARIO: PY – SROI (Payment Report #2 - Penalty Payment - Page 1 of 3) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee's weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/22/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction o 1/22/93 to notify them of the initial payment. Note: the initial payment is n required within 14 days but was not made for 21 days and is late. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 050 1/1/93 Days per week: 5 Thru Weeks Date Paid 1/21/93 3 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 1200.00

Gross 1200.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0

IP 1/22/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 # Occurrences 0

600.00 1 5 N

O
# Occurrences 0

# Occurrences 1

Permanent Impairment

Payment Adjustment P/A Code 050 P/A Total 1200.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/21/93 P/A Weeks 3 P/A Days 0

Benefit Adjustment

Paid to Date/Reduced Earnings/Recoveries

Death Dependent/ Payee Relationship

IAIABC First Report and Subsequent Report of Injury © Release 1

5-41

February 15, 2002

SECTION 5
SCENARIO: PY – SROI (Payment Report #2 - Penalty Payment - Page 2 of 3) Narrative: On 1/31/93 the claim administrator is notified that the employee returned to work on 1/29/93 with no restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to notify them that indemnity benefits are being suspended effective 1/28/93. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Payment From Code Date 050 1/1/93 050 1/22/93 Days per week: 5 Thru Weeks Date Paid 1/21/93 3 1/28/93 1 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 1200.00 400.00

Gross 1200.00 400.00

Sample of “S1” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0

S1 1/28/93 XX 1/1/93 1/29/93 1

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 # Occurrences 0

600.00 1 5 N

O
# Occurrences 0

# Occurrences 1

Permanent Impairment

Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0

Benefit Adjustment

Paid to Date/Reduced Earnings/Recoveries

Death Dependent/ Payee Relationship

IAIABC First Report and Subsequent Report of Injury © Release 1

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February 15, 2002

SECTION 5
SCENARIO: PY – SROI (Payment Report #2 - Penalty Payment - Page 3 of 3) Narrative: The jurisdiction assessed a penalty for the late first payment on 3/1/93. The amount of the penalty is 10% of the amount owed on the date of the late payment or 10% of $1,200.00 or $120.00 The penalty is payable to the employee. The claim administrator makes payment to the employee of the $120.00 penalty on 3/31/93. The jurisdiction requires a subsequent report for payment of penalties. The claim administrator transmits a payment report to the jurisdiction on 3/31/93 to show the penalty payment. Limitations Known To Date: N/A

Sample of Payment Input Fields: AWW: 600.00 Payment Code 050 050 310 From Date 1/1/93 1/22/93 3/31/93 Days per week: 5 Thru Weeks Date Paid 1/21/93 3 1/28/93 1 3/31/93 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 1200.00 400.00 120.00

Gross 1200.00 400.00 120.00

Sample of “PY” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death:
# Occurrences 0

PY 3/31/93 XX 1/1/93 1/29/93 1

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status:
# Occurrences 0 # Occurrences 1

600.00 1 5 N

O
# Occurrences 0

# Occurrences 1

Permanent Impairment

Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0

Benefit Adjustment

Paid to Date/Reduced Earnings/Recoveries PRR Code 310 PRR Amount 120.00

Death Dependent/ Payee Relationship

IAIABC First Report and Subsequent Report of Injury © Release 1

5-43

February 15, 2002

SECTION 5
SCENARIO: RB – SROI (Reinstatement of Benefits - #1 Different Benefit Type - Page 1 of 3) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee's weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not initially paid.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 400.00

Gross 400.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 400.00 P/A Amount 400.00 P/A Start 1/8/93 P/A End 1/14/93 P/A Weeks 1 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-44

February 15, 2002

SECTION 5
SCENARIO: RB – SROI (Reinstatement of Benefits - #1 Different Benefit Type - Page 2 of 3) Narrative: On 1/31/93 the claim administrator is notified that the employee returned to work on 1/29/93 with restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to notify them that indemnity benefits are being suspended effective 1/28/93.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 050 1/1/93 050 1/15/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/28/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00

Gross 400.00 400.00 800.00

Sample of “S1” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

S1 1/28/93 XX 1/1/93 1/29/93 2

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-45

February 15, 2002

SECTION 5
SCENARIO: RB – SROI (Reinstatement of Benefits - #1 Different Benefit Type - Page 3 of 3) Narrative: On 2/22/93 the claim administrator is notified that the employee could not continue to work full time and began working part time on 2/8/93 earning a weekly wage of $450.00. Claimant’s weekly wage is $600.00. The employee is due temporary partial wage replacement benefits starting on 2/8/93 at a weekly rate of 2/3 of the difference between the pre-injury weekly wage and the current weekly earnings or 2/3 of $150.00 = $100.00. On 2/22/93 the claim administrator issues the initial temporary partial check and sends a transmission to the jurisdiction to notify them of reinstatement of benefits. Limitations Known to Date: Multiple periods of disability for a specific benefit type are not reportable in a single transmission. Reason for the reinstatement of benefits is needed.
Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 050 1/1/93 050 1/15/93 070 2/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/28/93 2 2/21/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 A 450.00 Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00 200.00

Gross 400.00 400.00 800.00 200.00

Sample of “RB” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

RB 2/22/93 XX 1/1/93 1/29/93 2

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 2 Paid to Date/Reduced Earnings/Recoveries PRR Code 600 PRR Amount 450.00 PRR Code PRR Amount 601 450.00

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 2 Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0 P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days 070 200.00 100.00 2/8/93 2/21/93 2 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-46

February 15, 2002

SECTION 5
SCENARIO: RB – SROI (Reinstatement of Benefits - #2 Same Benefit Type - Page 1 of 3) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not initially paid.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 400.00

Gross 400.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 400.00 P/A Amount 400.00 P/A Start 1/8/93 P/A End 1/14/93 P/A Weeks 1 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-47

February 15, 2002

SECTION 5
SCENARIO: RB – SROI (Reinstatement of Benefits - #1 Same Benefit Type - Page 2 of 3) Narrative: On 1/31/93 the claim administrator is notified that the employee returned to work on 1/29/93 with restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to notify them that indemnity benefits are being suspended effective 1/28/93.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 050 1/1/93 050 1/15/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/28/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00

Gross 400.00 400.00 800.00

Sample of “S1” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

S1 1/28/93 XX 1/1/93 1/29/93 2

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents : Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-48

February 15, 2002

SECTION 5
SCENARIO: RB – SROI (Reinstatement of Benefits - #1 Same Benefit Type - Page 3 of 3) Narrative: On 2/22/93 the claim administrator is notified that the employee was once again totally off work due to the injury as of 2/8/93. On 2/22/93 the claim administrator reinstates total wage replacement benefits and sends a transmission to the jurisdiction to notify them of reinstatement of benefits. Limitations Known to Date: Multiple periods of disability for a specific benefit type are not reportable in a single transmission. Reason for the reinstatement of benefits is needed. There is question concerning whether the return to work date and qualifier are blanked out or continue to be filled with the previous return to work information. Note: The payment/adjustment code start date has been reset to the beginning date of the new period of lost time, yet the payment/adjustment code paid to date total is a cumulative field. There is a need for careful processing by the jurisdiction.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 050 1/1/93 050 1/15/93 050 2/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/28/93 2 2/21/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00 200.00

Gross 400.00 400.00 800.00 800.00

Sample of “RB” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

RB 02/22/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 2400.00 P/A Amount 400.00 P/A Start 2/8/93 P/A End 2/21/93 P/A Weeks 6 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-49

February 15, 2002

SECTION 5
SCENARIO: S1 – SROI (Suspension - Page 1 of 2) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as seven days had elapsed. On 1/14/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not initially paid.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 400.00

Gross 400.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 400.00 P/A Amount 400.00 P/A Start 1/8/93 P/A End 1/14/93 P/A Weeks 1 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-50

February 15, 2002

SECTION 5
SCENARIO: S1 – SROI (Suspension - Page 2 of 2) Narrative: On 1/31/93 the claim administrator is notified that the employee returned to work on 1/29/93 with no restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to notify them that indemnity benefits are being suspended effective 1/28/93. Limitations Known To Date: Multiple periods of disability for a specific benefit type are not reportable in a single transmission. Effective vs. action date and narrative reason for the suspension (for some “S” codes) in benefit are needed.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 050 1/8/93 050 1/1/93 050 1/15/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/28/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00

Gross 400.00 400.00 800.00

Sample of “S1” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

S1 1/28/93 XX 01/01/93 1/29/93 1

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Am ount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-51

February 15, 2002

SECTION 5
SCENARIO: VE – SROI (Volunteer) Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee is an unpaid volunteer. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as seven days had elapsed. The jurisdiction’s statute does not require payment of wage replacement to unpaid volunteers but does require reporting of the compensability determination within 14 days of the date disability began. On 1/14/93, the claim administrator determines that the claim is compensable. The claim administrator transmits a volunteer report to the jurisdiction on 1/14/93 to notify them of the determination. Note: If the jurisdiction’s statute requires payment of wage replacement benefits then an initial payment report would be sent when the first check was issued instead of the volunteer report.

Sample of Payment Input Fields : AWW: 0.00 Payment Code 350 From Date 1/1/93 Days per week: 5 Thru Weeks Date Paid 1/3/93 Weekly Rate: 0.00 Weekly A/D Rate Earning Daily Rate: 0.00 B/A Code Paid 200.00

Gross 200.00

Sample of “VE” Subsequent Data MTC: VE MTC Date: 1/14/93 Jurisdiction: XX Date Disability Began: 1/1/93 Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment # Occurrences 0 Payment Adjustment

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 1 Paid to Date/Reduced Earnings/Recoveries PRR Code PRR Amount 350 200.00

0.00 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

IAIABC First Report and Subsequent Report of Injury © Release 1

5-52

February 15, 2002

SECTION 5
SCENARIO: Recoveries – page 1 of 2 Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report on injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator determines that the claim is compensable and initiates payment to the employee. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not initially paid.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 300 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 400.00

Gross 400.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

IP 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 400.00 P/A Amount 400.00 P/A Start 1/8/93 P/A End 1/14/93 P/A/ Weeks 1 P/A Days 0

IAIABC First Report and Subsequent Report of Injury © Release 1

5-53

February 15, 2002

SECTION 5
SCENARIO: Recoveries - Page 2 of 2) Narrative: On 3/1/93 the claim administrator is notified that the employee returned to work on 2/15/93 with no restrictions. However, payment has already been made to the employee through 2/25/93. The employee has cashed the check but reimburses the claim administrator $720.00 on 3/1/93 for the overpayment. The claim administrator transmits a suspension report to the jurisdiction on 3/1/93 to notify them that indemnity benefits are being suspended effective 2/14/93 and showing the recovered overpayment. Note: When recovering money due to an overpayment adjust the actual payment amounts, etc. for the affected payment codes.

Sample of Payment Input Fields : AWW: 600.00 Payment Code 050 050 050 050 050 From Date 1/8/93 1/1/93 1/15/93 1/29/93 2/12/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/28/93 2 2/11/93 2 2/25/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 400.00 400.00 800.00 800.00 800.00

Gross 400.00 400.00 800.00 800.00 800.00

Sample of Refund Transmittal: Payment Recovery From Date Code Date 050 830 2/14/93

Thru Date 2/25/93

Weeks Rec’d 1.8

Weekly Rate 400.00

Gross 720.00

Paid 720.00

Sample of “S1” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

S1 2/14/93 XX 1/1/93 2/15/93 1

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 1 Paid to Date/Reduced Earnings/Recoveries PRR Code 830 PRR Amount 720.00

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 2480.00 P/A Amount 400.00 P/A Start 1/01/93 P/A End 2/14/93 P/A Weeks 6 P/A Days 1

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SCENARIO: Multiple Events – 04/IP (Multiple Payments on IP) - page 1 of 2 Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. On 1/8/93, the claim administrator determines that the claim is not compensable and is therefore denying the entire claim. The claim administrator transmits an 04 denial report (instead of the 00) to the jurisdiction on 1/8/93 to notify them that the entire claim is denied.

Sample of “04” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return to Work: Date of Death:

04 1/8/93 XX 1/1/93

Employment Status Code Wage: Wage Period: NBR Days Worked: Salary Continued Ind:

FT 600.00 1 5 N

Continued

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SCENARIO: Multiple Events – 04/IP (Multiple Payments on IP) - page 2 of 2

Narrative: The employee hires an attorney and litigates the issue of compensability. A hearing is held and on 3/19/94 the Judge determines that the claim is compensable and orders the following to be paid: temporary total wage replacement disability from 1 /1/93 through 4/1/93, a scheduled whole body permanent partial disability of 10% to the body as a whole, $10,000.00 in medical bills accrued to date, and $3,500.00 in employee attorney fees (to be paid in addition to the indemnity benefits to be paid). The employer has also incurred $1,800.00 in legal expenses to date. On 4/1/94 the claim administrator issues a check to cover all the moneys owed per the order. The claim administrator transmits an initial payment report to the jurisdiction on 4/1/94 to notify them of the initial payment. Note: None of these payments are compromise payments.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 330 1/1/93 340 1/1/93 350 1/1/93 030 4/2/93 050 1/1/93 Days per week: 5 Thru Weeks Date Paid 3/17/94 3/17/94 3/1/94 3/17/94 50 4/1/93 13 Weekly Rate: 400.00 Weekly A/D Rate Earning Daily Rate: 80.00 B/A Code Paid 1800.00 3500.00 10000.00 20000.00 5200.00

400.00 400.00

Gross 1800.00 3500.00 10000.00 20000.00 5200.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 1 Permanent Impairment Body Part 99 Percent 10.00

IP 4/1/94 XX 1/1/93 4/2/93 6

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 3 Paid to Date/Reduced Earnings/Recoveries PRR Code PRR Amount PRR Code PRR Amount PRR Code PRR Amount 330 1800.00 340 3500.00 350 4000.00

600.00 1 5 N 4/2/93 O # Occurrences Death Dependent/ Payee Relationship

# Occurrences 2 Payment Adjustment P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days 050 5200.00 400.00 1/1/93 4/1/93 12 0 030 20000.00 400.00 4/2/93 3/17/94 50 0

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SCENARIO: Multiple Events – FS/IP #1 (Employer Reimbursed Full Salary) - page 1 of 2 Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator initially determines that the claim is compensable. The employer is paying salary in lieu of compensation. The claim administrator transmits a full salary report to the jurisdiction on 1/14/93 to notify them. Note: The waiting period is not initially included in the benefits owed. However, if the payment/adjustment start date is unknown, the date disability began (1/1/93) is used as the start date.)

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 240 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 0 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid .00

Gross 400.00

Sample of “FS” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

FS 1/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 Y

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 240 P/A Total 0.00 P/A Amount 0.00 P/A Start 1/8/93 P/A End 1/14/93 P/A Weeks 0 P/A Days 0

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SCENARIO: Multiple Events – FS/IP #1 (Employer Reimbursed Full Salary) - page 2 of 2 Narrative: After two weeks, the employer decides not to continue paying salary in lieu of compensation and wants to be reimbursed for the two weeks already paid. On 1/28/93, claim administrator issues their initial payment and transmits an initial payment report to the jurisdiction. Note: the initial payment is probably made in two checks – one sent to the employee and one sent to the employer.

Sample of Payment Input Fields : AWW: 600.00 Payment Code 240 240 050 050 From Date 1/8/93 1/1/93 1/1/93 1/15/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/14/93 2 1/28/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 0.00 0.00 800.00 800.00

Gross 400.00 400.00 800.00 800.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

IP 1/28/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 N

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 050 P/A Total 1600.00 P/A Amount 400.00 P/A Start 1/1/93 P/A End 1/28/93 P/A Weeks 4 P/A Days 0

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SCENARIO: Multiple Events – FS/IP #2 (Employer Not Reimbursed Full Salary) - page 1 of 2 Narrative: Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator initially determines that the claim is compensable. The employer is paying salary in lieu of compensation. The claim administrator transmits a full salary report to the jurisdiction on 1/14/93 to notify them. Note: The waiting period is not initially included in the benefits owed. However, if the payment/adjustment start date is unknown, the date disability began (1/1/93) is used as the start date.)

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 240 1/8/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 0 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 Daily Rate: 80.00 B/A Code Paid 0.00

Gross 400.00

Sample of “FS” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

FS 01/14/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 Y

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 1 Payment Adjustment P/A Code 240 P/A Total 0.00 P/A Amount 0.00 P/A Start 1/8/93 P/A End 1/14/93 P/A Weeks 0 P/A Days 0

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SCENARIO: Multiple Events – FS/IP #1 (Employer Not Reimbursed Full Salary) - page 2 of 2 Narrative: After two weeks, the employer decides not to continue paying salary in lieu of compensation and does not want to be reimbursed for the two weeks already paid. On 1/28/93, claim administrator issues their initial payment and transmits an initial payment report to the jurisdiction.

Sample of Payment Input Fields : AWW: 600.00 Payment From Code Date 240 1/8/93 240 1/1/93 050 1/15/93 Days per week: 5 Thru Weeks Date Paid 1/14/93 1 1/7/93 1 1/28/93 2 Weekly Rate: 400.00 Weekly A/D Rate Earning 400.00 400.00 400.00 Daily Rate: 80.00 B/A Code Paid 0.00 0.00 800.00

Gross 400.00 400.00 800.00

Sample of “IP” Subsequent Data MTC: MTC Date: Jurisdiction: Date Disability Began: Date of Return/Release to Work: RTW Qualifier: Date of Death: # Occurrences 0 Permanent Impairment

IP 1/28/93 XX 1/1/93

Wage: Wage Period: NBR Days Worked: Salary Continued Ind: MMI: # of Dependents: Claim Status: # Occurrences 0 Benefit Adjustment # Occurrences 0 Paid to Date/Reduced Earnings/Recoveries

600.00 1 5 Y

O # Occurrences 0 Death Dependent/ Payee Relationship

# Occurrences 2 Payment Adjustment P/A Code 050 P/A Total 800.00 P/A Amount 400.00 P/A Start 1/15/93 P/A End 1/28/93 P/A Weeks 2 P/A Days 0 P/A Code P/A Total P/A Amount P/A Start P/A End P/A Weeks P/A Days 240 800.00 400.00 1/1/93 1/14/93 2 0

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TECHNICAL SCENARIOS
BATCH REJECTS: HEADER RECORD, TRANSACTIONS AND TRAILER RECORD Validate Header Record (Transaction Set ID: HD1) Each batch contains a header record (HD1), transaction record(s) and a trailer record (TR1). The header record is used to identify the trading partner transmitting the batch, the receiver, the interchange version ID, the date and time the transmission was sent, and the test/production indicator. The transmission profile, element requirements table and the edit matrix are used to edit the data elements in the header record. Any errors in these data elements would create edit errors that would cause the batch to be rejected at the header level. The audit file is used to determine a duplicate batch. If a batch is rejected at the header level, a new record is posted to the audit file with a batch processing status of rejected. The individual transactions within the batch are not processed. The process continues with the next batch. If a batch is accepted, a new record is posted to the audit file and the process continues to validate detail transactions.

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ACKNOWLEDGMENT SCENARIO 1: VALIDATE SENDER ID OF HEADER (HD1) The Sender ID is made up of the Sender FEIN, the FEIN of the sending party, filler and the Sender Postal Code, the postal code of the sending party. It is used to identify the sending party. If the Sender ID is invalid, manual verification of trading partner tables and/or communications will be required. No further processing of the batch will be done. The process continues with the next batch.

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ACKNOWLEDGMENT SCENARIO 2: VALIDATE REMAINING HEADER DATA ELEMENTS A batch with header errors is indicated by an ‘HD’ in the Application Acknowledgment Code of the AK1, ‘all zeros’ in the Record Sequence Number, the element number in error and the element error number for the error. ACK SCENARIO 2: ACKNOWLEDGMENT DETAIL
This scenario communicates what the AK1 would contain if a batch is rejected because of header error.

DATA NUMBER DN0001 DN0107 DN0108 DN0109 DN0006 DN0014 DN0008 DN0110 DN0111 DN0026 DN0015 DN0005 DN0002 DN0003 DN0112 DN0113 DN0114 DN0115 DN0116 DN0117

DATA ELEMENT NAME Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer FEIN Claim Administrator Mailing Postal Code Third Party Administrator FEIN Acknowledgment Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Jurisdiction Claim Number Maintenance Type Code (From Original Trans) Maintenance Type Date (From Original Trans) Request Code Free Form Text Number Of Errors Element Number Element Error Number Variable Segment Number

VALUES AK1 000000000 19970417 020000

HD

Number of header errors goes here. Header Data Element Number in error goes here. Header Element Error Number goes here.

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ACK SCENARIO 3: VALIDATE HEADER FOR DUPLICATE BATCH A batch is considered to be a duplicate when the combination of Sender ID, Date Transmission Sent, Time Transmission Sent and Interchange Version ID already exist in the audit file. A duplicate batch will be indicated by an ‘HD’ in the Application Acknowledgment Code of the AK1, ‘all zeros’ in the Record Sequence Number, ‘0001' in the Element Number and ‘057' in the Element Error Number. ACK SCENARIO 3: ACKNOWLEDGMENT DETAIL
This scenario communicates what the AK1 would contain if a batch is rejected because of duplicate batch.

DATA NUMBER DN0001 DN0107 DN0108 DN0109 DN0006 DN0014 DN0008 DN0110 DN0111 DN0026 DN0015 DN0005 DN0002 DN0003 DN0112 DN0113 DN0114 DN0115 DN0116 DN0117

DATA ELEMENT NAME Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer FEIN Claim Administrator Mailing Postal Code Third Party Administrator FEIN Acknowledgment Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Jurisdiction Claim Number Maintenance Type Code (From Original Trans) Maintenance Type Date (From Original Trans) Request Code Free Form Text Number Of Errors Element Number Element Error Number Variable Segment Number

VALUES AK1 000000000 19970417 020000

HD

01 0001 057

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ACK SCENARIO 4: VALIDATE TRAILER RECORD The trailer record contains the number of transactions within a batch. The trailer record is edited to make sure the number of transactions is the same as counters in the trailer. If the trailer record is rejected, the batch is rejected. This will be indicated by an ‘HD’ in the Application Acknowledgment Code of the AK1, ‘all nines’ in the Record Sequence Number, the Element Number for the data element in error and the Element Error Number referencing the error. Processing of that batch will cease and will resume with the next HD1 record. The entire batch will not be processed. ACK SCENARIO4: ACKNOWLEDGMENT DETAIL
This scenario communicates what the AK1 would contain if a batch is rejected because of trailer error.

DATA NUMBER
DN0001 DN0107 DN0108 DN0109 DN0006 DN0014 DN0008 DN0110 DN0111 DN0026 DN0015 DN0005 DN0002 DN0003 DN0112 DN0113 DN0114 DN0115 DN0116 DN0117

DATA ELEMENT NAME
Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer Fein Claim Administrator Mailing Postal Code Third Party Administrator FEIN Acknowledgment Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Jurisdiction Claim Number Maintenance Type Code (From Original Trans) Maintenance Type Date (From Original Trans) Request Code Free Form Text Number Of Errors Element Number Element Error Number Variable Segment Number

VALUES
AK1 999999999 19970417 020000

HD

Number of trailer errors goes here. Trailer Element Number goes here. Trailer Element Error Number goes here.

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ACKNOWLEDGMENT SCENARIO 5: VALIDATE BATCH FOR TRANSACTION EXISTENCE A batch is a set of records containing one header record, one or more transactions and one trailer record. A batch which contains no transaction(s) is indicated by an ‘HD’ in the Application Acknowledgment Code of the AK1, ‘all zeros’ in the Record Sequence Number, ‘0000-Entire Batch' Element Number and ‘061Event Criteria Not Met' Element Error Number for the error. ACK SCENARIO 5: ACKNOWLEDGMENT DETAIL
This scenario communicates what the AK1 would contain if a batch is rejected because it contains no transactions.

DATA NUMBER DN0001 DN0107 DN0108 DN0109 DN0006 DN0014 DN0008 DN0110 DN0111 DN0026 DN0015 DN0005 DN0002 DN0003 DN0112 DN0113 DN0114 DN0115 DN0116 DN0117

DATA ELEMENT NAME Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer FEIN Claim Administrator Mailing Postal Code Third Party Administrator FEIN Acknowledgment Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Jurisdiction Claim Number Maintenance Type Code (From Original Trans) Maintenance Type Date (From Original Trans) Request Code Free Form Text Number Of Errors Element Number Element Error Number Variable Segment Number

VALUES AK1 000000000 19970417 020000

HD

01 0000 061

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ACKNOWLEDGMENT SCENARIO 6: VALIDATE BATCH INTEGRITY A batch is a set of records containing one header record, one or more transactions and one trailer record. The transaction(s) within the batch contain a transaction set ID that corresponds to the transmission type code indicated within the interchange version ID of the HD1. If a transaction within the batch does not match the HD1 transaction type code, the entire batch will be rejected. A batch which contains invalid transactions is indicated by an ‘HD’ in the application acknowledgment code, ‘all zeros’ in the record sequence number, ‘0105-Interchange Version ID' in the element number and ‘064-Data Sequence relationship’ in the element error number. ACK SCENARIO 6: ACKNOWLEDGMENT DETAIL
This scenario communicates what the AK1 would contain if a batch is rejected because of invalid transactions within the batch.

DATA NUMBER DN0001 DN0107 DN0108 DN0109 DN0006 DN0014 DN0008 DN0110 DN0111 DN0026 DN0015 DN0005 DN0002 DN0003 DN0112 DN0113 DN0114 DN0115 DN0116 DN0117

DATA ELEMENT NAME Transaction Set ID Record Sequence Number Date Processed Time Processed Insurer FEIN Claim Administrator Mailing Postal Code Third Party Administrator FEIN Acknowledgment Transaction Set ID Application Acknowledgment Code Insured Report Number Claim Administrator Claim Number Jurisdiction Claim Number Maintenance Type Code (From Original Trans) Maintenance Type Date (From Original Trans) Request Code Free Form Text Number Of Errors Element Number Element Error Number Variable Segment Number

VALUES AK1 000000000 19970417 020000

HD

01 0105 064

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6.
Definitions, Glossary & Code Lists

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DICTIONARY
For

TRANSMISSION HEADER FIRST REPORT SUBSEQUENT REPORT ACKNOWLEDGMENT DETAIL TRANSMISSION TRAILER

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DATA FORMAT :
Definition: Data Length: Data Type: Computational Fields: "N" "$9.2" Non-Computational Fields: Not used for mathematical calculations. "DATE" Date format field: left justified, blank fill. CCYYMMDD format. CC = Century YY = Year MM = Month DD = Day Time format field: Only a valid time in military format, zero, or spaces are allowed in time fields. Use 24 hour military time. All zeros in a time field is valid and equivalent to 240000 or 2400. Spaces indicate absence of data. May be left blank for occupational disease or injury. HH = Hours MM = Minutes Alpha/Numeric format fields: left justified, blank fill. Data elements that are defined to be alphanumeric (A/N) consist of a sequence of any characters from common character code schemes of EBCDIC, ASCII, and CCITT International Alphabet 5. When using an alphanumeric field the significant characters are always left justified in the field with any remaining space in the field padded with spaces. Alphanumeric character set includes those selected from the uppercase letters, lower case letters, numeric digits, space character, and special characters as follows: A...Z a...z 0...9 , < . > / ? ; : ' " [ { ] } \ | ` ~ ! @ # $ % ^ & * ( ) - _ = +(space) Use of any special characters as record delimiters are subject to the trading partner agreement identifying delimiters. Use of any of the alphanumeric characters are permitted in data elements with the alphanumeric data type unless otherwise indicated in an Implementation Note. Revised: 2/15/02 Number Format: Unsigned, right justified, zero fill. Monetary amount format: Signed, right justified, zero fill, "$" and "." (decimal) implied, not included. The combination of data length and data type of a specified data field. The maximum number of characters, expressed as a whole number, that can be contained in a specific data field. A designation that indicates the intended interpretation, and processing of data contained in a specific data field.

"HHMM"

"A/N"

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SECTION 6 Element – Data Number:
ACCIDENT DESCRIPTION/CAUSE - DN38 Definition: A free form description of how the accident occurred and the resulting injuries. Business Need: To clarify what happen to the injured worker. Revised: 8/9/95 Source: IAIABC Format: 150 A/N Record: First Report ACKNOWLEDGMENT TRANSACTION SET ID - DN110 Definition: The transaction set identifier that identifies the transaction being acknowledged. Business Need: One of the codes needed to uniquely identify the transaction being acknowledged. Revised 8/9/95 Source: IAIABC Format: 3 A/N Values: 148 - First Report A49 - Subsequent Report HD1 - Transmission Header Record Record: Acknowledgment Detail Record (AK1) AGENCY CLAIM NUMBER - DN5 Definition:

The number assigned by the agency or commission to identify a specific claim. Business Need: To identify claim, allow for SSN or date of injury correction. Revised: 3/11/94 Source: IAIABC Format: 25 A/N Record: First Report Subsequent Report Acknowledgment Detail Record (AK1) Implementation Note: This number may be changed during the life of the claim by the jurisdiction.

AGREEMENT TO COMPENSATE CODE - DN75 Definition: A code used to identify the condition under which compensation benefits are being paid. Busi ness Need: To indicate whether the payments are being made with/without determination of liability. Revised: 8/9/95 Source: IAIABC Format: 1 A/N Values: W - Without Liability L - With Liability Record: Subsequent Report

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APPLICATION ACKNOWLEDGMENT CODE - DN111 Definition: A code used to identify the accepted/rejected status of the transaction being acknowledged. Business Need: To identify to the originator whether a detail transaction was accepted or rejected by the receiver, and if the receiver encountered critical and/or non-critical errors in the contents of the transaction. Revised: 8/9/95 Source: IAIABC Format: 2 A/N Values: HD - Batch Rejected TA - Transaction Accepted TE - Transaction Accepted with Errors TR - Transaction Rejected Record: Acknowledgment Detail Record (AK1) BENEFIT ADJUSTMENT CODE - DN92 Definition: Business Need: Revised: Source: Format:

A code used to identify an adjustment being applied to a weekly payment/adjustment amount, still in effect (non suspension). To meet jurisdictional financial reporting requirements. 6/7/95 (replaced weekly benefit with payment/adjustment) IAIABC Ref.: Benefit Offset Codes DCI Table 12 IAIABC Payment Adjustment Codes 4 A/N BDDD

B = Benefit Adjustment Type DDD = IAIABC Payment Adjustment Codes Example: Overpayment Credit for Permanent Total = C020 B A B C E H I K L M Meaning Apportionment/contribution - Weekly payment amount reduced for shared or partial liability(s). Subrogation - Weekly payment amount reduced for recovery from third party tortfeasor. Overpayment credit - Weekly payment amount reduced for benefits paid but not due. Employer provided pension - Weekly payment amount reduced for eligibility or payments under an employer provided pension program. Court ordered lien against workers' compensation benefits - Weekly payment amount reduced for court ordered liens. Intoxication - Weekly payment amount reduced due to employee's intoxication at the time of the injury. Claimant Attorney Fees - Weekly payment amount reduced for withholding or payment of fees to the claimant's attorney. Disability Insurance/Income - Weekly payment amount reduced for disability insurance/income eligibility or payment other than social security. Employer reimbursement (for full salary paid over and above the compensation rate) - Weekly payment amount reduced for repayment to employer for full salary paid over and above the compensation rate. Non-cooperation: Rehabilitation, training, education, medical - Weekly payment amount reduced for non-cooperation/failure to comply with jurisdictional requirements. Prepaid Benefit/Advance - Weekly payment amount reduced for reimbursement of prepaid benefit/advance.

N

P

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Social Security Retirement - Weekly payment amount reduced for eligibility or payments under the Federal Old Age Survivors Act, 42 USC 402. S Social Security Disability - Weekly payment amount reduced for eligibility or payments under the Federal Disability Act, 42 USC 423. T Acceleration of benefits - Weekly payment amount increased over and above the compensation rate. U Unemployment Compensation - Weekly payment amount reduced for eligibility or payments under unemployment compensation. V Safety Violations - Weekly payment amount reduced for safety violation(s). W Partial wage continuation - Weekly payment amount reduced for continuation of fringe benefits by the employer. (For example; room, board, health insurance, etc.) X Death Benefit Reduction - Weekly payment amount reduced for eligibility or payments to survivors. Y Partial reimbursement of Claimant attorney fees - Weekly payment amount increased to the employee for partial reimbursement of claimant attorney fees. Record: Subsequent Report R BENEFIT ADJUSTMENT START DATE - DN94 Definition: The first date a benefit adjustment was applied. Business Need: To meet jurisdictional financial reporting requirements. Revised: 3/11/94 Source: IAIABC Format: CCYYMMDD Record: Subsequent Report BENEFIT ADJUSTMENT WEEKLY AMOUNT - DN93 Definition: The weekly amount of benefit adjustment applied per Payment/Adjustment Code. Business Need: To meet jurisdictional financial reporting requirements. Revised: 7/24/95 Source: IAIABC Format: $9.2 Record: Subsequent Report CAUSE OF INJURY CODE - DN37 Definition: Business Need: Revised: Source: Format: Values: Record:

The code which corresponds to the cause of injury. Loss Prevention Management 3/11/94 DCI Fld 26 2 A/N See Appendix (Cause of Injury Codes) First Report

CLAIM ADMINISTRATOR ADDRESS LINE 1 - DN10 Definition: The mailing address of the claim administrator's processing facility for this claim. Business Need: Used to identify the Claim Administrator's facility processing the claim. Revised: 6/7/95 Source: IAIABC Format: 30 A/N Record: First Report Implementation Note: If claim is being administered by a Third Party Administrator, use the Third Party Administrator's address.

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CLAIM ADMINISTRATOR ADDRESS LINE 2 - DN11 Definition: The mailing address of the claim administrator's processing facility for this claim. Business Need: Used to identify the Claim Administrator's facility processing the claim. Revised: 6/7/95 Source: IAIABC Format: 30 A/N Record: First Report Implementation Note: If claim is being administered by a Third Party Administrator, use the Third Party Administrator's address. CLAIM ADMINISTRATOR CITY - DN12 Definition:

The city of the claim administrator's processing facility's mailing address for this claim. Business Need: Used to identify the Claim Administrator's facility processing the claim. Revised: 6/7/95 Source: IAIABC Format: 15 A/N Record: First Report Implementation Note: If claim is being administered by a Third Party Administrator, use the Third Party Administrator's city.

CLAIM ADMINISTRATOR CLAIM NUMBER - DN15 Definition: Identifies a specific claim within a claim administrator's claims processing system. Business Need: Business management Revised: 2/15/02 Source: IAIABC Format: 25 A/N Record: First Report Subsequent Report Acknowledgment Detail Record (AK1) Implementation Note: This data element shall not contain leading spaces or leading special characters. The number may contain embedded spaces and special characters. Montana understands that they may not be able to implement this in a timely fashion. CLAIM ADMINISTRATOR POSTAL CODE - DN14 Definition: The postal code of the claim administrator's processing facility's mailing address for this claim. Business Need: Used to identify the Claim Administrator's facility processing the claim. Revised: 8/9/95 Source: IAIABC Ref.: ANSI A51 for U.S. postal codes plus non-U.S. postal codes. Format: 9 A/N Record: First Report Subsequent Report Acknowledgment Detail Record (AK1) Implementation Note: If claim is being administered by a Third Part y Administrator, use the Third Party Administrator's postal code.

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CLAIM ADMINISTRATOR STATE - DN13 Definition:

The state of the claim administrator's processing facility's mailing address. Business Need: Used to identify the Claim Administrator's facility processing the claim. Revised: 3/11/94 Source: ANSI A22 Format: 2 A/N Record: First Report Implementation Note: If claim is being administered by a Third Party Administrator, use the Third Party Administrator's state.

CLAIM STATUS - DN73 Definition: Business Need: Revised: Source: Format: Values: `

Record: CLAIM TYPE - DN74 Definition:

A code representing the current status of the claim. To report the claim's current status. 6/7/95 IAIABC 1 A/N O - Open C - Closed R - Re-open X - Reopened/Closed Subsequent Report

A code representing the current benefit classification of the claim as interpreted by the jurisdiction. Business Need: To report the claim’s current type. Revised: 2/15/02 Source: IAIABC Format: 1 A/N Values: M - Medical Only I - Indemnity N - Notification Only B - Became Medical Only L - Became Lost Time T - Transfer (Claim Juris changed) Y – Cumulative Injury (MT only; effective 7/1/01) Z – Occupational Disease (MT only; effective 7/1/01) Record: Subsequent Report Implementation Note: When a jurisdiction code is changed, the Claim type code is changed to "T", transfer. A transaction with Maintenance Type Code S8, Jurisdiction Change, is used to submit a Subsequent Report to the "original" jurisdiction. Maintenance Type Code "00" is used to submit a 1st Report to the "New" jurisdiction. Maintenance Type Code "IP" is used to submit a Subsequent Report to the "New" jurisdiction. Values of Y and Z can only be sent to those jurisdictions that receive just "indemnity" claims on subsequent reports. Therefore, the valid value sets that any one jurisdiction can use are (M,I,N,B,L or T) or (I, T, Y, Z).

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CLASS CODE - DN59 Definition: A code which corresponds to the primary occupation in which the employee was engaged at the time of accident/injury, or injurious exposure. Business management and statistical analysis. 6/7/95 DCI Field 23 4 A/N NCCI or state specific codes First Report

Business Need: Revised: Source: Format: Values: Record: DATE DISABILITY BEGAN - DN56 Definition:

Business Need: Revised: Source: Format: Record: DATE LAST DAY WORKED - DN65 Definition: Business Need: Revised: Source: Format: Record: DATE OF HIRE - DN61 Definition:

The first day on which the employee originally lost time from work due to the occupational injury or disease or as otherwise defined by jurisdiction. Used in determining indemnity benefits. 8/9/95 IAIABC Ref.: DCI Fld 37 CCYYMMDD First Report Subsequent Report

The last paid work day prior to the initial date of disability as defined by jurisdiction. To assist in determining the date benefits should commence. 8/9/95 IAIABC CCYYMMDD First Report

The date the injured worker began his/her employment with the employer under which the claim is being filed. If there have been multiple periods of employment, this would be the beginning date of the current employment period. Business Need: For statistical analysis. Revised: 3/11/92 Source: IAIABC Ref.: DCI Fld 19 Format: CCYYMMDD Record: First Report Implementation Note: If only the employee's number of years employed is known, an appropriate date should be calculated using the same month as the Date of Injury month and 01 for the day.

DATE OF INJURY - DN31 Definition:

Business Need:

Revised: Source: Format: Record:

For traumatic injury, the date on which the accident occurred. For occupational disease or cumulative injury, the date of injury is the date of last injurious exposure to the cause or substance creating the condition, unless otherwise defined by statute. To determine employer responsibility, for determination of coverage, for claimant benefit entitlement determination, for jurisdiction compliance review. 3/11/94 IAIABC CCYYMMDD First Report Subsequent Report
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DATE OF MAXIMUM MEDICAL IMPROVEMENT- DN70 Definition: The date after which further recovery from or lasting improvements to an injury or disease can no longer be anticipated based upon reasonable medical probability. Business Need: To determine benefit eligibility. Revised: 3/11/94 Source: IAIABC Format: CCYYMMDD Record: Subsequent Report DATE OF REPRESENTATION - DN76 Definition: Business Need: Revised: Source: Format: Record: DATE OF RETURN TO WORK - DN68 Definition: Business Need:

The date the claim administrator recognizes the claimant has secured legal representation. Identifies date to begin communication via counsel. 6/7/95 IAIABC CCYYMMDD Subsequent Report

Revised: Source: Format: Record:

The first date on which the employee returned to work following the injury. To determine the effectiveness of return to work programs. To evaluate length of injury by disability sustained. To determine benefit payments. 8/9/95 IAIABC CCYYMMDD First Report

DATE OF RETURN/RELEASE TO WORK - DN72 Definition: The date, following the most recent disability period, on which the employee actually returned to work, or was released to Return To Work, as identified by the Return To Work Qualifier. Business Need: To identify the date the employee’s work status changed. To determine the employee’s eligibility for benefits. For use in statistical analysis. Revised: 6/7/95 Source: IAIABC Format: CCYYMMDD Record: Subsequent Report
Implementation Note: 1. The date of RTW can be one of two dates, either the actual date the person returned to work or the date the person was released to RTW. The value in the RTW qualifier will serve to identify whether the date is the actual or released RTW date. The date has to be present when the qualifier is coded. 2. The date must be updated to reflect the date associated with the updated RTW qualifier.

DATE PROCESSED - DN108 Definition:

Business Need: Revised: Source: Format: Record:

The date that the receiver processed the detail transaction. Together with time processed and a record sequence number it will uniquely identify a specific acknowledgment detail record. Needed for reconciliation. 8/9/95 IAIABC CCYYMMDD Acknowledgment Detail Record (AK1)

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DATE REPORTED TO CLAIM ADMINISTRATOR - DN41 Definition: The date the claim administrator who is processing the claim received notice of the loss or occurrence. Business Need: Used to insure compliance with jurisdiction claim processing time constraints. Revised: 3/11/94 Source: IAIABC Ref.: DCI Fld 9 Format: CCYYMMDD Record: First Report
Implementation Note: If the notice of loss or occurrence is passed from one entity to another; i.e. Carrier to TPA, then the date reported will be the date that the first entity had knowledge of the occurrence, whether notification was by phone, fax, mail, or any other means.

DATE REPORTED TO EMPLOYER - DN40 Definition: The date that the injury was reported to a representative of the employer. Business Need: To identify the date the employer was aware of the accident. Revised: 6/7/95 Source: IAIABC Ref.: DCI Field 32 Format: CCYYMMDD Record: First Report DATE TRANSMISSION SENT - DN100 Definition: Business Need: Revised: Source: Format: Record:

Actual date transmission of data sent. To identify when the transmission was sent. 6/7/95 IAIABC CCYYMMDD Transmission Header Record HD1

DEPENDENT/PAYEE RELATIONSHIP - DN97 Definition: The relationship of the dependent(s)/Payee(s) to the deceased employee; to which relationship and benefit entitlement may be determined by an adjudicator's decision for distribution of the death benefit. Business Need: To determine benefit entitlement. Revised: 9/16/94 Source: IAIABC Format: 2 A/N RN Values: R=Relationship 2 - Widow 3 - Widower 4 - Son or Daughter 5 - Brother or Sister 6 - Mother or Father 7 - Handicapped Child 8 - Jurisdiction Fund (ex: CA - Death without Dependents Fund, TX Subsequent Injury Fund) 9 – Other N = Numerical Birth Order 1-9 first to ninth for each Relationship classification. Record: Subsequent Report

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DETAIL RECORD COUNT - DN106 Definition:

Business Need: Revised: Source: Format: Record: ELEMENT ERROR NUMBER DN116 Definition: Business Need: Revised: Source: Format: Values:

The total number of detail records sent as part of this transmission. Transmission header and trailer records are not included in this count. To indicate the number of detail records included in a transmission for verification purposes. 8/18/94 IAIABC 9N Transmission Trailer Record (TR1).

A number to uniquely identify the edit performed on an element and is part of the Error Code. Identifies the error that was detected. 2/15/02 IAIABC 3 A/N 001 Mandatory field not present 002 Transaction Set ID invalid 003 Maintenance Type Code invalid for '148' 004 Maintenance Type Code invalid for 'A49' 005 State Code invalid 006 NCCI Nature Code invalid 007 NCCI Part of Body Code invalid 008 NCCI Cause of Injury Code invalid 009 Gender Code invalid 010 Marital Status Code invalid 011 Wage Period Code invalid 012 Indicator invalid 013 Employment Status Code invalid 014 Class Code (NCCI or State Specific) invalid 015 Industry Code (SIC or NAICS) invalid 016 Initial Treatment Code invalid 017 Claim Status Code invalid 018 Number of Days Worked must be 0-7 019 Days must be 0-6 020 Return to Work Qualifier Code invalid 021 Claim Type Code invalid 022 Agreement to Compensate Code invalid 023 Late reason Code invalid 024 Payment/Adjustment Code invalid 025 Benefit/Adjustment Code invalid 026 PTD/RE/Recovery Code invalid 027 Dependent/Payee Relationship Code invalid 028 Must be 0-9 029 Must be a valid Date (CCYYMMDD) 030 Must be A-Z, 0-9, or spaces 031 Must be a valid time 032 Must be valid on Zip Code Table 033 Must be <= Date of Injury 034 Must be >= Date of Injury 035 Must be >= Date Disability Began 036 Must be <= Date of Death 037 Must be <= Maintenance Type Code Date 038 Must be >= Payment/Adjustment Start Date 039 No match on database 040 All digits cannot be the same 041 Must be <= Current Date
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042 Not statutorily valid 043 Receiver ID invalid 044 Value is > required by jurisdiction 045 Value is < required by jurisdiction 046 Interchange Version ID invalid 047 Reinstated but not suspended 048 Duplicate First Report (148) 049 Duplicate Initial Payment (A49) 050 No matching Subsequent Report (A49) 051 Reduced Earnings prior to Initial Payment 052 Suspension prior to Initial Payment 053 No matching First Report (148) 054 Must be valid occurrence for segment 055 Must be <= Date of Hire 056 Detail Record Count not equal number records received 057 Duplicate Transmission/Transaction 058 Code/ID invalid 059 Value not consistent with value previously reported 060 Previous supporting documentation not received 061 Event Criteria not met 062 Required segment not present 063 Invalid event sequence/relationship 064 Invalid data sequence/relationship 065 Corresponding report/data not found 066 Invalid record count 067 Must be >= Policy Effective Date 068 Must be <= Policy Expiration Date 100 No Leading/Embedded Spaces Acknowledgment Detail Record (AK1).

Record: ELEMENT NUMBER - DN115 Definition: Business Need: Revised: Source: Format: Record: EMPLOYEE ADDRESS (LINE 1) - DN46 Definition: Business Need: Revised: Source: Format: Record: EMPLOYEE ADDRESS (LINE 2) - DN47 Definition: Business Need: Revised: Source: Format: Record:

A unique number assigned to each data element and is part of the Error Code. Identifies the element for which an error was detected. 8/18/94 IAIABC 4 A/N Acknowledgment Detail Record (AK1)

The mailing address used by the injured worker. To provide the injured worker’s mailing address. 6/7/95 IAIABC 30 A/N First Report

The mailing address used by the injured worker. To provide the injured worker’s mailing address. 6/7/95 IAIABC 30 A/N First Report

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EMPLOYEE CITY - DN48 Definition: Business Need: Revised: Source: Format: Record: EMPLOYEE DATE OF BIRTH - DN52 Definition: Business Need: Revised: Source:

The name of the city of the injured worker's mailing address. To provide the injured worker’s mailing address. 6/7/95 IAIABC 15 A/N First Report

The date the injured worker was born. To calculate the injured worker's age. 6/7/95 IAIABC Ref.:DCI Fld 18 Format: CCYYMMDD Record: First Report Implementation Note: If only the employee's age is known, an appropriate date should be calculated using the same month as the date of injury month and 01 for the day.

EMPLOYEE DATE OF DEATH - DN57 Definition: Business Need: Revised: Source: Format: Record: EMPLOYEE FIRST NAME - DN44 Definition:

The date the injured worker died. For benefit type determination. For statistical analysis. 6/7/95 IAIABC CCYYMMDD First Report Subsequent Report

Business Need: Revised: Source: Format: Record: EMPLOYEE LAST NAME - DN43 Definition:

The injured worker's legally recognized first name, which is used on legal documents, employment, Social Security, banking records, etc. To identify the injured worker. 6/7/95 IAIABC 15 A/N First Report

The injured worker's legally recognized last name, which is used on legal documents, employment, Social Security, banking records, etc. Business Need: To identify the injured worker. Revised: 6/7/95 Source: IAIABC Ref.: DCI Fld 15 Format: 30 A/N Record: First Report Implementation Note: Enter double last names with a hyphen separator, no spaces, to avoid last name editing errors. For name Suffix Jr, Sr, I, II, III, etc. enter last name comma and the suffix value, no spaces.

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EMPLOYEE MIDDLE INITIAL - DN45 Definition: Business Need: Revised: Source: Format: Record: EMPLOYEE PHONE - DN51 Definition: Business Need: Revised: Source: Format: Record: EMPLOYEE POSTAL CODE - DN50 Definition: Business Need: Revised: Source: Format: Record: EMPLOYEE STATE - DN49 Definition: Business Need: Revised: Source: Format: Record: EMPLOYER ADDRESS (LINE 1) - DN19 Definition: Business Need: Revised: Source: Format: Record: EMPLOYER ADDRESS (LINE 2) - DN20 Definition: Business Need: Revised: Source: Format: Record:

The injured worker's legally recognized middle initial. To identify the injured worker. 6/7/95 IAIABC 1 A/N First Report

A telephone number where the injured worker can be reached. To provide the injured worker’s telephone number. 6/7/95 IAIABC 10 A/N First Report

The postal code of the injured worker’s mailing address. To provide the injured worker’s mailing address. 6/7/95 IAIABC Ref.: ANSI A51 for U.S. postal codes plus non-U.S. postal codes. 9 A/N First Report

The state of the injured worker’s mailing address. To provide the injured worker’s mailing address. 6/7/95 ANSI A22 2 A/N First Report

The address of the employer's facility where the employee was employed at the time of the injury. To identify the address of the employer's facility. 6/7/95 IAIABC 30 A/N First Report

The address of the employer's facility where the employee was employed at the time of the injury. To identify the address of the employer's facility. 6/7/95 IAIABC 30 A/N First Report

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EMPLOYER CITY - DN21 Definition: Business Need: Revised: Source: Format: Record: EMPLOYER FEIN - DN16 Definition: Business Need: Revised: Source: Format: Record: EMPLOYER NAME - DN18 Definition: Business Need: Revised: Format: Record: EMPLOYER POSTAL CODE - DN23 Definition: Business Need: Revised: Source: Format: Record: EMPLOYER STATE - DN22 Definition: Business Need: Revised: Source: Format: Record:

The city of the employer's facility where the employee was employed at the time of the injury. To identify the address of the employer's facility. 6/7/95 IAIABC 15 A/N First Report

The FEIN of the employer where the employee was employed at the time of the injury. To identify the employer, minimize record data, and reference employer profile data. 8/9/95 IAIABC 9 A/N First Report Subsequent Report

The name of the employer where the employee was employed at the time of the injury. To identify the statutorily responsible employer. 8/9/95 30 A/N 148 First Report

The postal code of the employer's facility where the employee was employed at the time of the injury. To identify the address of the employer's facility 6/7/95 IAIABC Ref.: ANSI A51 for U.S. postal codes plus non-U.S. postal codes. 9 A/N First Report Subsequent Report

The state of the employer's facility where the employee was employed at the time of the injury. To identify the address of the employer's facility 6/7/95 ANSI A22 2 A/N First Report

EMPLOYER'S PREMISES INDICATOR - DN34 Definition: An indicator to denote whether the accident occurred at the employer’s address provided. Business Need: Loss control management Revised: 3/11/94 Source: IAIABC Format: 1 A/N Values: [Y|N] Record: First Report

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EMPLOYMENT STATUS CODE - DN58 Definition: A code used to indicate the employee's primary work Code status at the time of the injury with the covered employer. Business Need: For statistical analysis and benefit computations. Revised: 3/28/94 Source: IAIABC Ref.: DCI Fld 21, ANSI 584 Format: 2 A/N ANSI: Employment Status Codes (ANSI Codes)(#584) Hierarchy: In the event that two Employment Status Codes apply to an employee, the following hierarchy will determine which code, the topmost, will be reported, i.e. if employee is a part time seasonal worker, report as seasonal worker.

Hierarchical Order
1 2 3 4 5 6 7 8 9 10 11 12

FLAT/DCI Name
Piece Worker Volunteer Worker Seasonal Apprenticeship Full-Time Apprenticeship Part-Time Regular Employee Part-Time Employee Unemployed Retired On Strike Disabled Other

Flat/DCI Values
C 9 8 A B 1 2 3 6 4 5 7

ANSI Name
Piece Worker Volunteer Seasonal Apprenticeship Full-Time Apprenticeship Part-Time Full-Time Part-Time Not Employed Retired On Strike Disabled Other

ANSI Values
PW VO SL AD AP FT PT NE RT OS DS ZZ or UK

Record: FREE FORM TEXT - DN113 Definition: Business Need: Revised: Format: Record:

First Report

An unstructured field used to convey a trading partner's claim comments. Allows for free form communication. 8/18/94 60 A/N Acknowledgment Detail Record (AK1)

FULL WAGES PAID FOR DATE OF INJURY INDICATOR - DN66 Definition: Indicates whether full wages for the date of the accident/injury or illness were paid by the employer. Business Need: To assist in determining the date benefits should commence. Revised: 3/11/94 Source: IAIABC Format: 1 A/N [Y|N] Record: First Report GENDER CODE - DN53 Definition: Business Need: Revised: Source: Format: Values:

Record:

The code which indicates the sex of the employee. For statistical analysis. 3/11/94 ANSI Element 1068 1 A/N M - Male F - Female U - Unknown First Report
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INDUSTRY CODE - DN25 Definition: The code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System Manual published by the Federal Office of Management and Budget. Business Need: Statistical Revised: 2/15/02 Source: ANSI A113 Ref.: DCI Fld 12 Format: 6 A/N Record: First Report Implementation Note: The Industry Code selected should represent the primary nature of the employer's business. If the employer is assigned multiple Industry Codes, use the code that relates to the specific business operation for which the employee was employed at the time of injury. Ths data element may contain an SIC code or NAICS code. SIC Code will be identified with the characters ‘SC’ in the last two character positions of the data element. If SC is not present, the code is NAICS. Claim administrators will not send NAICS prior to 4/1/2002. Claim administrators will add the SC suffix to the SIC code beginning 1/1/2002 and no later than 4/1/2002. After 4/1/2002, state jurisdictions could receive either NAICS or SIC in claim reports.

INITIAL TREATMENT - DN39 Definition: Business Need: Revised: Source: Format: Values:

Record: INSURED LOCATION NUMBER - DN27 Definition: Business Need: Revised: Source: Format: Record:

A code used to identify the extent of medical treatment received by the employee immediately following the accident. To qualify the severity of the injury. 3/11/94 IAIABC 2 A/N 0 = No medical treatment 1 = Minor on-site remedies by employer medical staff 2 = Minor clinic/hospital medical remedies and diagnostic testing 3 = Emergency evaluation, diagnostic testing, and medical procedures 4 = Hospitalization > 24 hours 5 = Future Major Medical/Lost Time Anticipated (i.e. hernia case) First Report

A code defined by the insured/employer which is used to identify the employer's location of the accident. For insured loss prevention program management. 6/7/95 IAIABC 15 A/N First Report

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INSURED NAME - DN17 Definition:

The named insured of the policy or the financially responsible self insured approved by the jurisdiction. Business Need: To identify the insured in a hierarchically structured organization when the employer is not the parent organization. Revised: 6/7/95 Source: IAIABC Format: 30 A/N 148 90 A/N POC Record: First Report Implementation Note: Typically the parent company in a hierarchically structured organization.

INSURED REPORT NUMBER - DN26 Definition: Business Need: Revised: Source: Format: Record:

A number used by the insured to identify a specific claim. Business management 3/11/94 IAIABC 1st - 10 A/N Sub. - 25 A/N First Report Subsequent Acknowledgment Detail Record (AK1)

INSURER FEIN - DN6 Definition: Business Need: Revised: Source: Format: Record:

The FEIN of the carrier or self insured assuming the employer's financial responsibility for Workers' Compensation Claim(s). To identify financial responsibility and to reference claims payer data. 8/9/95 IAIABC 9 A/N First Report Subsequent Report Acknowledgment Detail Record

INSURER NAME - DN7 Definition: Business Need: Revised: Source: Format: Record:

The name of the carrier or self insured assuming the employer's financial responsibility for Workers' Compensation Claim(s). To identify financial responsibility and to reference claims payer data. 6/7/95 IAIABC 30 A/N First Report

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INTERCHANGE VERSION IDENTIFIER - DN105 Definition: A composite field comprised of: Transmission Type Code: The identifier that designates the type of transmission within a batch. Release Number field: Identifies the release level of the data of the record layout contained in the detail records that follow. Business Need: To identify the type and release level of the detail records contained within the batch transmission and to uniquely identify the version number to anticipate the format of the detail records that are to follow. Revised: 8/19/94 Source: IAIABC Format: Transmission type code 3 A/N Release Number 2 A/N Values: Transmission type code/release number: 148/01 - First Report Only A49/1A - Subsequent Report Only AK1/01 - Acknowledgment Detail Record Record: Transmission Header Record (HD1) JURISDICTION - DN4 Definition: Business Need: Revised: Source:

Format: Values: UL U1 U2 U3 U4 FC FE M1 Record:

The governing body or territory whose statutes apply. Used to identify the jurisdiction whose statutes apply. 6/7/95 IAIABC REF.: Appendix: ANSI Code List A22 (US Postal State Codes) plus list of non-state jurisdictions below (OSHA to be developed) 2 A/N Non-State Jurisdictions: Long Shore & Harbor Workers' Compensation Act Defense Base Act Non Appropriated Fund Instrumentalities Act Outer Continental Shelf Act War Hazards Compensation Act Federal Coal Mine Health & Safety Act Federal Employers Liability Act Admiralty I & II First Report Subsequent Report

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LATE REASON CODE - DN77 Definition: Business Need: Revised: Source: Format: Record: Values: Delays: L1 L2 L3 L4 L5 L6 L7 L8 L9 LA Coverage: C1 Errors: E1 E2 E3 E4 E5 E6 Disputes: D1 D2 D3 D4 D5 D6

A code which identifies the reason a payment/report was not made within a jurisdiction's time requirements. To communicate the reason a jurisdictionally required due date was not met. 6/7/95 IAIABC 2 A/N Subsequent Report

No excuse Late notification, employer Late notification, employee Late notification, state Late notification, health care provider Late notification, assigned risk Late investigation Tech processing delay/computer failure Manual processing delay Intermittent lost time prior to first payment Coverage lack of information Wrongful determination of no coverage Errors from employer Errors from employee Errors from state Errors from health care provider Errors from other claim administrator/IA/TPA Dispute concerning coverage Dispute concerning compensability in whole Dispute concerning compensability in part Dispute concerning disability in whole Dispute concerning disability in part Dispute concerning impairment

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MAINTENANCE TYPE CODE - DN2 Definition: Defines the specific purpose of individual records within the transaction being transmitted. Business Need: Identifies the purpose of the transaction Revised: 8/9/95 Source: IAIABC Format: 2 A/N Claim Values: MTC 00 01 02 04 AU CO MTC 02 04 4P AP CA CB CD CO FN FS IP P1 P2 P3 P4 P5 P7 P9 PJ PY RB RE S1 S2 S3 S4 S5 S6 S7 S8 S9 SJ UR VE MTC AN BM BW MN QT SA

First Report Values Original Cancel Change Denial Acquired/Unallocated Correction Subsequent Report Values Change Denial Partial Denial Acquired/Payment Change in Benefit Amount Change in Benefit Type Compensable Death No Dependents/Payees Correction Final Full Salary Initial Payment Partial Suspension, returned to work, or medically determined/qualified to return to work Partial Suspension, medical non-compliance Partial Suspension, administrative non-compliance Partial Suspension, Employee Death Partial Suspension, Incarceration Partial Suspension, Benefits Exhausted Partially Suspended pending settlement approval Partially Suspended pending appeal or judicial review Payment Report Reinstatement of Benefit Reduced Earnings Suspension, returned to work, or medically determined/qualified to return to work. Suspension, Medical non-compliance Suspension, Administrative non-compliance Suspension, Claimant Death Suspension, Incarceration Suspension, Claimant’s Whereabouts Unknown Suspension, Benefits Exhausted Suspension, Jurisdiction Change Suspended pending settlement approval Suspended pending appeal or judicial review Upon Request Volunteer Periodic Report Values Annual Bi-Monthly Bi-Weekly Monthly Quarterly Semi-Annual
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Definitions for First Report Values: 00 = Original: The original/initial first report transmitted between partners, including the re-transmission of a first report that was rejected due to a critical error. 01 = Cancel: The original first report was sent in error. Process: A previous 00 First Report must have been filed. 02 = Change: A change has been made to First Report data elements designated on the trading Partner Tables for MTC 02. Process: A first report must have been previously filed. 04 = Denial: The entire claim is being denied. Process: May or may not be the original (00) First Report. AU = Acquired/Unallocated: To identify that a claim has been acquired from a prior claim administrator. CO = Correction: Used in response to an acknowledgment containing non-critical errors. Process: The first submission of the First Report must use either 00,"Original", 04, "Denial", or AU", Acquired/Unallocated", Maintenance Type Codes. Definitions for Subsequent Report Values: 02 = Change: A change has been made to Subsequent Report data elements designated on the trading Partner Tables for MTC 02. Implementation Note: For 02 -- Changes in Benefit Amount or Benefit Type are processed through CA and CB Maintenance Type Codes respectively 04 = Denial: The entire claim is being denied. Process: Payments have been made or a subsequent report has been filed. 4P = Partial Denial: A specific benefit(s) has been denied. Process: A previous Subsequent Report may or may or may not have been filed. A previous First Report must have been filed. AP = Acquired/Payment: The first payment of indemnity benefits has been made by the acquiring claim administrator. CA = Change in Benefit Amount: A change in Payment/Adjustment Weekly Amount has been made for the same Payment/Adjustment Code. Process: A previous IP Subsequent Report has been filed. Implementation Note: The change in Payment/Adjustment amount is not in response to Reduced Earnings. CB = Change in Benefit Type: A change in Payment/Adjustment Code has been made or an introduction of an additional Payment/Adjustment Code has occurred. Process: A previous IP Subsequent Report has been filed. Implementation Note: For CB -- The effective date of the change in Payment/Adjustment code is the start date for that Payment/Adjustment Code. CD = Compensable Death No Dependents/Payees: The injured worker has died as a result of a covered injury and no payment(s) of indemnity benefits have been made pending further beneficiary investigation. Process: A previous Subsequent Report may or may not have been filed. CO = Correction: Used in response to an acknowledgment containing non-critical errors. Process: 02 is used when there is a change of an element designated on the trading partner tables for MTC 02... CO is used in response to an acknowledgment containing non-critical errors. The Original MTC is used in response to an acknowledgment containing critical errors. FN = Final: Closed claim, no further payments of any kind anticipated. Process: An IP or FS Subsequent Report must have previously been filed, and a previous periodic Subsequent Report may or may not have been filed.
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FS = Full Salary: The employer is paying the injured worker's salary in lieu of compensation, and the claim administrator is not paying any indemnity benefits at this time. Process: A previous Subsequent Report may or may not have been filed. IP = Initial Payment: The first payment of indemnity benefits has been made. Process: A previous Subsequent Report (other than IP) may or may not have been filed, but no previous IP reports have been filed for this claim by the same claim administrator/TPA. P1 = Partial Suspension, returned to work, or medically determined/qualified to return to work: Payment(s) of one concurrent indemnity benefit has stopped because the injured worker has returned to work, and payment(s) of other indemnity benefits continue. P2 = Partial Suspension, Medical Non-Compliance: Payment(s) of one concurrent indemnity benefit has stopped because of medical non-compliance, and payment(s) of other indemnity benefits continue. P3 = Partial Suspension, Non compliance with administrative/ jurisdictional requirements not including medical: Payment(s) of one concurrent indemnity benefit has stopped because of administrative non compliance, and payment(s) of other indemnity benefits continue. P4 = Partial Suspension, Non-Compensable Employee Death: Payment(s) of one concurrent indemnity benefit has stopped because the employee has died not as a result of the compensable injury and payment(s) of other indemnity benefits continue. P5 = Partial Suspension Incarceration: Payment(s) of one concurrent indemnity benefit has stopped because the claimant has been incarcerated, and payment(s) of other indemnity benefits continue. P7 = Partial Suspension, Benefits/Entitlement Exhausted: Payment(s) of one concurrent indemnity benefit has stopped because limits of benefit or entitlement have been reached, and payment(s) of other indemnity benefits continue. P9 = Partially Suspended pending settlement approval: Payment(s) of one concurrent indemnity benefit has stopped pending settlement approval, and payment(s) of other indemnity benefits continue. PJ = Partially Suspended pending appeal or judicial review: Payment(s) of one concurrent indemnity benefit has stopped pending appeal or judicial review, and payment(s) of other indemnity benefits continue. PY = Payment: Identifies payment information for which reporting is required by the jurisdiction. Values used with a PY code: 080, 310, 320, 330, 340, 350, 360, 370, 380, 390, 400, 420, 440, 501, 580, 800, 810, 820,830, 840. Implementation Note: Used for reporting payments other than indemnity benefits. RB = Reinstatement of Benefit: Indemnity payments have resumed. Process: A previous subsequent report has been filed with a Suspension Maintenance Type Code. Implementation Note: For RB -- The effective date of reinstatement in the Payment/ Adjustment Code is the start date for that Payment/Adjustment code. (see also Payment/Adjustment Code Start Date implementation notes.) Implementation Note: For every RB there must be a corresponding suspension MTC (i.e. a 1 for 1 match). The Payment/Adjustment Code being resumed may or may not have been previously paid. RE = Reduced Earnings: The injured worker has returned/been released to return to work and RE codes 600-624 or 650-674 are filed. Process: An IP or CB report has already been filed. Implementation Note: This code is similar to the Periodic MaintenanceType codes - the user must reference the Report Due Submission Due Date Criteria to determine when a submission is required.
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S1 = Suspension, returned to work, or medically determined/qualified to return to work: All payments of indemnity benefits have stopped because the employee has returned to work or has been medically determined qualified to return to work. S2 = Suspension Medical Non-Compliance: All payments of indemnity benefits have stopped because of medical non compliance. Implementation Note: Non-compliance of any party, relating to a medical issue. For example: Employer, Dr., Employee. This includes vocational rehabilitation for those states that consider vocational rehabilitation medical. S3 = Suspension Non compliance with administrative/jurisdictional requirements not including medical: All payments of indemnity benefits have stopped because of administrative non-compliance. Implementation Note: Non-compliance of any party, relating to a non-medical issue. For example: Employer, Dr., Employee. This includes vocational rehabilitation for those states that do not consider vocational rehabilitation medical. S4 = Suspension Non-compensable Employee Death: All payments of indemnity benefits have stopped because the employee has died not as a result of the compensable injury. S5 = Suspension Incarceration: All payments of indemnity benefits have stopped because the employee has been incarcerated. S6 = Suspension Employee’s Whereabouts Unknown: All payments of indemnity benefits have stopped because the employee's whereabouts are unknown. S7 = Suspension Benefits/Entitlement Exhausted: All payments of indemnity benefits have stopped because limits of benefit or entitlement have been reached. S8 = Suspension Jurisdiction Change: All payments of indemnity benefits have stopped because the jurisdiction has been changed. Implementation Note: When a jurisdiction code is changed, the Claim type code is changed to "T", transfer. A transaction with Maintenance Type Code S8, Jurisdiction Change, is used to submit a Subsequent Report to the "original" jurisdiction. Maintenance Type Code "00" is used to submit a First Report to the "New" jurisdiction. Maintenance Type Code "IP" is used to submit a Subsequent Report to the "New" jurisdiction. S9 = Suspended pending settlement approval: All payments of indemnity benefits have stopped pending settlement approval. SJ = Suspended pending appeal or judicial review: All payments of indemnity benefits have stopped pending appeal or judicial review. UR = Upon Request: Submitted in response to a specific request from the Trading Partner. VE = Volunteer: The employee is a volunteer for the covered employer, and no indemnity payments will be made by the carrier. Process: No previous Subsequent Reports have been filed. Definitions for Periodic Report Values: Periodic Reports are Subsequent Reports that commence and terminate according to Trading Partner Table options, and repeat at specified intervals during that period. AN = Annual: Submitted at yearly intervals based on the report trigger criteria column located on the event table. BM = Bi-Monthly: Submitted at two month intervals based on the report trigger criteria column located on the event table. Submitted at two week intervals based on the report trigger criteria column located on the event table.
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BW = Bi-Weekly:

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MN = Monthly: Submitted at one month intervals based on the report trigger criteria column located on the event table. Submitted at three month intervals based on the report trigger criteria column located on the event table. Submitted at six month intervals based on the report trigger criteria column located on the event table.

QT = Quarterly:

SA = Semi-Annual:

Record: As noted by MTC Code above, plus all apply to Acknowledgment -Detail Record (AK1). MAINTENANCE TYPE CODE DATE - DN3 MULTI REF. Implementation Note: For P1-PJ: The date the suspension was effective may be the same or before the end date of the last Payment/Adjustment code paid. MULTI REF. Implementation Note: For S1-SJ: The date the suspension was effective may be the same or before the end date of the last Payment/Adjustment code paid. MULTI REF. Implementation Note: For 04 and 4P: The MTC date and the date of denial on the supporting paper document may differ. Definition: Business Need: Revised: Source: Format: Record: Designates the date corresponding to the Maintenance Type Code. To fulfill jurisdictional reporting requirements: i.e. date reported, date of first payment, etc. 3/11/94 IAIABC CCYYMMDD First Report Subsequent Report Acknowledgment Detail Record (AK1)

First Report Values MTC 00: Date the Maintenance Type Code 00 transaction was moved to the transmission queue or flagged for transmission. MTC 01: Date the Maintenance Type Code 01 transaction was moved to the transmission queue or flagged for transmission. MTC 02: Date the Maintenance Type Code 02 transaction was moved to the transmission queue or flagged for transmission. MTC 04: Date the Maintenance Type Code 04 transaction was moved to the transmission queue or flagged for transmission. MTC AU: Date the Maintenance Type Code AU transaction was moved to the transmission queue or flagged for transmission. MTC CO: Maintenance Type Code Date of the Original Transaction being corrected that contained non-critical error(s). Subsequent Report Values MTC 02: Date the Maintenance Type Code 02 transaction was moved to the transmission queue or flagged for transmission. MTC 04: Date the Maintenance Type Code 04 transaction was moved to the transmission queue or flagged for transmission. MTC 4P: Date the Maintenance Type Code 4P transaction was moved to the transmission queue or flagged for transmission. MTC AP: Issue date of initial indemnity benefit check after acquiring the file. MTC CA: Date the change in Payment/Adjustment amount was effective. MTC CB: Date the Maintenance Type Code CB transaction was moved to the transmission queue or flagged for transmission. MTC CD: Date the Maintenance Type Code CD transaction was moved to the transmission queue or flagged for transmission. MTC CO: Maintenance Type Code Date of the Original Transaction being corrected that contained non-critical error(s). MTC FN: Date the Maintenance Type Code FN transaction was moved to the transmission queue or flagged for transmission.
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MTC FS: MTC IP: MTC P1-PJ: MTC PY: MTC RB: MTC RE: MTC S1-SJ: MTC UR: MTC VE: Date the Maintenance Type Code FS transaction was moved to the transmission queue or flagged for transmission. Issue date of initial indemnity benefit check. The last date through which an indemnity benefit(s) is due. Issue date of payment. Issue date of the check reinstating indemnity benefits. Date the Maintenance Type Code RE transaction was moved to the transmission queue or flagged for transmission. The last date through which indemnity benefit(s) are due. Date the Maintenance Type Code UR transaction was moved to the transmission queue or flagged for transmission. Date the Maintenance Type Code VE transaction was moved to the transmission queue or flagged for transmission.

Periodic Report Values AN, BM, BW, MN, QT, SA: Date the Periodic Maintenance Type Code transaction was moved to the transmission queue or flagged for transmission. MARITAL STATUS CODE - DN54 Definition: Business Need: Revised: Source: Format: Values:

Record: NATURE OF INJURY CODE - DN35 Definition: Business Need: Revised: Source: Format: Value: Record:

The code which indicates the marital status of the employee. Statistical analysis and benefit calculations. 3/11/94 ANSI Element 1067 Ref.: DCI Fld 17 1 A/N U = Widowed, Divorced, Single, Unmarried M = Married S = Separated K = Unknown First Report

The code which corresponds to the nature of the injury sustained by the employee. Loss prevention management. 3/11/94 DCI Field 25 2 A/N See Appendix NCCI Table 8 Codes First Report

NUMBER OF BENEFIT ADJUSTMENTS - DN80 (NBR. BENEFIT ADJUSTMENTS) Definition: The number of Benefit Adjustment segment occurrences. Business Need: A technical processing requirement that specifies the number of variable segments that follow. Revised: 3/11/94 Source: IAIABC Format: 2N Max. Occ: 10 Values: [0 through 10] Record: Subsequent Report

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NUMBER OF DAYS WORKED - DN64 (NBR. DAYS WORKED) Definition: Business Need: Revised: Source: Format: Record:

The number of the employee's regularly scheduled work days per week. To calculate a partial week of disability. 3/11/94 IAIABC - ANSI 1N First Report Subsequent Report

NUMBER OF DEATH DEPENDENT/PAYEE RELATIONSHIPS - DN82 (NBR. DEATH DEP/PAYEE RELATIONSHIPS) Definition: The number of Death/Dependent Payee segment occurrences. Business Need: A technical processing requirement that specifies the number of variable segments that follow. Revised: 6/7/95 Source: IAIABC Format: 2N Max. Occ: 12 Values: [0 through 12] Record: Subsequent Report NUMBER OF DEPENDENTS - DN55 (NBR. OF DEPENDENTS) Definition: Business Need: Revised: Source: Format: Record: NUMBER OF ERRORS - DN114 (NBR. ERROR CODE) Definition: Business Need: Revised: Source: Format: Values: Record:

The number of dependents as defined by the administering jurisdiction. May be used to determine benefits. 3/11/95 IAIABC 2N First Report Subsequent Report

The number of error code segment occurrences. A technical processing requirement that specifies the number of variable segments that follow. 8/18/94 IAIABC 2N [0 through 99] Acknowledgment Detail Record (AK1)

NUMBER OF PAID TO DATE/REDUCED EARNINGS/RECOVERIES - DN81 (NBR. PTD/REDUCED EARNINGS/RECOVERI ES) Definition: The number of Paid To Date/Reduced Earnings/Recovery segment occurrences. Business Need: A technical processing requirement that specifies the number of variable segments that follow. Revised: 6/7/95 Source: IAIABC Format: 2N Max. Occ: 25 Values: [0 through 25] Record: Subsequent Report

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NUMBER OF PAYMENTS/ADJUSTMENTS - DN79 (NBR. PYMNTS/ADJS) Definition: The number of Weekly Payments/Adjustments segment occurrences. Business Need: A technical processing requirement that specifies the number of variable segments that follow. Revised: 3/11/94 Source: IAIABC Format: 2N Max. Occ: 10 Values: [0 through 10] Record: Subsequent Report NUMBER OF PERMANENT IMPAIRMENTS - DN78 (NBR. PERMANENT IMPAIRMENTS) Definition: The number of Permanent Impairment segment occurrences. Business Need: A technical processing requirement that specifies the number of variable segments that follow. Revised: 6/7/95 Source: IAIABC Format: 2N Max. Occ: 6 Values: [0 through 6] Record: Subsequent Report OCCUPATION DESCRIPTION - DN60 Definition: Business Need: Revised: Source: Format: Record:

Identifies the primary occupation of the employee at the time of the accident or injurious exposure. For claim investigation/loss prevention. 6/7/95 IAIABC 30 A/N First Report

ORIGINAL TRANSMISSION DATE - DN102 Definition: The value obtained from the Date Transmission Sent field of the Header Record of the originating transmission. Business Need: To allow a receiving party the ability to match back to the original batch file for reconciliation purposes. Used in conjunction with the Original Transmission Time field in the acknowledgment process. Revised: 8/19/94 Source: IAIABC Format: CCYYMMDD Record: Transmission Header Record (HD1). ORIGINAL TRANSMISSION TIME - DN103 Definition: The value obtained from the Time Transmission Sent field of the Transmission Header Record of the originating transmission. Business Need: To allow a receiving party the ability to match back to the original batch file for reconciliation purposes. Used in conjunction with the Original Transmission Date field in the acknowledgment process. Revised: 2/15/02 Source: IAIABC Format: HHMMSS Record: Transmission Header Record (HD1). Implementation Note: Use 24 hour military time (00:00:00 through 24:00:00). All zeros in a time field is valid and equivalent to 240000 or 2400. Spaces indicate absence of data.
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PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT - DN96 (PTD/REDUCED EARNINGS/RECOV. AMOUNT) Definition: The amount defined by the Paid To Date/Reduced Earnings/Recoveries Code. Business Need: To meet jurisdictional financial reporting requirements. Revised: 6/7/95 Source: IAIABC Format: $9.2 Record: Subsequent Report PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE - DN95 (PTD/REDUCED EARNINGS/RECOVERIES CODE) Definition: A code that identifies the type of Paid To Date/Reduced Earnings/Recoveries made. Business Need: To meet jurisdiction financial reporting requirements. Revised: 6/7/95 Source: IAIABC Ref.: DCI Section 4 and others to be developed Format: 3 A/N Values: [300|310|320|330|340|350|360|370|380|390|400|420|430|440 600|650|800|810|820|830|840] 300 Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Funeral Expenses Paid to Date Sum of the funeral expenses paid for this claim. DCI Fld 67 Penalties Paid to Date Sum of the penalties paid for this claim. DCI Fld 79 Interest Paid to Date Sum of the interest paid for this claim. IAIABC Employer's Legal Expenses Paid to Date Sum of the employer's legal expenses paid for this claim. DCI Fld 76 Claimant's Legal Expenses Paid to Date Sum of the claimant’s legal expenses paid for this claim. DCI Fld 77 Total Payments to Physicians to Date Sum of services paid to physicians for this claim. DCI Fld 62 Hospital Costs Paid to Date Sum of services paid to hospitals for this claim. DCI Fld 61 Other Medical Paid to Date Sum of medical services not otherwise reported for this claim. DCI Fld 63 Vocational Rehabilitation Evaluation Paid to Date Sum of vocational rehabilitation evaluation services for this claim. DCI Fld 56
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310

320

330

340

350

360

370

380

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390 Term: Def.: Source: 400 Term: Def.: Source: 420 Term: Def.: Source: Term: Def. Source: 440 Term: Def.: Vocational Rehabilitation Education Paid to Date Sum of vocational rehabilitation education payments for this claim. DCI Fld 58 Other Vocational Rehabilitation Paid to Date Sum of vocational rehabilitation services not otherwise reported for this claim. DCI Fld 59 Expert Witness Fees Paid to Date Sum of fees paid to expert witnesses for this claim. DCI Fld 78 Unallocated Prior Indemnity Benefits Paid To Date Sum of prior Indemnity Benefits paid to date that cannot be classified by a specific Payment Adjustment Code for this claim. IAIABC

430

Unallocated Prior Medical Paid To Date Sum of prior Medical paid to date that can not be classified by a specific Paid To Date Code for this claim. Source: IAIABC Implementation Note: Does not include Contract Medical Term: Def.: Source: Term: Def.: Source: Term: Def.: Source: Implementation Note: Pharmaceutical Paid To Date Sum of medication payments for this claim. IAIABC Physical Therapy Paid To Date Sum of physical therapy payments for this claim. IAIABC Actual Reduced Earnings The weekly wages of an employee on restricted duty. IAIABC 601-624 represents sequential weekly actual reduced earnings reported in a single transaction. The 600 represents the first occurrence.

450

460

600-624

650-674

Term: Def.:

Deemed Reduced Earnings The estimated weekly wages an employee would have earned had the employee actually returned to work with physical restrictions. Source: IAIABC Implementation Note: 651-674 represents sequential weekly deemed reduced earnings reported in a single transaction. The 650 represents the first occurrence. Term: Def.: Source: Term: Def.: Source: Special Fund Recovery Sum of monies recovered from special funds for this claim. IAIABC Deductibles Recovery Sum of monies recovered through insured reimbursement of deductible amounts for this claim. IAIABC

800

810

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820 Term: Def.: Source: Term: Def.: Source: 840 Term: Def.: Subrogation Recovery Sum of monies recovered through subrogation for this claim. IAIABC Overpayment Recovery Sum of monies recovered due to overpayment of indemnity, medical or expenses for this claim. IAIABC

830

Unspecified Recovery Sum of monies recovered through salvage, apportionment/ contribution, and all others not otherwise defined for this claim. Source: IAIABC Record: Subsequent Report Implementation Note: To ensure that a claim reflects costs actually incurred, recoveries made under code 830 will be backed out of the appropriate Payment/Adjustment or Paid to Date codes. Recoveries made under codes 800, 810, 820, and 840 will not be backed out of their respective Payment/Adjustment or Paid to Date codes.

PART OF BODY INJURED CODE - DN36 Definition: Business Need: Revised: Source: Format: Values: Record:

The code which corresponds to the part of the body to which the employee sustained injury. Loss prevention management. 6/7/95 DCI Field 24 2 A/N See appendix NCCI Table 7 codes First Report

PAYMENT/ADJUSTMENT CODE - DN85 (PYMNT/ADJ CODE) Definition: A code that identifies the payment or adjustment being made. Business Need: To meet jurisdiction financial reporting requirements. Revi sed: 9/16/94 Source: IAIABC Format: 3 A/N Specific Payment Adjustment Codes: [010|020|021|030|040|050|051|070|080|090|240|410] Compromised Payment Adjustment Codes: [500|501|510|520|524|530|540|550|551|570|580|590]

Comparison Chart:
Specific ------010 020 021 030 040 050 051 070 080 090 240 410 Compromised 500 501 510 520 521 530 540 550 551 570 580 590 524 541 Description Unspecified Medical Fatal Permanent Total Permanent Total Supplemental Permanent Partial Scheduled Permanent Partial Unscheduled Temporary Total Temporary Total Catastrophic Temporary Partial Employers Liability Permanent Partial Disfigurement Employer Paid Vocational Rehabilitation Maintenance

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Payment Adjustment Description Definitions: Unspecified -- Amounts that cannot be assigned to a specific Benefit Type. Medical -- Compromised settlement amount paid to the employee to conclude past, present, and/or future medical exposure. Fatal -- Benefits paid or payable for the death of the claimant resulting from a work -related accident or occupational injury or disease. Permanent Total -- Benefits paid or payable for the loss of or the permanent loss of use of any body part or function which renders the claimant unable to engage in any employment or occupation. Permanent Total Supplemental Payments -- Benefits paid to supplement permanent total benefits. Permanent Partial/Scheduled -- Benefits paid or payable as established by a statutory list (schedule) of payments for certain injuries. The benefit amount is determined by the part of body that was injured subject to limitations set forth in the statute. Includes: Wage Loss Without Impairment -- Florida (Accident Dates of 8/1/79 through 12/31/93) benefits paid or payable for injuries not resulting in permanent disability, but with an impairment rating of at least 1% and post-injury wages of less than 80% of the pre-injury wage. Impairment Income Benefits: -- Paid scheduled Impairment Benefits on Permanent Partial claims. (Florida Accident Dates 1/1/94 and subsequent.) Supplemental Earnings Without Permanent Partial -- Louisiana (Accident Dates of 7/1/83 and subsequent) Benefits paid or payable for injuries which are not covered by permanent partial schedule who suffer wage loss of at least 10%. Scheduled Disabilities -- (Michigan) Benefits paid or payable for injuries which specifically appear on the schedule. Economic Recovery -- Minnesota (Accident Dates of 1/1/84 and subsequent) Benefits paid or payable for permanent partial injuries not covered in the schedule. Permanent Partial/Unscheduled -- Benefits paid or payable for injuries to parts of the body not covered by a schedule. These benefits are payable for the claimant's actual wage loss or reduction in wage earning ability, subject to limitations set forth in the statute. Includes: Supplemental Income Benefits: -- Paid supplemental benefits after the expiration of Scheduled Impairment benefits on Permanent Partial Claims. (Florida Accident Dates 1/1/94 and subsequent.) Supplemental Earnings and Permanent Partial --Louisiana (Accident Dates of 7/1/83 and subsequent) Benefits paid or payable for the anatomical loss of use or 25% loss of physical function of a member in addition to permanent partial benefits. Other Partial Disability -- (Michigan) Benefits paid or payable for injuries not appearing on the schedule.

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Temporary Total -- Benefits paid or payable for the period during which the claimant is unable to perform any work for pay as a result of disability from which that individual can be expected to fully recover and which period precedes the date of maximum medical improvement. Temporary Total Catastrophic Loss Benefits -- Benefits paid for catastrophic injuries. Temporary Partial -- Benefits paid or payable for the period during which the claimant, as a result of a disability from which he/she is expected to fully recover, is unable to perform work for his/her regular pay, but is receiving a reduced rate of pay and which period precedes the date of maximum medical improvement. Employers Liability -- Reports the indemnity loss portion of Employers Liability, DCI Fields #76#79. Permanent Partial/Disfigurement -- Benefits paid or payable for any scarring or cosmetic defect. Includes: Impairment Without Wage Loss -- Florida (Accident Dates of 8/1/79 through 12/31/93) Benefits paid or payable for amputation, loss of 80% or more of vision of either eye after correction, or serious facial or head disfigurement resulting from an injury, not resulting in a Permanent Total award without any wage loss benefits. Permanent Partial Without Supplemental Earnings -- Louisiana (Accident Dates of 7/1/83 and subsequent) Benefits paid or payable for permanent partial injuries without supplemental earnings. Impairment Compensation -- Minnesota (Accident Dates of 1/1/84 and subsequent) Benefits paid or payable for scheduled permanent partial injuries. Employer Paid -- Wages paid by the employer to the claimant during their absence from work. Vocational Rehabilitation Maintenance -- Weekly maintenance benefits paid while the claimant is participating in a vocational rehabilitation program. Record: Subsequent Report PAYMENT/ADJUSTMENT DAYS PAID - DN91 (PYMNT/ADJ DAYS PAID) Definition: The number of days paid for a specific Payment/Adjustment Code. Business Need: To meet jurisdictional financial reporting requirements. Revised: 3/11/94 Source: IAIABC Format: 1N Values: [0 through 6] Record: Subsequent Report Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0".

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PAYMENT/ADJUSTMENT END DATE - DN89 (PYMNT/ADJ END DATE) Definition: For Weekly Benefits: The last date of a benefit period for which benefits were paid. For Adjustments: The last date for which the adjustment is applied. Business Need: To meet jurisdictional financial reporting requirements. Revised: 3/28/94 Source: IAIABC Format: Date Record: Subsequent Report Implementation Note: For Periodic Reports with compromised Payment/Adjustment Code 500, the end date is the date on which the payment was mailed. For other Payment/Adjustment Codes, future End Dates are acceptable. Implementation Note: For 240 Payment/Adjustment Code, if unknown, use Return To Work date. If Return To Work date is unknown, use Maintenance Type Code date. PAYMENT/ADJUSTMENT PAID TO DATE - DN86 (PYMNT/ADJ PAID TO DATE) Definition: The cumulative amount paid for the Payment/Adjustment identified by the associated Payment/Adjustment Code. Business Need: To meet jurisdictional financial reporting requirements. Revised: 3/11/94 Source: IAIABC Format: $9.2 Record: Subsequent Report Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0.00". PAYMENT/ADJUSTMENT START DATE - DN88 (PYMNT/ADJ START DATE) Definition: For Weekly Benefits: The first Start Date of a benefit period for which benefits were paid. For Adjustments: The first date for which the adjustment is applied. Business Need: To meet jurisdictional financial reporting requirements. Revised: 3/11/94 Source: IAIABC Format: Date Record: Subsequent Report Implementation Note: When there are multiple benefit periods for a Payment/Adjustment Code, the Start Date will be reset to the first compensated day for the current benefit period. For periodic reporting, the earliest date for that Payment/Adjustment code which was paid on the claim. Implementation Note: For 240 Payment/Adjustment Code, if unknown, use date disability began.

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PAYMENT/ADJUSTMENT WEEKLY AMOUNT - DN87 (PYMNT/ADJ AMOUNT) Definition: The net weekly rate for the Payment/Adjustment Code being paid as modified by any applicable Benefit Adjustment(s). Business Need: To meet jurisdictional financial reporting requirements. Revised: 2/3/95 Source: IAIABC Format: $9.2 Implementation Note: This amount will equal the weekly rate determined by jurisdiction statute (i.e. Comp Rate) plus or minus any applicable Benefit Adjustment for the corresponding benefit type. This is equal to the gross weekly rate when there are no Benefit Adjustments. Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0.00". PAYMENT/ADJUSTMENT WEEKS PAID - DN90 (PYMNT/ADJ WEEKS PAID) Definition: The number of whole weeks paid for a specific Payment/Adjustment Code. Business Need: To meet jurisdictional financial reporting requirements. Revised: 3/11/94 Source: IAIABC Format: 4N Record: Subsequent Report Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0". PERMANENT IMPAIRMENT BODY PART Definition: Business Need: Revised: Source: Format: Values: Record: CODE - DN83 A code referencing the anatomic classification of the injury. To identify the part(s) of body permanently impaired. 3/11/94 IAIABC Ref.: DCI Fld 24 3 A/N See appendix NCCI Table 7 codes and whole body “99”. Subsequent Report

PERMANENT IMPAIRMENT PERCENT - DN84 Definition: Report the amount of anatomic or functional abnormality or loss which results from the injury and exists after the date of maximum medical improvement. Business Need: To determine benefits. Revised: 3/11/94 Source: IAIABC Format: 3.2 N Record: Subsequent Report POLICY EFFECTIVE DATE - DN29 Definition: Business Need: Revised: Source: Format Record:

The date that the contract/policy became effective. To validate coverage compliance. 6/6/95 IAIABC Ref.: DCI Fld 3 CCYYMMDD First Report

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POLICY EXPIRATION DATE - DN30 Definition: Business Need: Revised: Source: Format: Record: POLICY NUMBER - DN28 Definition: The date that the contract/policy expired. To validate coverage compliance. 6/6/95 IAIABC CCYYMMDD First Report

The number assigned to the contract/policy for that employer or association group. Business Need: Identify contract. Revised: 2/15/02 Source: DCI Field 2 Format: 18 AN Record: First Report Implementation Note: Report the alphanumeric characters used for uniquely identifying the policy. Do NOT report any embedded blanks, marks of punctuation, or special characters.

POSTAL CODE OF INJURY SITE - DN33 Definition:

The postal code that corresponds to the location where the injury occurred. Business Need: To determine the location of the accident. Revised: 3/11/94 Source: IAIABC Ref.: DCI Fld 14 Format: 9 A/N Record: First Report Implementation Note: For United States territories, this will be the U.S. Post Office zip codes.

PRE-EXISTING DISABILITY - DN69 Definition: Business Need: Revised: Source: Format: Values: Record: RECEIVER IDENTIFIER - DN99 Definition:

Identifies the existence of a disability that existed prior to the injury. To identify injuries pertaining to a claim and identify situations of recovery. 3/11/94 IAIABC 1 A/N [Y|N] Subsequent Report

A composite or group level made up of: Receiver FEIN - The primary FEIN of the receiving party; Filler Receiver Postal Code - Postal code of the receiving party. Business Need: To uniquely identify the receiver. Revised: 8/18/94 Source: IAIABC Format: 25 A/N (Receiver FEIN 9 A/N, Filler 7 spaces, Receiver postal code 9 A/N. Record: Transmission Header Record (HD1) Implementation Note: Filler is reserved for possible future use in the event FEIN is not sufficient to uniquely identify the sending party.

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RECORD SEQUENCE NUMBER - DN107 Definition: Identifying control number that must be unique within a transmission. The number is assigned by the originator of a transaction. Business Need: To uniquely identify a transaction in the event trading partners need to reconcile transactions. Revised: 8/22/94 Source: IAIABC Format: 9N Values: 000000000 = Header Error 000000001 thru 999999998 = Detail Record Identifier 999999999 = Trailer Error Record: Acknowledgment-Detail Record (AK1). Implementation Note: Currently assigned by receiver at the time transmission is received. It is assigned sequentially. It is suggested that the sender make a corresponding assignment in their file prior to transmission, although the information cannot be transmitted with current 148/A49 release levels.

REQUEST CODE - DN112 Definition: Business Need: Revised: Source: Format: Values: Record: RETURN TO WORK QUALIFIER - DN71 (RTW QUALIFIER) Definition:

A code used to convey additional information such as the need to follow up or respond manually to a transaction. To have the ability to communicate the need for additional information associated with a transaction electronically. 8/18/94 IAIABC 3 A/N 0 = None 1 = Contact Sender Acknowledgment-Detail Record (AK1)

A code identifying the employee's return to work status, with or without physical restrictions. Business Need: For determining benefit eligibility. For statistical analysis. Revised: 6/7/95 Source: IAIABC Format: 1 A/N Values: 1 - Actual RTW without physical restrictions 2 - Actual RTW with physical restrictions 5 - Released RTW without physical restrictions 6 - Released to RTW with physical restrictions Record: Subsequent Report Implementation Note: The qualifier code must be updated to reflect: 1) the proper value associated with an updated Date of Release/Return to Work OR 2) a change occurring in the code values

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SALARY CONTINUED INDICATOR - DN67 Definition: The employer has paid or is paying the employee's salary in lieu of compensation during an absence caused by a work-related injury. Business Need: To assist in determining the date benefits should commence. Revised: 6/7/94 Source: IAIABC Format: 1 A/N Values: [Y|N] Record: First Report Subsequent Report Implementation Note: If the employer is reimbursed the full statutory amount for the benefit period paid by the employer, then the indicator should be re-set to "N". SELF INSURED INDICATOR - DN24 Definition:

Business Need: Revised: Source: Format: Values: Record: SENDER IDENTIFIER - DN98 Definition:

An indicator that identifies the employer as one who retains the risks arising from their operations and bears the financial responsibility. To identify employers who are financially responsible for the claim. 3/11/94 IAIABC 1 A/N [Y|N] First Report

Composite or group level code made up of: Sender FEIN - The FEIN of the sending party; Filler Sender Postal code - Postal code of the sending party. Business Need: To identify the sending party. Revised: 8/18/94 Source: IAIABC Format: 25 A/N (Sender FEIN 9 A/N, Filler 7 spaces, Sender postal code 9 A/N. Record: Transmission Header Record (HD1) Implementation Note: Filler is reserved for possible future use in the event FEIN is not sufficient to uniquely identify the sending party.

SOCIAL SECURITY NUMBER - DN42 Definition:

A number assigned by the Social Security Administration used to identify the employee. Business Need: Used to identify the employee. Revised: 6/7/95 Source: DCI Field 10 Format: 9 A/N Record: First Report Subsequent Report Implementation Note: If the Social Security Number is not available, the number to be used will be defined by the jurisdiction.

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TEST/PRODUCTION INDICATOR - DN104 Definition: The Trading Partner's EDI participation status for a specific transaction. Business Need: To communicate whether the batch being transmitted is in a test or production status. Revised: 8/18/94 Source: IAIABC Trading Partner Table Format: 6 A/N Values: T = Test (pilot/parallel or test) P = Production Record: Transmission Header Record (HD1) THIRD PARTY ADMINISTRATOR FEIN - DN8 Definition: The FEIN of the Third Party Administrator (TPA), Independent Adjuster, contracted to adjust the claim on behalf of the Carrier or Self Insured. Business Need: To provide means of contacting the contracted adjuster. Revised: 6/7/95 Source: IAIABC Format: 9 A/N Record: First Report Subsequent Report Acknowledgment Detail Record (AK1) Implementation Note: Used only if the Third Party Administrator is processing payments to the employee. THIRD PARTY ADMINISTRATOR NAME - DN9 Definition: The Name of the Third Party Administrator (TPA), Independent Adjuster, contracted to adjust the claim on behalf of the Carrier or Self Insured. Business Need: To provide means of contacting the contracted adjuster. Revised: 3/11/94 Source: IAIABC Format: 30 A/N Record: First Report Implementation Note: Used only if the Third Party Administrator is processing payments to the employee. TIME OF INJURY - DN32 Definition: Business Need: Revised: Source: Format: Record: Implementation Note:

The time at which the accident occurred. To fulfill jurisdictional reporting requirements. 2/15/02 IAIABC HHMM First Report Only a valid time in military format, zeros, or spaces are allowed in time fields. Use 24 hour military time. All zeros in a time field is valid and equivalent to 240000 or 2400. Spaces indicate absence of data. May be left blank for occupational disease or cumulative injury.

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TIME PROCESSED - DN109 Definition: The time that the receiver processed the detail transaction. Together with date processed and a record sequence number, it will uniquely identify a specific acknowledgment detail record. Business Need: Needed for reconciliation. Revised: 8/9/95 Source: IAIABC Format: HHMMSS Record: Acknowledgment Detail Record (AK1) Implementation Note: Only a valid time in military format, zeros, or spaces are allowed in time fields. Use 24 hour military time. All zeros in a time field is valid and equivalent to 240000 or 2400. Spaces indicate absence of data.

TIME TRANSMISSION SENT - DN101 Definition:

The time the sender prepared the batch file for transmission. Together with the Date Transmission Sent will uniquely identify a specific transmission batch. Business Need: Needed for reconciliation. Revised: 8/9/95 Source: IAIABC Format: HHMMSS Record: Transmission Header Record (HD1) Implementation Note: Only a valid time in military format, zeros, or spaces are allowed in time fields. Use 24 hour military time. All zeros in a time field is valid and equivalent to 240000 or 2400. Spaces indicate absence of data

TRANSACTION SET ID - DN1 Definition: Business Need: Revised: Source: Format: Values:

A code that identifies the transaction being sent/received. Data processing. 8/18/94 ANSI 329 3 A/N IAIABC ANSI 148 148 First Report of Injury A49 148 Subsequent/interim/final report AK1 824 Acknowledgment Detail Record HD1 NA Transmission Header Record TR1 NA Transmission Trailer Record Record: First Report Subsequent Report Acknowledgment-Detail Record Transmission Header Record Transmission Trailer Record Implementation Note: The prefix A is used to avoid possible conflicts with future ANSI

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VARIABLE SEGMENT NUMBER - DN117 Definition: A number to identify the occurrence of the variable segment in error and is part of the Error Code. Business Need: For those fields that are part of the variable segment - to identify the occurrence of the variable segment on which an error was detected. Revised: 8/18/94 Source: IAIABC Format: 2 A/N Record: Acknowledgment Detail Record (AK1) Implementation Note: The variable segment number is used to identify which occurrence is in error of a multiple occurrence field. This field is zero for a single occurrence field. WAGE - DN62 Definition: For First Report: The reported employee's pre-injury wage for the Wage Period. For Subsequent Report: The average wage of the employee at the time of injury as calculated by the Claims Administrator or jurisdictional authority for the Wage Period. Business Need: To be used in determining the rate of compensation. Revised: 3/11/94 Source: IAIABC Format: $9.2 Record: First Report Subsequent Report Implementation Note: This amount may include commissions, piecework earnings, and other forms of income converted to a normal scheduled work week, plus the estimated value of lodging, food, laundry and other payments in kind; and concurrent employment earnings, as per jurisdictional requirements. WAGE PERIOD - DN63 Definition: Business Need: Revised: Source: Format:

Record:

A code indicating the time period during which the Wage was earned. To relate earnings amount to earnings period. 3/11/94 IAIABC 2 A/N First Report Values Subsequent Report Values 6 = Daily 1 = Weekly 1 = Weekly 2 = Bi-Weekly 4 = Monthly 4 = Monthly First Report Subsequent Report

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GLOSSARY
RELEASE 1
Revision Date: 2/15/02

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This page is meant to be blank.

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ACKNOWLEDGMENT LEVEL
Definition: For a given transaction set, the receiving trading partner will specify whether they can support acknowledgments for all transactions, only transactions with errors, and/or only transactions that are rejected. It should be noted that providing multiple options indicates that the receiving trading partner is capable of supporting filtered acknowledgments. Options not supported must be removed/crossed-off. 9/25/96

Revised:

ACKNOWLEDGMENT MODE
Definition: For any given transaction set, the receiver will indicate whether they can support electronic, paper or no acknowledgments. Any unsupported option should be removed/crossed-off by the receiving trading partner. 9/25/96

Revised:

ACKNOWLEDGMENT RECORD (AK1)
Definition: A transaction returned as a result of an original report. It contains enough data elements to identify the original transaction and any technical and business issues found with it. 9/25/96

Revised:

ACQUIRED FILE
Definition: Revised: A claim previously administered by a different claim administrator. 6/7/95

ANSI BATCHES
Definition: Revised: A dataset containing transactions formatted according to X12 standards. 9/25/96

ANSI DATA ELEMENT SEPARATOR
Definition: Revised: The character used as a data element separator when transmitting transactions formatted according to X12 standards. 9/25/96

ANSI ISA QUALIFIER, PROD
Definition: Revised: ANSI ID Code Qualifier to be specified in an ISA segment when transmitting production transactions formatted according to X12 standards. 09/25/96

ANSI ISA QUALIFIER, TEST
Definition: Revised: ANSI ID Code Qualifier to be specified in an ISA segment when transmitting test transactions formatted according to X standards. 12 9/25/96

ANSI SEGMENT TERMINATOR
Definition: Revised: The character used as a segment terminator when transmitting transactions formatted according to X12 standards. 9/25/96

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ANSI SUB-ELEMENT SEPARATOR
Definition: Revised: The character used as a sub-element separator when transmitting transactions formatted according to X12 standards. 9/25/96

ANSI VERSION #
Definition: Revised: The ANSI version number used when transmitting transactions formatted according to X12 standards. 9/25/96

APPENDED AK1 OUTBOUND
Definition: Revised: An AK1 record appended with the audit ID from the original transaction the AK1 is responding to. 9/25/96

APPENDED FROI
Definition: Revised: A First Report of Injury record appended with the audit ID of the batch it came in. 9/25/96

APPENDED SROI
Definition: Revised: A Subsequent Report of Injury record appended with the audit ID of the batch it came in. 9/25/96

AUDIT FILE
Definition: Revised: A file containing a log of each batch received. It includes a unique audit ID and all of the batch’s data elements. 9/25/96

BATCH
Definition: A set of records containing one Header, one or more detail transactions and onetrailer records. For ANSI this is equivalent to the transaction contained within ST and SE segments. FROI and SROI cannot be mixed within a batch. 9/25/96

Revised:

BUSINESS CONTACT E-MAIL ID
Definition: Revised: The E-mail address where a Business Contact may be reached. 9/25/96

BUSINESS CONTACT E-MAIL NETWORK
Definition: Revised: The E-mail network where a Business Contact may be reached. 9/25/96

BUSINESS CONTACT FAX
Definition: Revised: The fax number where a Business Contact may be reached. 9/25/96

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BUSINESS CONTACT NAME
Definition: Revised: The name of the Business Contact. 9/25/96

BUSINESS CONTACT PHONE
Definition: Revised: The phone number where a Business Contact may be reached 9/25/96

BUSINESS CONTACT TITLE
Definition: Revised: The title of the Business Contact or the role the contact performs within a given trading partner agreement. 9/25/96

CARRIER
Definition: Revised: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer. 5/26/92

CLAIM ADMINISTRATOR
Definition: Revised: Carrier, third party administrator, state fund, self-insured. 6/7/95

CLAIMANT
Definition: Revised: A person claiming Workers’ Compensation benefits. 7/1/97

COMPROMISED PAYMENT
Definition: Revised: Payment made to limit or end past, present, and/or future liability. 7/1/97

CONCURRENT INDEMNITY BENEFITS
Definition: Revised: Weekly indemnity payments are being made for two or more benefity type codes for a common period of time. 7/1/97

CONTRACT MEDICAL
Definition: Contract medical costs are the actual costs incurred by the carrier under medical contracts with physicians, hospitals, and other which cannot be allocated to a particular claim. 8/9/95

Revised:

DATA ELEMENT
Definition: Revised: A single piece of information e.g. Date of Birth 7/1/97

DENIAL
Definition: Revised: Benefit entitlement of the entire claim or a portion thereof has been rejected. 7/1/97

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DIRECT CONNECT OPTION
Definition: If data can be transmitted directly to the receiving trading partners computer, the receiving trading partner must provide (or have available upon request) the technical specifications needed to support this media type. All pertinent data (telephone numbers, baud rates, communications protocol, transmission window, etc.) must be available for the sender to develop the send process if the direct connect option is selected. 9/25/96

Revised:

DOWNLOADED ANSI BATCHES
Definition: Revised: A dataset containing transactions formatted according to X12 standards, after it has been downloaded from an electronic medium into the receiver s system. 9/25/96

DOWNLOADED FLAT FILE BATCHES
Definition: A dataset containing transactions formatted according to IAIABC proprietary standards, after it has been downloaded from an electronic medium into the receivers system. 9/25/96

Revised:

EDI ACTIVITY LOG
Definition: A file maintained by a sender to keep track of the history of electronic transactions submitted for a claim. It is used in combination with the Event Table to determine what transactions need to be submitted. 9/25/96

Revised:

EDIT MATRIX
Definition: Revised: Identifies edits to be applied to each data element. Senders will apply them before submitting a transaction and receivers will confirm at reception time. 9/25/96

ELECTRONIC MAILBOX ACCT ID, PROD
Definition: Revised: The account ID used by a trading partner to interchange production transactions, when using a Value Added Network (VAN). 9/25/96

ELECTRONIC MAILBOX ACCT ID, TEST
Definition: Revised: The account ID used by a trading partner to interchange test transactions, when using a Value Added Network (VAN). 9/25/96

ELECTRONIC MAILBOX MESSAGE CLASS, PROD
Definition: Provides a means to cluster similar production files in different compartments within a partner’s VAN account ID. SPECIALNOTE: Message Class is not recommended for usage because it is not a feature standard to all commercial VANs. If the Receiver allows usage, this information must be coordinated between both trading partners. 9/25/96

Revised:

ELECTRONIC MAILBOX MESSAGE CLASS, TEST
Definition: Provides a means to cluster similar test files in different compartments within a partner’s VAN account ID. SPECIAL NOTE: Message Class is not recommended for usage because it is not a feature standard to all commercial VANs. If the Receiver allows usage, this information must be coordinated between both trading partners. 9/25/96

Revised:

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ELECTRONIC MAILBOX NETWORK
Definition: Revised: The name of the Value Added Network service through which data will be electronically interchanged. 9/25/96

ELECTRONIC MAILBOX USER ID, PROD
Definition: Revised: The user ID specified by a trading partner to interchange production transactions, when using a Value Added Network (VAN). 9/25/96

ELECTRONIC MAILBOX USER ID, TEST
Definition: Revised: The user ID specified by a trading partner to interchange test transactions, when using a Value Added Network (VAN). 9/25/96

ELEMENT REQUIREMENT TABLE
Definition: Revised: A receiver specific list of requirement codes for each data element depending on the Maintenance Type Code. 9/25/96

EMPLOYEE
Definition: Revised: A person receiving remuneration for their services. 5/26/92

EMPLOYER
Definition: Revised: POC: any entity (e.g. d/b/a, AKA, TA etc.) of the insured. Multiple entities can exist for an insured. 7/3/95

EVENT TABLE
Definition: Revised: A receiver specific table, which identifies the conditions which trigger a report and the timeliness requirements to do it. 9/25/96

EXISTING CLAIMS DATA
Definition: Revised: Data extracted from the partner s specific application. Data will be used to validate incoming transactions or to build outgoing transactions. 9/25/96

FEIN
Definition: Revised: Federal Employers Identification Number. Corporation/Business US Federal Tax ID. Individual’s US Social Security Number. 7/4/92

FIXED LENGTH ANSI
Definition: Revised: A translated X12 file. A fixed length ANSI file contains one segment per record and does not contain separators and delimiters. 9/25/96

FLAT FILE BATCHES
Definition: Revised: A dataset containing transactions formatted according to IAIABC proprietary standards. 9/25/96

FLAT FILE RECORD DELIMITER
Definition: Revised: The character used to physically indicate end of record when submitting transactions formatted according to IAIABC proprietary standards. 9/25/96
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FLAT FILE RELEASE #
Definition: Revised: The release number used when transmitting transactions formatted according to the IAIABC proprietary standards. 9/25/96

FOLLOW-UP FORM
Definition: Revised: The hard-copy form, pamphlet, or form number, that is required to be sent out at the time an EDI transaction is submitted. 9/25/96

FOLLOW-UP RECEIVER
Definition: Revised: A code (from a valid code list) to identify the receiver of a Follow-Up Form. 9/25/96

FORMATS
Definition: The technical method used to exchange information, e.g., IAIABC Flat & Hard Copy, WCPOLS, ANSI X12. The business requirements remain constant. The technology is different. Refer to the Section 6 Dictionary for format explanations. 6/7/95

Revised:

FROI
Definition: Revised: First Report of Injury. A report required by a Jurisdiction to communicate that an onthe-job incident has occurred. 9/25/96

FUNCTIONAL 997-IN
Definition: Revised: Functional Response to a sending trading partners receipt of an ANSI transaction. 9/25/96

FUNCTIONAL 997-OUT
Definition: Revised: A Receiving trading partner’s functional response to receipt of an ANSI transaction. 9/25/96

HEADER RECORD (HD1)
Definition: Purpose: Note: Revised: The record that precedes each batch. This and the trailer record are an envelope that surround a batch of transactions. To uniquely identify a sender, as well as the date/time a batch is prepared and the transaction set contained within the batch. For ANSI files, the header record fields are mapped out of the BGN, ISA, GS and ST segments as described in the ANSI 148-implementation guide. 9/25/96

IMPLEMENTATION DATE, “FROM”
Definition: Revised: The effective begin date of the production level indicator for a trading partner. 9/25/96

IMPLEMENTAT ION DATE, “THRU”
Definition: Revised: The effective end date of the production level indicator for a trading partner. 9/25/96

IMPLEMENTATION GUIDE
Definition: User friendly specifications issued by an industry organization such as the IAIABC. Sets the objectives and parameters of Trading Partner Agreements. May also be exchanged between partners for their unique requirements, e.g. Employer/Carrier. 6/7/95

Revised:

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INDEMNITY BENEFITS
Definition: Benefits paid to the employee, employee's dependent, or jurisdiction Fund, for wage replacement, permanent partial impairment, vocational rehabilitation maintenance, or dependency benefits. Indemnity Benefit Code Table: 010, 020, 021, 030, 040, 050, 051, 070, 090, 240, 410, 500, 510, 520, 521, 524, 530, 540, 541, 550, 551, 570, 590 6/7/95

Revised:

INDEPENDENT ADJUSTER
Definition: Revised: Third party administrator (TPA). 5/26/92

INJURY BATCH
Definition: Revised: A group of like injury transactions. The individual transactions comprise an injury batch. 9/25/96

INJURY TRANSACTION
Definition: Revised: An individual injury report. 9/25/96

MAINTENANCE TYPE CODE HIERARCHICAL STRUCTURE
Definition: Revised: Hierarchy to be used when submitting multiple MTC s on the same claim in one day. New Element 11/23/93

MTC HIERARCHICAL STRUCTURE OF USE
First Report 01 04 00 CO 02 Subsequent Report VE FS CD IP *Sx - RB* RE CB CA CO 02 PY FN A code higher on the list will take precedence over a lower code. Locate the “MTC’s” on the above chart. Use the topmost MTC. For example, if a 00 (original) first report and a 01 (cancel) were filed on the same day, the 01 would take precedence. *Sx and RB can be filed together with the same transmission set date. MTC 04 for the Subsequent Report can be filed in conjunction with all other Subsequent MTC’s. The 04 MTC on the Sub will indicate a denial of only part of a claim. If a Sub report has been transmitted, a 04 MTC on the first report would be filed to deny a claim in its entirety.

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MASTER TRADING PARTNER FEIN
Definition: The Federal Employer’s Identification Number of your business entity. This, along with the 9-position postal code (Zip+4) in the trading partner address field will be used to identify a unique trading partner. 9/25/96

Revised:

MASTER TRADING PARTNER MAILING ADDRESS
Definition: The mailing address used to receive deliveries via the U.S. Postal Service for your business entity. This should be the mailing address that would be used to receive materials pertaining to this trading partner agreement. 9/25/96

Revised:

MASTER TRADING PARTNER NAME
Definition: Revised: The name of the business entity corresponding with the Master FEIN. 9/25/96

MASTER TRADING PARTNER PHYSICAL ADDRESS
Definition: The street address of the physical location of your business entity. It will represent where materials may be received regarding “this” trading partner agreement if using a delivery service other than the U.S. Postal Service. 9/25/96

Revised:

PAYMENT ADJUSTMENT ELEMENT REQUIREMENT TABLE
Definition: Revised: A table that supplements the Element Requirement table. It supports the documentation of the differences in reporting requirements based on payment type. 9/25/96

PERIODIC QUALIFIER
Definition: Revised: Value: Q1, Q2 Q1 O C E Q2 I M E N STATUS If Open During Period If Closed During Period Either Open or Closed During Period ACTIVITY If Indemnity payments were made If Medical payments were made If Either Medical or Indemnity payments were made No payments/activity has occurred. Code values that describe the types of claims that are required to be reported periodically (e.g. open claims, closed claims). 9/25/96

PILOT/PARALLEL
Definition: Dual reporting (current/IAIABC EDI standards) Production data (real claims) Loaded to test/production system IAIABC Data does not yet satisfy receiver’s reporting requirements Temporary as defined by trading partners with Production as the goal. 9/25/96

Revised:

PRODUCTION
Definition: A trading Partner is sending Production Data (real claims). The data is loaded to jurisdiction production system No dual (paper/EDI) reporting to receiver from sender. IAIABC data satisfies receiver’s reporting requirements. 9/25/96
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PRODUCTION LEVEL INDICATOR
Definition: Reflects an EDI participation status for a specific transaction. It indicates whether the transaction being sent is being targeted to a receivers production or test system. Transactions performed while under parallel status should have the test indicator set. TECHNICAL NOTE: This flag is set at the batch header level in the HD1. Therefore, all transactions within a batch must be at the same production level. 9/25/96

Revised:

PROFILE ID
Definition: A free-form field used to uniquely identify a given profile between any given pair of trading partners. This field becomes critical when more than one profile exists between a given pair of trading partners. It is used for reference purposes. 9/25/96

Revised:

PTD
Definition: Revised: Paid to date 6/7/95

RECEIVER NAME
Definition: Revised: The name of the business entity corresponding with the Master FEIN. 9/25/96

RECONCILED ACK TRANSACTION
Definition: An appended acknowledgment transaction that has been reconciled against the EDI Activity Log. The EDI Activity Log contains the original transmissions with the Date/Time original transaction sent and record sequence number. 9/25/96

Revised:

RECONCILIATION ERROR REPORT
Definition: Revi sed: A file containing the acknowledgment transactions that were unable to be reconciled with the EDI Activity Log. 9/25/96

RECORDS/TRANSACTIONS
Definition: A group of Data Elements that satisfy a specific business requirement, e.g. 1st Report, Initial Payment, purchase order, medical bill.

RECOVERIES
Definition: Revised: Monies brought into a claim from external sources. 7/92

REDUCED EARNINGS
Definition: Revised: The actual or deemed weekly earnings of an employee who has returned to work with employment restrictions that may result in reduced earnings. 6/7/95

REGULATORY/REPORTING AGENCY
Definition: Revised: Jurisdiction, OSHA, State Agency, etc. 7/92

RELEASE/VERSION
Definition: Revised: A snapshot of EDI specifications at a given point in time to document development work and/or referenced by Tutorial or Implementation Guide as prescribed usage. 6/7/95

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REPORT DUE CRITERIA
Definition: Revised: The criteria that determines the latest date that a report must be completed and submitted for a specific trigger to be considered timely. 9/25/96

REPORT DUE VALUE
Definition: Revised: A value that is used to modify or define a Report Due Criteria. 9/25/96

REPORT LIMIT NUMBER
Definition: Revised: When present, this value reflects the maximum number of periodic reports required. 9/25/96

REPORT REQUIREMENT CRITERIA
Definition: Criteria used in conjunction with Report Requirement Effective Date (From and Thru), to determine whether the corresponding event requirements are applicable for a particular claim. An example of Report Requirement Criterion is Date of Injury, where different events may apply depending on its value; this is where the From and Thru dates come into play to identify the specific event which applies to a claim. 9/25/96

Revised:

REPORT REQUIREMENT EFFECTIVE DATE, FROM
Definition: Revised: The first date that a claim meeting the Report Requirement Criteria will be reported for a specific report trigger. 9/25/96

REPORT REQUIREMENT EFFECTIVE DATE, THRU
Definition: Revi sed: The last date that a claim meeting the Report Requirement Criteria will be reported for a specific report trigger. 9/25/96

REPORT TRIGGER CRITERIA
Definition: Criteria used in conjunction with Report Trigger Value to determine if an event must be triggered for a claim covered according to the Report Requirement Criteria, and Report Requirement Effective Dates. If multiple conditions can independently trigger an event, then each condition must be listed separately. An example of Report Requirement Criterion is Indemnity Benefits Paid, and when associated with the corresponding Report Trigger Value will determine whether a report must be triggered for a particular claim. 9/25/96

Revised:

REPORT TRIGGER VALUE
Definition: Revised: Used in conjunction with report Trigger Criteria, it determines whether a report must be triggered. 9/25/96

SELF INSURED
Definition: A jurisdictional approved or acknowledged employer, group fund, or association assuming financial risk and responsibility for their employees' Workers' Compensation claims. 9/16/94

Revised:

SENDER NAME
Definition: Revised: The business name of the sending party 9/25/96

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SORTED FROI
Definition: A dataset containing First Report of Injury transactions sorted in such a way to efficiently use the Trading Partner tables. The particular order will depend on the specific partner system design. 9/25/96

Revised:

SORTED SROI
Definition: A dataset containing Subsequent Report of Injury transactions sorted in such a way to efficiently use the Trading Partner tables. The particular order will depend on the specific partner system design. 9/25/96

Revised:

SROI
Definition: Revised: Subsequent Report of Injury. A report required by a Jurisdiction to communicate information related to workers’ compensation payments. 9/25/96

SUSPENSION
Definition: Revised: Indemnity benefits payments have been interrupted/terminated due to associated circumstances. 7/17/92

TECHNICAL CONTACT E-MAIL ID
Definition: Revised: The E-mail address where a Technical Contact may be reached. 9/25/96

TECHNICAL CONTACT E-MAIL NETWORK
Definition: Revised: The E-mail network where a Technical Contact may be reached. 9/25/96

TECHNICAL CONTACT FAX
Definition: Revised: The fax number where a Technical contact may be reached 9/25/96

TECHNICAL CONTACT NAME
Definition: Revised: The name of the Technical Contact 9/25/96

TECHNICAL CONTA PHONE CT
Definition: Revised: The phone number where a Technical Contact may be reached 9/25/96

TECHNICAL CONTACT TITLE
Definition: Revised: The title of the Technical Contact or the role the contact performs within a given trading partner agreement. 9/25/96

TEST
Definition: - Sending production/test data. - May not involve others outside of your organization. - No link between current receiver reporting requirements and IAIABC data. - Will likely not load to production. - Trading Partner requirements may not have been established. - To move to pilot/parallel or production is the goal. 8/9/95

Revised:

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THIRD PART ADMINISTRATOR
Definition: Revised: A business entity providing claim services on behalf of the carrier, or self insured. 5/26/92

TRADING PARTNER AGREEMENT
Definition: A set of expectations, responses, between two entities exchanging data electronically: e.g. what transactions to send, what format to use, what data elements to include. when, where to send it, testing to be performed, etc. 6/7/95

Revised:

TRADING PARTNER PROFILE
Definition: A form to uniquely identify a trading partner and contact information. Each member in a partnership will fill out the information as it pertains to them and then exchange it with their trading partner(s). 9/25/96

Revised:

TRADING PARTNER TYPE
Definition: Revised: The business function a given trading partner performs within a given agreement. Most common functions are listed on the form itself. If other, please specify. 9/25/96

TRAILER RECORD (TR1)
Definition: Revised: A record designed by the IAIABC to designate the end of a batch of transactions and to provide with a count of records contained within the batch. 9/25/96

TRANSACTION SET ID
Definition: Revised: A code that identifies the transaction being sent/received. 9/25/96

TRANSMISSION
Definition: Revised: Consists of one or more batches sent or received during a communication session. 9/25/96

TRANSMISSION FREQUENCIES
Definition: All frequencies the receiving trading partner will accept transmission for the transaction sets identified within a Transmission Profile. Frequencies that cannot be supported by the receiving trading partner should be removed/crossed-off the list. 9/25/96

Revised:

TRANSMISSION PROFILE
Definition: A form used to communicate all allowable options the receiver of Workers Compensation data will provide to a sender. The receiver is responsible for providing the information on the first page of this form, indicating all their requirements, and, where applicable, the supported options from which a sender can select. The sender will then complete page 2 of this form providing their data in the allotted spaces, and indicating their selections where the receiver provides choices. This information is then returned to the receiver 9/25/96

Revised:

TRANSLATORS
Definition: An application (Software) that translates information between your system and the format you send or receive. IAIABC and WCPOLS translators are typically self developed. ANSI translators are typically off the shelf solutions that are easily upgradeable and can process several versions. 6/7/95

Revised:

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TUTORIAL
Definition: Revised: A broad interpretation of an implementation guide used to express the general intentions of the developers, e.g., align use for several lines of business. 6/7/95

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APPENDIX

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285

PART OF BODY CODE

Simple data element/code references: 1270/PB 1460/ Source: ASWG (Advisory Statistical Work Group); code list dated 1/16/98 Available from: National Council on Compensation Insurance Products and Services 901 Peninsula Corporate Circle Boca Raton FL 33487 Abstract The publication describes parts of body. The part of body affected classification identifies the part of the injured person's body directly affected by the nature of injury or illness.

TABLE 7: PART OF BODY CODES
I. HEAD 10 Multiple Head Injury – any combination of below parts 11 Skull 12 Brain 13 Ear(s) – includes: hearing, inside eardrum 14 Eye(s) – includes: optic nerves, vision, eyelids 15 Nose – includes: nasal passage, sinus, sense of smell 16 Teeth 17 Mouth – includes: lips, tongue, throat, taste 18 Soft Tissue 19 Facial Bones – includes jaw II. NECK 20 Multiple Neck Injury – any combination of below parts, excluding hands and wrists combined 21 Vertebrae – includes: spinal column bone, “cervical segment” 22 Disc – includes spinal column cartilage, “cervical segment” 23 Spinal Cord – includes: nerve tissue, “cervical segment” 24 Larynx – includes: cartilage and vocal cords 25 Soft Tissue – other than larynx or trachea 26 Trachea III. UPPER EXTREMITIES 30 Multiple Upper Extremities – any combination of below parts, excluding hands and wrists combined 31 Upper Arm – Humerus and corresponding muscles, excluding clavicle and scapula 32 Elbow – radial head 33 Lower Arm – forearm – radius, ulna, and corresponding muscles 34 Wrist – carpals and corresponding muscles 35 Hand – metacarpals and corresponding muscles (excluding wrist or fingers) 36 Finger(s) – other than thumb and corresponding muscles 37 Thumb 38 Shoulder(s) – armpit, rotator cuff, trapezius, clavicle, scapula 39 Wrist(s) and Hands(s)

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IV. TRUNK 40 Multiple Trunk – any combination of below parts 41 Upper Back Area (Thoracic Area) – upper back muscles, excluding vertebrae, disc, spinal cord 42 Low Back Area (Lumbar Area and Lumbo-Sacral) – lower back muscles, excluding sacrum, coccyx, pelvis, vertebrae, disc, spinal cord 43 Disc – spinal column cartilage other than cervical segment 44 Chest – including Ribs, Sternum and soft tissue 45 Sacrum and Coccyx – final nine vertebrae - fused 46 Pelvis 47 Spinal Cord – nerve tissue other than cervical segment 48 Internal Organs – other than heart and lungs 49 Heart 60 Lungs 61 Abdomen Including Groin – excluding injury to internal organs 62 Buttocks – soft tissue 63 Lumbar and/or Sacral Vertebrae (Vertebrae NOC Trunk) – bone portion of the spinal column V. LOWER EXTREMITIES 50 Multiple Lower Extremities – any combination of below parts 51 Hip 52 Upper Leg – femur and corresponding muscles 53 Knee - patella 54 Lower Leg – tibia, fibula, and corresponding muscles 55 Ankle - tarsals 56 Foot – metatarsals, heel, Achilles tendon and corresponding muscles (excluding ankle or toes) 57 Toe(s) 58 Great Toe VI. MULTIPLE BODY PARTS 64 Artificial Appliance – braces, etc. 65 Insufficient Info to Properly Identify – Unclassified – insufficient information to identify part affected 66 No Physical Injury – mental disorder 90 Multiple Body Parts (including body systems and body parts) – applies when more than one major body part has been affected such as an arm and a leg and multiple internal organs 91 Body Systems and Multiple Body Systems – applies to the functioning of an entire body system that has been affected without spedific injury to any other part, as in the case of poisoning, corrosive action, inflammation affecting internal organs, damage to nerve centers, etc. Does NOT apply when the systemic damage results from an external injury affecting an external part, such as a back injury which includes damage to the nerves of the spinal cord.

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SECTION 6 284 NATURE OF INJURY CODE

Simple data element/code references: 1270/NI 1463/Source: ASWG (Advisory Statistical Work Group); code list dated 1/16/98 Available from: National Council on Compensation Insurance Products and Services 901 Peninsula Corporate Circle Boca Raton FL 33487 Abstract The publication describes nature of injury. The nature of injury or illness classification identifies the injury or illness in terms of its principal characteristics. Reprinted with permission.

TABLE 8: NATURE OF INJURY CODES
I. SPECIFIC INJURY 01 No Physical Injury – i.e. glasses, contact lenses, artificial appliance, replacement of artificial appliance 02 Amputation – cut off extremity, digit, protruding part of body, usually by surgery, i.e. leg, arm 03 Angina Pectoris – chest pain 04 Burn – (heat) burns or scald: the effect of contact with hot substances (chemical) burns: tissue damage resulting from the corrosive action of chemicals, fumes, etc. (acids, alkalis) 07 Concussion – brain, cerebral 10 Contusion – bruise – intact skin surface; hematoma 13 Crushing – to grind, pound, or break into small bits 16 Dislocation – pinched nerve, slipped/ruptured disc, herniated disc, sciatica, complete tear, H.P.subluxation, MD dislocation 19 Electric Shock - electrocution 22 Enucleation – removal of organ or tumor 25 Foreign Body 28 Fracture – breaking of bone or cartilage 30 Freezing – frostbite and other effects of exposure to low temperature 31 Hearing Loss or Impairment – traumatic only: a separate injury, not the sequella of another injury 32 Heat Prostration – heat stroke, sun stroke, heat exhaustion, heat cramps and other effects of environmental heat; does not include sunburn 34 Hernia – the abnormal protrusion of an organ or part through the containing wall of its cavity 36 Infection – the invasion of a host by organisms such as baceria, fungi, viruses, protozoa or insects, with or without manifest disease 37 Inflammation – the reaction of tissue to injury characterized clinically by heat, swelling, redness, and pain 40 Laceration – cuts, scratches, abrasions, superficial wounds, calluses, wound by tearing 41 Myocardial Infarction - heart attack, heart conditions, hypertension; the inadequate blood flow to the muscular tissue of the heart 42 Poisoning – General (Not OD or Cumulative Injury) – a systemic morbid condition resulting from the inhalation, ingestion or skin absorption of a toxic substance affecting the metabolic system, the nervous system, the circulatory system, the digestive system, the respiratory system, the excretory system, the musculoskeletal system, etc.; includes chemical or drug poisoning, metal poisoning, organic diseases and venomous reptile and insect bites; does NOT include effects of radiation, pneumoconiosis, corrosive effects of chemicals, skin surface irritations, septicemia, or infected wounds 43 Puncture – a hole made by the piercing or a pointed instrument 46 Rupture 47 Severance – to separate, divide, or take off 49 Sprain – internal derangement; a trauma or wrenching of a joint, producing pain and disability depending on degree of injury to ligaments

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52 53 54 55 58 59 Strain – internal derangement; the trauma to the muscle or musculotendinous unit from violent contraction or excessive forcible stretch Syncope – swooning, fainting, passing out; no other injury Asphyxiation – strangulation, drowning Vascular - cerebrovascular and other conditions of circulatory systems NOC, excludes heart and hemorrhoids; includes strokes, varicose veins – non-toxic Vision Loss All Other Specific Injuries, NOC

II. OCCUPATIONAL DISEASE OR CUMULATIVE INJURY 60 Dust Disease NOC (All other Pneumoconiosis) 61 Asbestosis – lung disease; a form of pneumoconiosis, resulting from protracted inhalation of asbestos particles 62 Black Lung – the chronic lung disease or pneumoconiosis found in coal miners 63 Byssinosis – the pneumoconiosis of cotton, flax, and hemp workers 64 Silicosis – pneumoconiosis resulting from inhalation of silica (quartz) dust 65 Respiratory Disorders (Gases, Fumes, Chemicals, etc.) 66 Poisoning – Chemical (Other than Metals) 67 Poisoning – Metal – man-made 68 Dermatitis – rash, skin, or tissue inflammation including boils, etc.: generally resulting from direct contact with irritants or sensitizing chemicals such as drugs, oils, biologic agents, plants, woods, or metals which may be in the form of solids, pastes, liquids or vapors and which may be contacted in the pure state or in compounds or in combination with other materials; do NOT include skin tissue damage resulting from corrosive action of chemicals, burns from contact with hot substances, effects of exposure to radiation, effects of exposure to low temperatures or inflammation or irritation resulting from friction or impact 69 Mental Disorder – a clinically significant behavioral or psychological syndrome or pattern typically associated with either a distressing symptom or impairment of function, i.e. acute anxiety, neurosis, stress, non-toxic depression 70 Radiation – all forms of damage to tissue, bones or body fluids produced by exposure to radiation 71 All Other Occupational Disease Injury NOC 72 Loss of Hearing 73 Contagious Disease 74 Cancer 75 AIDS 76 VDT-Related Disease – video display terminal disease other than carpal tunnel syndrome 77 Mental Stress 78 Carpal Tunnel Syndrome – soreness, tenderness and weakness of the muscles of the thumb caused by pressure on the median nerve at the point where it goes through the carpal tunnel of the wrist. May involve damage to the hands, wrists, forearms, elbow and shoulders. May also include ganglion cysts in the wrist area. 80 All Other Cumulative Injuries, NOC III. MULTIPLE INJURIES 90 Multiple Physical Injuries Only 91 Multiple Injuries Including Both Physical and Psychological

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SECTION 6 281 CAUSE OF INJURY CODE

Simple data element/code references: 1270/CN 1461/Source: ASWG (Advisory Statistical Work Group); code list dated 1/16/98 Available from: National Council on Compensation Insurance Products and Services 901 Peninsula Corporate Circle Boca Raton FL 33487 Abstract The publication describes cause of injury. The code categorizes the object or activity from which the injury was inflicted, e.g. chemical, hand tool, lifting. Reprinted with permission.

TABLE 9: CAUSE OF INJURY CODES
I. BURN OR SCALD-HEAT OR COLD EXPOSURE 01 Chemicals 02 Hot Object or Substances 03 Temperature Extremes 04 Fire or Flame 05 Steam or Hot Fluids 06 Dust, Gases, Fumes or Vapors 07 Welding Operations 08 Radiation 09 Contact With, NOC 11 Cold Objects or Substances 14 Abnormal Air Pressure 84 Electrical Current II. CAUGHT IN, UNDER, OR BETWEEN 10 Machine or Machinery 12 Object Handled 13 Caught In, Under, or Between, NOC 20 Collapsing Materials (Slides of Earth) – either man made or natural III. CUT, PUNCTURE, SCRAPE, INJURED BY 15 Broken Glass 16 Hand Tool, Utensil; Not Powered 17 Object Being Lifted or Handled 18 Powered Hand Tool, Appliance 19 Cut, Puncture, Scrape, NOC IV. FALL, SLIP OR TRIP INJURY 25 From Different Level (Elevation) – off wall, catwalk, bridge, etc. 26 From Ladder or Scaffolding 27 From Liquid or Grease Spills 28 Into Openings – shafts, excavations, floor openings, etc. 29 On Same Level 30 Slipped, Did Not Fall 31 Fall, Slip, Trip, NOC 32 On Ice or Snow 33 On Stairs

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V. MOTOR VEHICLE 40 Crash of Water Vehicle 41 Crash of Rail Vehicle 45 Collision or Sideswipe with Another Vehicle – both vehicles in motion 46 Collision with a Fixed Object – standing vehicle or stationary object 47 Crash of Airplane 48 Vehicle Upset – overturned or jackknifed 50 Motor Vehicle, NOC VI. STRAIN OR INJURY BY 52 Continual Noise 53 Twisting 54 Jumping 55 Holding or Carrying 56 Lifting 57 Pushing or Pulling 58 Reaching 59 Using Tool or Machinery 60 Strain or Injury By, NOC 61 Wielding or Throwing 97 Repetitive Motion – carpal tunnel syndrome VII. STRIKING AGAINST OR STEPPING ON 65 Moving Parts of Machine 66 Object Being Lifted or Handled 67 Sanding, Scraping, Cleaning Operation 68 Stationary Object 69 Stepping on Sharp Object 70 Striking Against or Stepping On, NOC VIII. STRUCK OR INJURED BY – INCLUDES KICKED, STABBED, BIT, ETC. 74 Fellow Worker, Patient 75 Falling or Flying Object 76 Hand Tool or Machine in Use 77 Motor Vehicle 78 Moving Parts of Machine 79 Object Being Lifted or Handled 80 Object Handled by Others 81 Struck or Injured, NOC – includes kicked, stabbed, bit, etc. 85 Animal or Insect 86 Explosion or Flare Back IX. RUBBED OR ABRADED BY 94 Repetitive Motion – callous, blister, etc. 95 Rubbed or Abraded, NOC X. MISCELLANEOUS CAUSES 82 Absorption, Ingestion or Inhalation, NOC 87 Foreign Matter (Body) in Eye(s) 89 Person in Act of a Crime – robbery or criminal assault 90 Other Than Physical Cause of Injury 98 Cumulative, NOC – all other 99 Other – Miscellaneous, NOC

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FIPS Codes

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TABLE 1
FIPS Alpha State Codes for the States and the District of Columbia FIPS State Name Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Colombia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Code AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS FIPS State Name Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Code MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

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TABLE 2
FIPS Alpha State Codes for Outlying Areas of the United States, the Freely Associated States, and Trust Territory FIPS Area Name American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands of the U.S. Code AS FM GU MH MP PW PR UM VI Status 1 3 1 3 1 4 1 2 2

Status:
1. Under U.S. sovereignty 2. An aggregation of nine UB territories: Bakers Island, Howland Isla nd, Jarvis, Island, Johnston Atoll, Kingman Reef, Midway Island, Palmyra and Wake Island. Each territory is assigned a FIPS County Code in FIPS PUB 6–3, and may be individually identified through a combination of the FIPS State Code (UM) and the appropriate FIPS County Code. 3. A compact of Free Association with the United States of America is now in full force. It was announced by Presidential proclamation on November 3, 1986. 4. Remains a trust Territory.

TABLE 3
FIPS numeric State codes for the individual minor Outlying Island Territories FIPS Area Name Baker Island Howland Island Jarvis Island Johnston Atoll Kingman Reef Midway Islands Navassa Island Palmyra Atoll Wake Island Code 81 84 86 67 89 71 76 95 79

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