NEW JERSEY EDI IMPLEMENTATION GUIDE

For the reporting of

First (FROI) and Subsequent (SROI) Reports of Injury

Revised on May 15, 2002 for implementation on 7/5/02 COMPENSATION RATING & INSPECTION BUREAU

Table of Contents
Original Release and Revisions .................................................................................................................5 Foreword ......................................................................................................................................................7 EDI Legislation ...........................................................................................................................................7 EDI Implementation Assistance .................................................................................................................8 Required Implementation Date ..................................................................................................................8 Use of Data Received through EDI............................................................................................................9 Acknowledgements....................................................................................................................................9 New Jersey Statutes and Rules Authorizing EDI ...................................................................................10 Important New Jersey Terminology.........................................................................................................21 Organization of Information in this Manual ............................................................................................27 New Jersey Methods of Delivery..............................................................................................................29 Background of State EDI Reporting Standards......................................................................................30 Executive Summary: Managing an EDI Implementation .......................................................................31 Information and Help.................................................................................................................................33 NJCRIB/NJDWC Official Web Pages ......................................................................................................33 NJCRIB Staff Phone & E-Mail..................................................................................................................33 NJCRIB Vendor Help Line and E-mail .....................................................................................................33 NJDWC Contact Information for Business/Law/Regulations Issues and Questions ...............................33 IAIABC Web Page & Phone Number.......................................................................................................33 Frequently Asked Question Document on the NJCRIB Web Page .........................................................33 NCCRIB EDI Reporting Process..............................................................................................................34 Steps to Implement NJCRIB EDI ..............................................................................................................35 NJCRIB EDI Requirements......................................................................................................................35 Specific Changes from the Current Process............................................................................................35 Participant Specific Changes ...................................................................................................................35 Report and Data Requirements................................................................................................................37 First Report of Injury (FROI) ....................................................................................................................37 L&I 1 .....................................................................................................................................................38 WC-1 ....................................................................................................................................................39 WC-2 ....................................................................................................................................................40 First Report of Injury (FROI) - Form IA-1 .............................................................................................41 First Report of Injury (FROI) - Form IA-1 OSHA ..................................................................................42 First Report of Injury (FROI) - Flat File Data Element List ...................................................................43 FROI Crosswalk Table – L&I 1, WC-1, & WC-2 to IAIABC IA-1 and Flat File .....................................45 Subsequent Report of Injury (SROI) ........................................................................................................49 WC-3 ....................................................................................................................................................50 WC-3 (continued) .................................................................................................................................51 New Jersey Benefit Status Letter .........................................................................................................52 Subsequent Report of Injury (SROI) - Flat File Data Element List .......................................................54 SROI Crosswalk Table - NJ Forms to NJ Benefit Status Letter and IAIABC Flat File .........................56 EDI Reports and Related Events..............................................................................................................62 FROI Requirements Table .......................................................................................................................63 SROI Requirements Table.......................................................................................................................66 NJCRIB FROI & SROI Event Tables .......................................................................................................68 Approved EDI Formats..............................................................................................................................69 NJCRIB Data Edits.....................................................................................................................................69 New Jersey Edit Matrix Table ..................................................................................................................70 Conditional Data Elements/Edits .............................................................................................................77

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Acknowledgement and Correction Process .............................................................................................79 Transaction Sequence Requirements .....................................................................................................80 First Reports ............................................................................................................................................80 Subsequent Reports ................................................................................................................................80 Reporting Process Functions and Options ............................................................................................82 Manage State Reporting Requirements...................................................................................................82 Capture State Report Data ......................................................................................................................82 Data Entry Products .............................................................................................................................83 Data Content and Quality Editing Products ..........................................................................................83 Translate Data into or from IAIABC or ANSI formats...............................................................................83 Translator Products ..............................................................................................................................83 Manage Communications/Transmissions................................................................................................84 Communications Management Products .............................................................................................84 VANs ....................................................................................................................................................84 E-Mail Address .....................................................................................................................................84 Manage Acknowledgements, Replacement Reports, and Corrections ...................................................85 Manage Acknowledgements, Replacement Reports, and Corrections Products ................................85 Submitting Options to Consider ...............................................................................................................85 Workers Compensation EDI Reporting Products.................................................................................85 Stand Alone and Server-Based Workers Compensation EDI Reporting Products ..............................86 Web-based Data Entry & EDI Reporting Services ...............................................................................86 Claim EDI Reporting Services..............................................................................................................86 In-house Vs. Vendor Products and Services........................................................................................86 What can an Experienced EDI Vendor or Service Provider do for you?..............................................87 NJCRIB EDI Trading Partner Process .....................................................................................................88 1. Contact the IAIABC/Purchase the IAIABC EDI Release I Implementation Guide................................88 2. Appoint an EDI Coordinator .................................................................................................................88 3. Review NJ EDI Data Requirements and Claim Events that Require Reporting...................................89 4. Examine your NJ WC Business Processes and Determine how NJ EDI Requirements Fit with Them .............................................................................................................................................................89 5. Complete and Return the NJ EDI Trading Partner Agreement ............................................................89 NJCRIB EDI Project Agreement Sample .............................................................................................90 Trading Partner Agreement.................................................................................................................92 6. Complete and Return the Sender’s Trading Partner Profile.................................................................94 New Jersey Trading Partner Profile Application and Confirmation Form .............................................95 Instructions for Completing the New Jersey Trading Partner Profile Application and Confirmation Form .....................................................................................................................................................97 NJCRIB Trading Partner Profile .........................................................................................................100 7. Schedule Changes to your Internal Business Processes and Systems.............................................102 8. Contact the NJCRIB EDI Test Coordinator to Review Schedule Testing ..........................................102 Exemptions from Testing ...................................................................................................................102 Test Status Advisory...........................................................................................................................103 9. Schedule Training and Implementation for your Staff ........................................................................103 NJCRIB Test and Production Process ..................................................................................................104 Purpose..................................................................................................................................................104 NJCRIB Test Schedule – Test Plan Development ................................................................................104 Test Plan Procedures ............................................................................................................................105 Test Overview for WEB Users ...............................................................................................................105 Test Overview for VAN Mailbox Users...................................................................................................106 Step 1: Pretest Requirements ............................................................................................................106 Step 2: Technical Capability Test File ................................................................................................106 Step 3: Business Content Test File ....................................................................................................107 Step 4: NJ Test Completion (First Report of Injury) ...........................................................................109 Step 5: Business Content Test File (Subsequent Reports of Injury) ..................................................109 Step 6: NJ Test Completion (Subsequent Report of Injury) ...............................................................111

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Ongoing Monitoring of Production Status ..............................................................................................111 Communication Requirements ..............................................................................................................112 New Jersey Policy for the Addition of External Connections..............................................................112 Network Requirements.......................................................................................................................113 Application Software Requirements ...................................................................................................113 Processing Requirements ..................................................................................................................114 Restrictions.........................................................................................................................................114 Appendices ..............................................................................................................................................115 Appendix 1 - Transaction Examples ......................................................................................................115 First Report of Injury – Scenario.........................................................................................................115 IAIABC Flat Files ................................................................................................................................115 Acknowledgement to First Report of Injury Scenario .........................................................................118 Subsequent Report of Injury (NJCRIB “Final” or SA Report) Scenario ..............................................119

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Original Release and Revisions
The New Jersey EDI Implementation Guide was originally released on March 15, 2002 and revised last on 5/15/02. Please report any errors for correction to NJCRIB: contact MIS Manager, NJCRIB 60 Park Place, Newark, NJ 07102, Telephone number -- 973-622-6014 Ext. 275. Summary of Changes – 5/15/02: Title Page -- new edition date. Pages 45 - 48 • • • • • • Class Code – Changed to Mandatory to agree with Page 64. Number of Days Worked Per Week – Made Conditional; however required if more than seven days of lost time incurred or if DN 56, Date Disability Began, completed. Postal Code of Injury Site – Made Mandatory to agree with Page 64. Date Disability Began – Condition added—Required if one or more days of lost time incurred or if DN 64 completed. Date Reported to Claims Administrator – Changed from Mandatory to Optional to agree with page 64. Return to Work Date – Information erroneously omitted added for DN 68.

Page 53 – Second Page of Claimant Benefit Letter revised to include Employer Paid Benefit information. Page 54 • • Date Disability Began – Added conditional statement to agree with Page 45. Number of Days Worked Per Week – Added conditional statement to agree with Page 45.

Page 62 – Page Corrected by adding Cancel (01) to the list of MTCs valid in New Jersey. Page 65 – Number of Days Worked Per Week – made conditional; required if DN 56 completed. Page 67 • • • • Benefit Adjustment segment data requirements removed. Variable segment headings and number of occurrences added.

Page 68 -- Event Table A first report of injury, 00 is not required if the work related injury resulted only in first aid. The Denial, 04, First Report of Injury applies only if the denial follows the 00 first report of injury and is due immediately. A claim denied outright before any First Report is filed with no money paid on the claim, does not require either a 00 Original First Report or a 04 Denial. If monies are paid on a denied claim, the 00 followed by the 04 is required. A CO, Correction, is sent only if appropriate to correct the outstanding error. Some errors are not corrected via the CO but through other transactions and may not be reported on a New Jersey claim. For example a CA, Change in Amount, transaction is an EDI standard transaction used to report a correction to wage and weekly rate information. However, the CA is not a valid transaction for NJ claims. An SA is not needed following a Cancel, 01, or following a Denial, 04, if there are no monies paid on the denied claim. Send an SA on a denied claim only if there were monies paid on
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the claim. Send the SA on a denied claim within 26 weeks of the date denied. Pages 70, 71, 74 & 76 -- Edit Matrix • • • • • Error Message 039 added for DN 8, TPA FEIN for FROI if MTC = 01, 02, 04, or CO – DN 8 must be the same as previous 00 or AU, whichever is latest FROI. Error Message 037 removed from DN 29, Policy Effective Date. Error Message 041 removed from DN 88 and DN 89, Payment/Adjustment Start and End Dates (may be future dates). Edits removed for DNs 92, 93 and 94 as requirements for these Data Elements have been deleted. Date Disability Began and Number of Days Worked Per Week are Conditional data elements and are edited differently depending upon whether they appear on the FROI or on the SROI.

Pages 77 and 78 – Edit Conditions – Conditional statements reworked to provide clearer statement for each condition. Page 83 – Revised Data Entry Products to intended use for NJ statutory non-insureds only. Page 92 & 94 – Trading Partner Agreement, Appendix, Item E.1. Added clarification that New Jersey Compensation Rating and Inspection Bureau will not pay or incur any expense for trading partner’s reports or New Jersey’s reports to the Trading Partner. Page 95 – Clarified when to complete Sections D, I, J, and K on the Trading Partner Profile Application Page 97 – 100 -- Clarified Trading Partner Profile Instruction concerning when to provide SC-Web Option, Technical Contact, Vendor Contact and EDI Communication Information.

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Foreword
EDI Legislation
The New Jersey Division of Workers’ Compensation -Department of Labor (NJDWC) and the New Jersey Compensation Rating and Inspection Bureau - Department of Banking and Insurance (NJCRIB) have compiled this New Jersey Implementation Guide (Guide). The Guide provides information necessary to implement legislation signed by the Governor on January 5, 2002. Specifically, the Workers’ Compensation Law - N.J.S.A. 34:15-96 through 99 has been amended to alter the method of submitting First Reports of Injury (FROI) and Subsequent Reports of Injury (SROI). Prior to the new legislation, New Jersey employers were required to report work-related injury or occupational disease information to their insurance carrier or third party administrator and to the NJDWC using FROI paper forms L&I-1 and WC-1. Additionally, insurance carriers or third-party claim administrators (TPA) were also required to report related information to NJDWC via SROI forms WC-2 and WC-3. State workers were required to file form RM-2 to report their claim to their employer and the DWC. Under the new legislation, employers are required to provide FROI and SROI information only to their insurance carrier or third party administrator (TPA). The carrier or TPA is required to submit FROI and SROI information in electronic format to NJCRIB using the International Association of Industrial Accident Boards and Commission’s (IAIABC) Release 1 Electronic Data Interchange (EDI) standards. Additionally the insurance carrier or TPA is required to send a copy of the FROI to the employer using either the electronic format or on the IA-1 paper report form. Additionally, the insurance carrier or TPA is required to send the information on the SROI to the employee using the New Jersey Benefit Status Letter. Similarly, authorized self-insureds and statutory noninsureds not using TPAs also will report directly to NJCRIB in the IAIABC Release 1 EDI format. The date for the transition to EDI submission of FROI and SROI reports will be based on the claim’s date of injury that is July 5, 2002. The legislation, signed by the Governor on January 5, 2002, requires implementation six months following its enactment. Reports required on injuries and occupational disease claims occurring prior to July 5, 2002, must continue to be reported in accordance with the provisions of the statute prior to the changes implemented on July 5, 2002. The paper and electronic formats established by the IAIABC have also been adopted. Accordingly, the present New Jersey L&I-1, RM-2, WC-1, WC-2, and WC-3 paper forms will be replaced by the IAIABC IA1 and the New Jersey Benefit Status Letter forms. No Paper submissions will be accepted by NJDWC or NJCRIB for injuries or occupational disease claims occurring on or after July 5, 2002.

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EDI Implementation Assistance
This Guide, when used in conjunction with the IAIABC Release 1 EDI Implementation Guide, provides the business and technical information to meet NJCRIB EDI submission requirements and includes the data and code requirements for EDI submissions to NJCRIB and the paper counterparts to employers and injured workers. EDI compentency and business data quality content testing is required of each NJCRIB insurance carrier or TPA (Trading Partner) per the NJCRIB Scheduled Test Plan prior to the implementation of production EDI reporting. Approval must be secured from NJCRIB at the end of the testing period and prior to submission of any production EDI transactions. Upon implementation of EDI production transmission, paper filing from employers and carriers will no longer be required. After July 5, 2002, any paper submissions will be deemed noncompliant with the statute. Any carrier or self-insured employer who is not reporting FROI or SROI transactions electronically will be deemed noncompliant with the statute. Electronic submissions of the FROI and SROI reports are those sent electronically either through an inhouse facility, or through an experienced EDI vendor. An experienced EDI vendor is one who is experienced in the IAIABC Release 1 EDI format and who has been sending electronic submission to other states. Please see the “Information and Help” section of this Guide and the IAIABC web site for more details.

Required Implementation Date
As indicated above, the required implementation date is July 5, 2002. However, there are tasks that must be accomplished during the six-month period from the signing of the legislation to the required implementation date. During the six-month period immediately following enactment of legislation, carriers, authorized selfinsureds, statutory noninsureds, and TPAs not yet approved for EDI submissions may file either the New Jersey paper forms or the IAIABC IA-1, included in this guide with NJDWC. No paper forms will be accepted by the NJDWC for accidents occurring on or after July 5, 2002 --all filings for injuries and occupational disease claims must be made via the IAIABC Release 1 electronic formats. Note also that financial penalties may be associated with paper filings to NJCRIB or NJDWC on claims occurring on or after July 5, 2002 and which are beyond the required EDI filing date of July 5, 2002. There are two exceptions to the July 5, 2002 required implementation date: 1. Injuries/occupational disease claims with a Date of Injury prior to July 5, 2002 continue to be reported in accordance to previous NJDWC Reporting requirements. EDI submissions must be made on all injuries or occupational disease claims occurring on or after July 5, 2002. However, early EDI implementation may begin once the EDI trading partner has achieved “production” status at the conclusion of its testing. 2. Injuries/occupational disease claims occurring on or after July 5, 2002 may be exempted from EDI submission if the New Jersey Trading Partner has requested and been granted a variance. Those Trading Partners granted a variance must continue to report via the New Jersey approved paper forms under the terms of the variance to the New Jersey Division of Workers’ Compensation.

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Use of Data Received through EDI
Data received through the New Jersey EDI Reporting is available only to NJCRIB and NJDWC as required by statute. The NJCRIB EDI vendor will assure the data security and confidentiality of the EDI process for the data received by and processed by the vendor.

Acknowledgements
NJDWC and NJCRIB wish to thank all individuals and organizations including the IAIABC, Insurers, Self Insurance Association, NJ Public Entity Fund Administrators, and Third Party Administrators for their input and cooperation.

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New Jersey Statutes and Rules Authorizing EDI

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Important New Jersey Terminology
The following definitions apply to the New Jersey documents and EDI processes described in this Implementation Guide.

ADMINISTRATOR
Synonymous with Claim Administrator.

ANSI ASC X12
American Standards National Institute, Accredited Standards Committee, X12 - is an organization that develops Electronic Data Interchange (EDI) communication standards. The “X” represents “Communications” and “X12” is the twelfth Communication Standards Committee under ASC. This organization is also referred to as “ANSI X12,” “ASC X12” or just “X12” Also, see “X12N.”

AUTHORIZATION PROCESS
The initial step taken by a “reporter” to become a trading partner with the NJCRIB – the completion of the Trading Partner Agreement.

BATCH
A set of records containing one IAIABC Header record, one or more FROI or SROI transactions, and one Trailer record, ANSI equivalent. Any error in the Header record or the Trailer record will cause the rejection of the entire Batch without further transaction level edits being applied. A batch may not mix the 148 (FROI) and the A49 (SROI) transaction types together.

BUSINESS COMPETENCE
A term used to describe whether the data content meets the quality standards of the NJCRIB.

BUSINESS RULES
The business requirements that dictate when a report is created, edited, and when and how transmitted.

CARRIER
An Insurance Company licensed to write Workers’ Compensation and Employer’s Liability Insurance in New Jersey and a member of NJCRIB.

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CLAIM ADMINISTRATOR
The organization that services workers’ compensation claims according to jurisdiction rules. An Administrator may be an Insurer, a Third Party Administrator, an Independent Adjuster, a Selfadministered Self-insured Employer, or Statutory Noninsured.

DATA ELEMENT
A single piece of defined information contained within a transaction (FROI or SROI). Each Data Element is assigned a reference number (DN - Data Number) and includes a definition and format (length and data type) and may if it is a code list acceptable values or reference the code source (for example, Employer FEIN is 15 AN).

DISA
Data Interchange Standards Association - is the Secretariat of X12. DISA manages the EDI standards database, arranges standards development meetings, and provides educational conferences and seminars.

EDI
(EDI) is the computer-to-computer exchange of data or information in a standardized format. In workers’ compensation. EDI refers to the electronic transmission of claims information from Claims Administrators (insurers, self-administered self-insured employers, and third party administrators) to a State Workers’ Compensation Agency.

EDITED DATA
A term used to describe the information on a transaction after it has been processed through the NJCRIB system edits and found to contain valid data.

ELECTRONIC FORMAT
A term used to refer to IAIABC EDI Release 1 format and standards.

ENVIRONMENT
The boundary and conditions under which an application runs or in which files are manipulated or processed.

EVENT
A specific business occurrence, such as the occurrence of an accident, satisfying the waiting period, the initial payment on a claim, suspension, or the reinstatement of a benefit, etc. Such events when entered into a computer system may be defined as a trigger for a jurisdiction-required report.

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EXPERIENCED EDI VENDORS
EDI Vendors who are knowledgable of IAIABC EDI Release 1 standards, and provide services such as EDI report submission products, translation, communications management, report backup, data security, and network servicing (NSP) including high speed transmission lines. Some EDI vendors also provide web-based products. All experienced EDI vendors have demonstrated EDI competence in several IAIABC EDI states.

FROI
First Report of Injury – a group of transactions that occur at the early stages of claim processing that typically report the entities involved, and describes the accident and resulting injuries.

IAIABC
International Association of Industrial Accident Boards and Commissions – an organization, whose members are industrial accident, workers’ compensation, or other governmental bodies as well as associate members comprised of other industry-related organizations and individuals.

IG
An abbreviation used to refer to an Implementation Guide.

MTC
Maintenance Transaction Code – A Code that identifies the purpose of a transaction. The MTC (DN#2) is included in all EDI transactions. For example: Original FROI (00), Semi-Annual (SA). The Semi-Annual Report is the last (final) report due on an open or closed claim.

NJCRIB
New Jersey Department of Banking and Insurance-Compensation Rating & Inspection Bureau, the direct recipient of all EDI claim transmissions on behalf of NJDWC.

NJDWC
New Jersey Division of Workers’ Compensation, the ultimate recipient of all FROI & SROI information. Also, the direct recipient of any hard-copy claim forms prior to the EDI mandate of July 5, 2002.

PRODUCTION (STATUS)
A designation that a Trading Partner has completed all EDI implementation testing satisfactorily as determined by the NJCRIB EDI Test Coordinator, and who may submit electronically if approved prior to July 5, 2002 and must report all claims electronically from July 5, 2002 forward.

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RAW DATA
Refers to the transaction and its contents as it is received from a sender by the NJCRIB and before the data is subjected to the NJCRIB EDI System’s automated edits.

RECEIVER
See NJCRIB.

REPORTER
The entity required by law to file or may be allowed by law or regulation to file for itself or on behalf of customers or clients. In New Jersey, this is the Trading Partner.

SELF INSURED
An employer authorized by the Commissioner of Banking & Insurance to self-insure its obligations under the New Jersey Law (N.J.S.A. 34-15-77).

SENDER
An entity that forwards the Trading Partner’s information in the IAIABC EDI Release 1 format to and receives EDI acknowledgments from NJCRIB. This entity is required to complete the Trading Partner Profile.

SROI
Subsequent Report of Injury – a group of transactions that report claim processing changes to, or current totals of benefits paid on a claim.

STATUTORY NON-INSURED
Statuatory Non-Insured employers are public government entities (i.e., the state, county, municipality, or school district). They are not required to purchase workers’ compensation insurance, but they do have to make provisions to cover any costs that could arise from workers’ compensation claims filed against them.

TECHNICAL COMPETENCE
A term that refers to both the ability to communicate electronically and that the file structure used is appropriate.

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TEST PERIOD
The initial environment or phase in which the trading partner/sender/reporter sends a series of transactions that are analyzed for both the technical and business content.

TEST PLAN
A plan developed by the NJCRIB EDI Test Coordinator and the Sender’s EDI Coordinator outlining the events, the time frame, and the responsibilities of each party for testing and evaluating data sent in the Test environment.

TPA
A Third Party Administrator that provides the claim administration services on behalf of Carriers, Selfinsureds or Statutory Noninsureds.

TRADING PARTNER
A Carrier, Self-Administered, Statutory Noninsured, or TPA responsible for providing the claim handling service for claims.

TRANSLATOR
Software that uses data conversion mapping rules to convert data from one format to another. Normally, for EDI processing, this term refers to a product the converts data between proprietary (not a national or industry standard) formats and X12 format. Refer to the Vendor section of this Implementation Guide for further information.

TRANSACTION
In this guide, a Transaction refers to one detail record (example FROI or SROI) and contains data elements as defined in the IAIABC record layouts, which are found in the IAIABC EDI Release I Implementation Guide. See MTC also listed in this Glossary.

TRANSACTION TYPE
Explains the purpose of a transaction. For example: Original FROI (00), Semi-Annual (SA). See Event and MTC listed in this Glossary.

TRANSMISSION FILE
One or more batches shipped together from the sender to the receiver.

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VAN
A Value Added Network, VAN, is an organization that facilitates the exchange of data between trading partners by performing some or all of the following services: extended hours of operation (often 24 x 7), a mailbox from which EDI transactions may be sent or received, communication functions to monitor and assure successful data transfer, data recovery, and data security, etc.

X12N
X12 Insurance Subcommittee - is the X12 subcommittee that develops EDI standards for the insurance industry.

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Organization of Information in this Manual
This NJCRIB EDI Implementation Guide is being presented to you in a sequence we anticipate will match a claim administrator’s interests and managerial responsibilities. The following synopsis of its sections may be of assistance. The Background of State EDI Reporting Standards (page 29) is provided to convey that state EDI reporting originated as a claim administrator effort and that continues today with states and claim administrators working together at the IAIABC. The goals are to: • • • Simplify state reporting requirements through standardization, Assist states to manage their Workers’ Compensation Systems, and Reduce state reporting costs.

The Executive Summary: Managing an EDI Implementation (page 31) is provided to draw attention to the various implementation tasks and options to consider. Information and Help (page 33) is provided as a source for New Jersey state assistance, NJ’s vendor’s assistance, access to current information, related projects and topics, as well as other vendor and consultant services and options. The Steps to Implement NJCRIB EDI (page 35) refer to Specific Changes from the Current Process (NJ DWC process) (page 35) providing a base from which to understand the new requirements. The Report and Data Requirements (page 37) are presented in several stages: 1. NJ DWC forms with IAIABC data number notations indicate current data used in electronic reporting. 2. IAIABC paper forms and electronic data lists describe the First Report of Injury (FROI) and Subsequent (SROI) data requirements. 3. Cross-references for FROIs and SROIs provide an analysis of the requirements and relate the previous reporting methods to the new electronic reporting requirements. This section identifies several data definitions that must be considered. An introduction to EDI Reports and Related Events (page 62) identifies situations in which the NJCRIB EDI reports are due. A table of NJCRIB events is provided. The Approved EDI Formats (page 69) section describes the technical formats authorized by NJCRIB in business terms. (Technical data for the formats is provided in the IAIABC Release 1 Implementation Guide and again in the appendix of this Guide.) Data Quality is a key philosophy of all EDI systems. EDI is an interactive relationship between your company and NJCRIB. Data you submit must pass NJCRIB Edits. The NJCRIB EDI system will acknowledge each Report (transaction) you submit. Transactions that fail must be resent. Data Errors must be corrected. The NJCRIB Data Edits (page 69) provide NJCRIB edit rules and an overview of how this process works. The Transaction Sequence Requirements (page 80) section expresses the order in which a claim administrator will submit reports to NJCRIB and the business events to which they correspond. Therefore, reports and transactions must be in the correct order of business events. Educational information to bridge claim administrator knowledge and EDI processes is provided throughout the guide. The Reporting Process and Functions & Options (page 82) section lists a combination of in-house and vendor EDI solutions. It includes several basic tips that will assist you to make the proper decisions for your company.

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The NJCRIB EDI Trading Partner Process (page 88) section walks you through completing a Trading Partner Agreement and a Trading Partner Profile. The Trading Partner Agreement documents report and data requirements the NJCRIB EDI system will expect from you. The Trading Partner Profile relays information that is used by NJCRIB and your system (or if you elect to use one to send your information, the vendor’s system) to communicate electronically with each other. Therefore, your reporting option choices will determine some of the information on the Trading Partner Profile; option selections must first be selected. The Test and Production Process (page 104) describes the procedure you will use in proving your technical capability, the quality of your data, and thereby, the elimination of paper reporting. You will be deemed out of compliance with the statutory requirements if the quality of your data in your EDI submissions falls below NJCRIB’s data quality requirements even after you reach “production” status following your testing.

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New Jersey Methods of Delivery

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Background of State EDI Reporting Standards
A specific set of standards for workers’ compensation reporting formats is now available. New Jersey Division of Workers Compensation (NJDWC) and New Jersey Compensation Rating & Inspection Bureau (NJCRIB) also share their objectives. Development of the standards began in 1989 when a group of national Claim Administrators worked with the North Carolina Workers’ Compensation agency to develop the first state-accepted electronic Report of Injury. Their objective was to reduce state reporting administrative processes and costs. Their project was successful and provided almost immediate benefit to both the claim administrators and North Carolina. Based on the success of the North Carolina project, the participants set out to duplicate the process in other states. Many changes to the North Carolina model were needed. State reporting had to be considered in the broadest terms instead of by state or locality. The group continued to meet under the International Association of Industrial Accident Boards and Commissions (IAIABC) umbrella unofficially to satisfy antitrust requirements. This group identified several major categories of Claim Administrator and Employer Reports and when state-required reports were to be submitted, it identified which data was required. This allowed creation of a data element dictionary and a reporting event table that could be used by any state and which was based on the claim administrator claim handling process. The developers used existing and widely used data standards to leverage system enhancements implemented by many claim administrators and state administrators. As a result, the group reduced numerous data elements and reporting situations into a more concise data list and a manageable set of reporting conditions that would meet the needs of most states. The initial process took several years to accomplish. Its success is attributable to the state and claim administrator participants who painstakingly and patiently reviewed state requirements and claim administrator processes that benefited both parties. Their work continues today to expand the use of these EDI standards. As state participation grew, these copyrighted standards are now available from the IAIABC. Contact the IAIABC at (608) 277-1479 or visit their web site at http://www.iaiabc.org to acquire a copy of the standards, which may be downloaded from their site at no cost to you.

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Executive Summary: Managing an EDI Implementation
If you are a Claim Administrator who has not been involved in fulfilling state Workers’ Compensation electronic reporting requirements before, it may all seem foreign and totally technical to you. In reality, EDI, while it is all about business, does have two sides. It’s about using data that originates in your claim handling processes to meet jurisdictional reporting requirements. Ideally, it shifts report generation from a manual process to an automated or software-assisted process. Therefore, your initial task is to assess the requirements, compare them to your manual and automated processes, and determine your best business solution. EDI does have a considerable technical or “Information Systems” component, but it is based on your business associations and business processes. The technical side of EDI has three major components. 1. Your computer-based claim processing system where claim data is stored. 2. An EDI management system or a component that contains jurisdiction requirements: a. the required report types, b. when they are required, c. when they are due,

d. their data requirements, e. required edits, f. the states response to each report.

3. A system that manages the exchange of reports between your organization, states, your clients, etc. Due to the differences between Claim Administrator claim handling processes and their computer systems, each administrator may have very different capabilities. Each must assess the best way to modify their claim handling process and determine how to implement the three technical EDI components. The solution may be to use your own technical staff to build the technical components, use a bridge or vendor system, or, if your volume is low, to subscribe to the NJCRIB web-based or Internet solution. Some may conclude that a mixture of in-house development and vendor products and services work best for them – others will conclude a different solution works best for them depending on the services available to you, the technology you already use, and cost constraints. The following is a possible list of tasks to perform. The list is not intended to be all-inclusive or be in the optimal order. Its primary goal is to raise your awareness to allow your own managerial skills and insight to take over. 1. Determine if your company is subject to the NJCRIB requirements and the mandate implementation date of July 5, 2002. 2. Acquire a copy of the “IAIABC Release 1 EDI Implementation Guide” from the IAIABC. 3. Develop a basic understanding of EDI and NJCRIB reporting requirements. 4. Scan the Information and Help (page 33) section. 5. Read the Steps to Implement NJCRIB EDI Requirements (page 35) to know what will be required of your claims process and electronic reports to NJCRIB. 6. Perform a high-level comparison of NJCRIB requirements against your current claim computer system capabilities. 7. Read the Report Process Functions & Options of Claim Administrator and vendor EDI products and services options to consider. NJ CRIB EDI Implementation Guide
Page 31 May 15, 2002

8. Based on your high-level assessment of existing capabilities and EDI requirements, conceptualize how your organization might implement the various options and which solution might be the most appropriate. 9. Use your organization project development process to initiate a formal project proposal involving business and technical departments using the detailed NJCRIB business requirements. Be sure to scope the project to include anticipated related EDI projects. 10. Use the information resources to expand your knowledge of state EDI reporting. 11. Use industry meetings and other business contacts to identify claim administrators that have participated in the development of the standards or have successfully implemented EDI in other states. Inquire about how they implemented EDI and what they would do differently now. What were their experiences building EDI solutions or with vendor products or services? 12. Determine your scheduled New Jersey Test Date. Refer to the NJCRIB Test Schedule on the web site. 13. Complete and submit your Trading Partner Agreement form and your Trading Partner Profile to the NJCRIB EDI Test Coordinator at least two weeks prior to the first date of your scheduled Test Period. 14. Monitor the NJCRIB official web site for new information and requirements changes. Attend training sessions. 15. Implement your EDI solutions and document all processes. 16. Train Claim and Technical personnel for their roles and duties. 17. Prepare and begin submission of Test processes with NJCRIB on the first date of your assigned Test Period. 18. Begin submission of Production Transactions on the approved Production date and no later than July 5, 2002. 19. Monitor and update processes and train staff accordingly as any process issues occur. 20. Continue to check the NJCRIB web site periodically and participate in any NJCRIB EDI initiatives that may develop. 21. Pass your experiences along to help those who follow your organization into EDI.

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Information and Help
NJCRIB/NJDWC Official Web Pages
www.NJCRIB.com www.dwc.dol.state.nj.us

NJCRIB Staff Phone & E-Mail

Technical Contact: phone: (800) 240-0088 e-mail: njedi@hnc.com fax: (949) 655-3375

NJCRIB Vendor Help Line and E-mail

e-mail: njedi@hnc.com or phone (800) 240-0088 fax (949) 655-3375

NJDWC Contact Information for Business/Law/Regulations Issues and Questions

Division of Workers’ Compensation Attn: EDI Coordinator P.O. Box 381 Trenton, NJ 08625-0381 e-mail dwcedi@dol.state.nj.us phone number: (609) 292-2515

IAIABC Web Page & Phone Number

Web Site address: www.iaiabc.org/html/impguide.htm phone number: (608) 277-1479 (Madison, WI)

Frequently Asked Question Document on the NJCRIB Web Page

www.njcrib.com

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NCCRIB EDI Reporting Process

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Steps to Implement NJCRIB EDI
NJCRIB EDI Requirements
The objectives of this section are: 1. To convey the NJCRIB EDI Reporting requirements as clearly as possible. 2. To prepare you to assess your organization’s capabilities and determine the best way for your organization to meet NJCRIB requirements.

Specific Changes from the Current Process
This section summarizes the more significant changes so that you may better understand the transitional process. Format: Data Content: Changes from New Jersey state paper forms to national standard electronic formats. Is predominantly the same as existing NJDWC requirements but expressed using IAIABC terminology and definitions so that it is consistent with national standards. Requirements are stated in specific terms that allow computer processing so that New Jersey employers and administrators may replace their manual reporting process with an automated process. EDI submissions of IAIABC FROI and SROI reports in Flat or ANSI formats will be required six months (July 5, 2002) following the enactment date of the legislation (January 5, 2002). OSHA requirements remain.

Methodology:

Effective:

Participant Specific Changes
Current: New: Differences: New Jersey employers are responsible to report via paper forms, L&I-1, and WC1 to their insurance carrier or third party administrator and to the NJDWC. Employers will report FROI or SROI information only to the Insurer or TPA using any agreed upon format. Employer: 1. Stops reporting to NJDWC. 2. Continues to report to the Insurer or TPA. 3. Is not required to use the L&I-1 and WC-1. 4. May use any agreed upon format, such as telephone, IAIABC flat, ANSI, or paper formats to communicate with the Insurer or TPA.

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Current: New:

Insurers and TPAs are responsible to report via paper forms WC-2 and WC-3 to NJDWC. Insurers and TPAs are responsible to report via IAIABC electronic flat or ANSI formats to NJCRIB, and to the employer in electronic or paper FROI or SROI format, and to the employee in SROI paper format using the New Jersey Benefit Status Letter. Insurer/TPA: 1. Stops reporting to NJDWC using the WC-2 and WC-3 forms. 2. Begins reporting to NJCRIB using IAIABC FROI or SROI in flat or ANSI formats. 3. Copies FROI to the Employer using IAIABC flat, ANSI, or paper formats. 4. Copies SROI to the employee using New Jersey Benefit Status Letter paper format.

Differences:

Current: New:

Self-Insureds and Noninsureds responsible to report via paper forms L&I-1 and WC-1, and WC-2 and WC-3 to NJDWC. Self-Insureds and Non-Insureds are responsible to report via IAIABC electronic flat or ANSI formats to NJCRIB, and to the employee in paper format using the New Jersey Benefit Status Letter. Self-Insureds and Noninsureds: 1. Stops reporting to NJDWC and using the paper forms L&I-1 and WC-1, and WC-2 and WC-3. 2. Begins reporting to NJCRIB using IAIABC FROI or SROI in flat or ANSI formats. 3. Copies SROI to the employee in paper IA-2 or New Jersey Benefit Status Letter format.

Differences:

Current: New:

NJDWC receives reports in paper format. NJCRIB receives reports electronically and edits them for data content and quality before being moved into NJCRIB computer system and then to the NJDWC. An Acknowledgement that the report was either accepted, rejected, and/or contained data errors is sent to the submitter. The submitter must either replace any rejected reports or submit corrections to data errors. Insurer, TPA, Self-Insured, and Noninsured 1. Must submit NJCRIB reports electronically and monitor them for data content and quality. 2. Must replace rejected reports. 3. Must correct data errors. 4. Are placed in an out-of-compliance mode if data quality falls below the required data quality level. 5. Are monitored for compliance. Failure to achieve and maintain EDI performance requirements may subject the carrier to subsequent EDI audits until EDI standards are achieved with possible penalty exposure.

Differences:

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Report and Data Requirements
The existing New Jersey L&I-1, RM-2, WC-1, WC-2, and WC-3 forms have been enclosed with modifications to show the new reporting data requirements. Each Data Element that is included in the new requirements is identified on each New Jersey report form by its Data Number (DN#). A DN# is a reference to an Industry Standard, IAIABC Data Element. Definitions for these elements can be found in the IAIABC E.D.I. Release 1 Implementation Guide. A DN# in “Blue” identifies First Report (FROI) data elements. A DN# in “Red” identifies Subsequent Report (FROI) data elements. Not all existing data elements are included in the EDI Reports; therefore, certain data elements will not have a DN#. In some situations, existing and new data requirements have similar intent/usage but are not the same. These are labeled “MOD” for modified. The new requirements include data not present on the existing New Jersey Forms. Many of these tend to be standard use identifiers required for automated processing. Others are typical of common employer and claim administrator bureau and occupational reporting. The additional data element requirements are provided in two separate FROI and SROI data element lists. The FROI and SROI information required in New Jersey lists relate the data to the New Jersey form source if any, and to the IAIABC Paper and Electronic Reports. Those reports are also provided.

First Report of Injury (FROI)
The forms and lists for First Reports of Injury are on the following pages.

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L&I 1

DN28

DN29
DN82

DN30

DN7 DN24

DN31

DN16
DN25

DN18 DN19, DN20, DN21, DN22, DN23 DN44, DN43, DN45 DN46, DN47, DN48, DN49, DN50 DN51 DN33, DN34 DN38 DN42 DN60 DN64
DN53

DN52

DN62, DN63

DN35, DN36 DN57 DN65 DN68

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WC-1

DN4

DN43, DN44, DN45 DN46, DN47, DN48, DN49, DN50

DN60 ----------DN54--------DN42

DN53

DN18 DN19, DN20, DN21, DN22, DN23 DN16 DN62 DN62

DN55 DN57

---------DN31------DN68

DN32

DN62

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WC-2
DN4

DN44, DN43, DN45 DN46, DN47, DN48, DN49, DN50

DN60 ----------DN54------------------DN31------- DN32 DN68 DN42 DN57

DN53

DN18 DN19, DN20, DN21, DN22, DN23 DN16 DN62 DN62

DN55

DN62

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First Report of Injury (FROI) - Form IA-1

DN18 DN19, DN20, DN21, DN22, DN23

DN15 DN4 DN26 DN33, DN34 DN5

DN2

DN27

DN7

DN29

DN30

DN7, DN9 DN10, DN11, DN12, DN13, DN14

DN6

DN28

DN8

DN43, DN44, DN45

DN52 DN53

DN42 DN54

DN61 DN60 DN58

DN46, DN47, DN48, DN49, DN50

DN51 DN62 DN63

DN55 DN64

DN59 DN66 DN67 DN65 DN40 DN56

DN31

DN32

DN34

DN37

DN36

DN38

DN38

DN38

DN38 DN68 DN57

DN37

DN39

DN41

DN3

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First Report of Injury (FROI) - Form IA-1 OSHA

DN18 DN19, DN20, DN21, DN22, DN23

DN15 DN4 DN26 DN33 DN34 DN5

DN2

DN27

DN7

DN29

DN30

DN7, DN9 DN10, DN11, DN12, DN13, DN14

DN6

DN28

DN8

DN43, DN44, DN45 DN46, DN47, DN48, DN49, DN50

DN52 DN53

DN42 DN54

DN61 DN60 DN58

DN51 DN62 DN63

DN55 DN64

DN59

DN66 DN67

DN31

DN32

DN65

DN40

DN56

DN34 DN38

DN37 DN38

DN36

DN38

DN38

DN38 DN68 DN57

DN37

DN39

DN41

DN3

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First Report of Injury (FROI) - Flat File Data Element List First Report of Injury Requirements
Groupings No Transaction 1 2 3 Jurisdiction 4 5 Claim Admin. 6 7 8 9 10 11 12 13 14 15 Insured 16 17 18 19 20 21 22 23 24 25 26 27 Policy Data Name Transaction Set Id Maintenance Type Code Maintenance Type Code Date Jurisdiction Agency Claim Number Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin. Address Line 1 Claim Admin. Address Line 2 Claim Admin. City Claim Admin. State Claim Admin. Postal Zip Claim Admin. 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 Edits Must Be 148, A49, HD1 or TR1 Must Be 00, 04, 01, 02, CO, or AU Must Be a Valid Date CCYYMMDD Must be "NJ"

Required if TPA is reporting Required if TPA is reporting

(Policy Fields are only Mandatory for Insured Employers) 28 Policy Number O IF Self-Insured or DN 24 = Yes; Required if DN 24 = No. 29 Policy Effective Date O IF Self-Insured or DN 24 = Yes; Required if DN 24 = No. Must Be a Valid Date CCYYMMDD, Must Be < or = Date of Injury. 30 Policy Expiration Date O IF Self Insured or DN 24 = Yes; Required if DN 24 = No. Must Be a Valid Date CCYYMMDD and Must Be > or = Date of Injury. Accident 31 Date of Injury 32 Time of Injury NJ CRIB EDI Implementation Guide Must be< or = Date Reported to Employer and Must Be a Valid Date CCYYMMDD.

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First Report of Injury Requirements
33 34 35 36 37 38 39 40 Postal Code of Injury Site Employers Premise Indicator Nature of Injury Code Part of Body Injured Code Cause of Injury Code Accident Description / Cause Initial Treatment Code Date Reported to Employer

Must Be a Valid Date CCYYMMDD And Must Be > or = Date of Injury. 41 Date Reported to Claims Admin. Must Be a Valid Date CCYYMMDD Employee 42 43 44 45 46 47 48 49 50 51 52 53 54 55 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

56 Date Disability Began

57 Employee Date of Death

Required if Date of Death DN 57 completed. Must Be Numeric and required If Date of Death DN 57 completed. Must Be a Valid Date CCYYMMDD and Required if lost time = one or more days and if DN 64 completed. Required If death claim, Else N/A. If Applicable it Must Be a Valid Date CCYYMMDD and Must be > or = Date of Injury. Must be a valid code. Must be a valid code. Must Be a Valid Date CCYYMMDD

Employment 58 59 60 61 62 63 64 65

Employment Status Code Class Code Occupation Description Date of Hire Wage Wage Period Number of Days Worked Date Last Day Worked

Must Be Numeric Required if DN 56 completed; Must Be a Valid Date CCYYMMDD.

66 Full Wages Paid for Date of Injury Must be either Yes or No Indicator. 67 Salary Continued Indicator Must be either Yes or No 68 Date of Return To Work Must Be a Valid Date CCYYMMDD Required if employee able to return to regular duties, Else N/A.

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FROI Crosswalk Table – L&I 1, WC-1, & WC-2 to IAIABC IA-1 and Flat File
Employer’s NJ L&I-1 Form L&I-1, WC-1, and WC-2 Forms No 1. Carrier’s name 1. If self-insured indicate “self-insured” 1. Carrier’s address IAIABC 1A-1 Form Jurisdiction Agency Claim No. Yes Self-Insured Indicator Carrier’s address EDI FROI Elements DN 4 – mandatory DN 5 – conditional DN 7 – mandatory DN 24 – mandatory DN 10 – 12-14 mandatory DN 11 – conditional No 1A. Policy number 1B. Policy effective date 1B. Policy expiration date 2. Date of injury or illness 2. Time of day No No No No No 3. Employer name 7. Employer address Claim Administrator address Yes Yes Yes Yes Yes Insurer’s FEIN Claim Adm. Claim No. TPA's FEIN TPA's Name Insured name (Parent Organization) Yes Yes DN 10 – 12-14 mandatory DN 11 – conditional DN 28 – conditional DN 29 – conditional DN 30 – conditional DN 31 – mandatory DN 32 – mandatory DN 6 – mandatory DN 15 – mandatory DN 8 – conditional DN 9 – conditional DN 17 – optional DN 18 – mandatory DN 19, 21-23 mandatory DN 20 - conditional 8. Employer telephone number 4. Employer FEIN number 5. SIC number No No 6. Number of employees in firm 9. Nature of business 7. Location if different from mailing address 10. Employee name No Yes Yes Yes Insured Report No. Insured Location No. No No Yes Yes Employee Middle Initial No (not needed) DN 16 – mandatory DN 25 – mandatory DN 26 – conditional DN 27 – conditional No (not needed) No (not needed) No (not needed) DN 43 – 44 mandatory DN 45 – conditional

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Employer’s NJ L&I-1 Form 15. Employee home address

IAIABC 1A-1 Form Yes

EDI FROI Elements DN 46, 48–50 mandatory DN 47 – conditional

18. Employee telephone number 11. Social Security Number 12. Date of birth 13. Age 14. Sex No 16. Occupation (Job title) No No 19. Wages 20. Number of hours worked per day

Yes Yes Yes No Yes Employment Status Yes Date of Hire Class Code Yes Number of days worked per week

DN 51 – conditional DN 42 – mandatory DN 52 – mandatory No (not needed) DN 53 – mandatory DN 58 – conditional DN 60 – mandatory DN 61 – conditional DN 59 – Mandatory DN 62 – 63 mandatory DN 64 – Conditional; Required if lost time = or > 7 days or if DN 56 completed No (not needed) DN 55 – conditional DN 54 – conditional DN 67 – mandatory DN 33 – Mandatory DN 34 – mandatory DN 38 – mandatory

17. Department where employed See WC-1.7 See WC-1.5 No 21. Location where accident occurred No 22. What was employee doing (cause)

No Number of dependents Marital status Salary continued indicator Postal code of injury site Employer premise indicator Specific activity or work process that employee is engaged in All equip. Material or chems. Used at acc. How injury occurred object or substance that injured employee

23. Object or substance machine or tool that directly injured employee

No (not needed)

No 24. Nature of injury and part of body No No

Cause of injury code (cause) Type of injury/illness code (nature) Part of body code (part) Date disability began

DN 37 – mandatory DN 35 – mandatory DN 36 – mandatory DN 56 – conditional; Required if lost time => 1 day or if DN 64 completed.

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Employer’s NJ L&I-1 Form 25. Did employee die? If yes, give date of death 26. Unable to work day after (Last day worked) 27. Returned to work 28. Treating doctor 29. Treating doctor’s address 30. Hospital Name 31. Hospital Address No No No No Completed by: (preparer name) Title of preparer: Signature of preparer: Date this form prepared: Employer’s NJ WC-1 Form 1. Name and address of employee 8. Name and address of employer 8. FEIN number of employer 2. Occupation of title 3. Age 4. Sex 5. Marital status 6. Social Security Number 7. Number of dependents 9. Date of accident 10. Did employee die? If yes, give date of death 11. Did employee return to work

IAIABC 1A-1 Form Date of Death

EDI FROI Elements DN 57 – conditional; Required if employee dies as a result of the injury. DN 65 – conditional DN 68 – conditional No (not needed) No (not needed) No (not needed) No (not needed) DN 41 – optional DN 39 – mandatory DN 40 – mandatory DN 66 – conditional No (not needed) No (not needed) No (not needed) No (not needed)

Yes Yes Yes Yes Yes Yes Date reported to claims administrator Initial treatment code Date reported to employer Full-wages-pd.-for-date-ofinj. indicator Yes Yes No Yes

Yes

DN 54 – conditional

Yes

DN 55 – conditional

No

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Employer’s NJ L&I-1 Form 12. Date returned to work

IAIABC 1A-1 Form Return to Work Date

EDI FROI Elements DN 68, Conditional; Required if Employee returned to full duty at time FROI filed. No (not needed)

13. Probable date returned to work 14. Average earnings 15. Wages per day 16. Wages per hour 17. Was board and lodging furnished? 18. Number of hours in regular work day 19. Number of days in regular work day 20. Amount of weekly wages Date this form prepared: Signature of preparer: Title of preparer: Carrier’s WC-2 Form 1-20 same as in WC-1 Date this form was prepared Signature of preparer: Title of preparer: Signature of employee: Signature of witness: No Compensation was or is to be paid NJDWC Guarantee payment of compensation Signature

No

No

No (not needed)

No Witness name No

No (not needed) No (not needed) No (not needed)

No

No (not needed)

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Subsequent Report of Injury (SROI)
The forms and lists for First Reports of Injury are on the following pages.

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WC-3
DN4

DN31 DN57

DN42

DN75

DN95, DN96

DN64

DN62 DN3

DN56
DN90

DN88

DN72

DN83, DN84
DN87 DN90 DN86 DN85

DN85 = 030/040

DN90 for DN85 = 030/040

DN86 for 030/040

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WC-3 (continued)

DN4

DN31

DN42

DN3 DN86, DN95

DN97 DN87 DN90 DN86 for “010”

DN85, DN87 DN87 for “010” DN93, code=300

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New Jersey Benefit Status Letter
[Claim Administrator Letterhead] [Claim Administrator Address] DATE of NOTICE: [DATE] TO:[NAME OF INJURED EMPLOYEE] [ADDRESS] DN48, DN49, DN50 [CITY, STATE, ZIP] [DATE OF INJURY] DN42 [EMPLOYEE SSN] DN15 [CLAIM ADMINISTRATOR CLAIM #] DN5 [JURISDICTION CLAIM #] Dear [Injured Worker Name], I am handling your claim for workers’ compensation benefits. In accordance with New Jersey law, I am sending you a summary of your claim and benefits paid to date. The information contained in this notice has been provided to the state in an electronic format. Only the boxes checked or information provided applies to your workers’ compensation claim. This notice is with reference to the following status of your workers’ compensation claim: (claim administrator selects all applicable) ( ) ( ) ( ) You were released to return to work on [RTW or RRTW Date]
DN72 DN31 DN46, DN47 DN44, DN43

.
DN70

Your injury reached maximum medical improvement status on [MMI Date] Your injury was assigned a permanent impairment rating as follows:
[Permanent Impairment Percent] DN 84 of the [Permanent Impairment Body Part] DN 83 [Permanent Impairment Percent] DN 84 of the [Permanent Impairment Body Part] DN 83 [Permanent Impairment Percent] DN 84 of the [Permanent Impairment Body Part] DN 83 [Permanent Impairment Percent] DN 84 of the [Permanent Impairment Body Part] DN 83 [Permanent Impairment Percent] DN 84 of the [Permanent Impairment Body Part] DN 83 [Permanent Impairment Percent] DN 84 of the [Permanent Impairment Body Part] DN 83

.

( )

DN57

This workers’ compensation claim involves a fatality that occurred on [Date of Death] and we [have/have not] been providing death benefits on this claim.

According to our records, your injury occurred while you were working for: [NAME OF EMPLOYER]
DN18 DN19, DN20, DN21, DN22, DN23 DN62

[EMPLOYER’S ADDRESS]

At the time of the injury, your average weekly wage was [$0000000.00] . Items such as overtime, lodging, uniforms, etc. [were/were not applicable] to the average weekly wage calculation, pursuant to jurisdictional requirements. Based on your average weekly wage, your weekly benefit rate was DN87 calculated at [$0000000.00] .

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****If maximum medical improvement box was checked above, insert this paragraph: Once maximum medical improvement has been reached, you are no longer eligible for temporary disability benefits; but if you sustained a permanent disability, you may be entitled to permanent benefits. The weekly benefit is defined by statute with a value based upon degree of impairment. ****If the employer continued salary during the temporary disability benefit period (DN 67 Salary Continued Indicator Y/N = Yes), include the following paragraph. Your employer elected to continue paying your salary during your temporary disability period and in lieu of workers compensation benefits except for the following benefits we provided and that are listed below. ****The following paragraph will be used on all letters: To date, we have provided the following workers’ compensation indemnity benefits for your injury: Benefit Description
DN85 (text descr instead of code#)

Paid To Date
DN 86

From/Through Dates
DN88/DN89

# Weeks# Days
DN90 DN91

(*****insert printout of benefits paid by benefit type*****) _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ _______________________ ______________ ______________________ _____ _____ If you do not agree with the information contained in this letter, please contact me via one of the methods below. Adjuster’s Name: Telephone #: Fax #: E-Mail Address: You may write to the New Jersey Division of Workers’ Compensation at P.O. Box 381, Trenton, NJ 08625-0381, or contact them via email at dwcedi@dol.state.nj.us.

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Subsequent Report of Injury (SROI) - Flat File Data Element List Subsequent Report of Injury Requirements
Grouping No Transaction 1 2 3 Jurisdiction 4 Claim Admin. 6 8 Data Name Edits

Transaction Set Id Must be 148, A49, AK1, HD1 or TR1. Maintenance Type Code Must be SA, 04, 02, or CO. Maintenance Type Code Date Must be a valid date CCYYMMDD. Jurisdiction Insurer FEIN TPA FEIN Must be "NJ.”

Required if Third Party Administrator is reporting.

14 Claim Admin. Postal Zip Employee 42 Social Security Number 55 Number Of Dependents 69 Pre-Existing Disability 56 Date Disability Began Required if Death Benefits paid (Payment Adjustment Code = 010 or 510). Must be either Yes or No. Must = Yes if Employee had a pre-existing disability. Required if lost time is = > one day, or if DN 64, Number of Days Worked Per Week is completed; else N/A. Must be a valid date CCYYMMDD. Required if Max Med Improvement has been reached. Must be a valid date CCYYMMDD. Required if Date Return/Release to Work, DN 72, completed. Must be a valid date CCYYMMDD. Required if returned to work, or if DN 71 Completed. Must be a valid date CCYYMMDD. Required if Fatal benefits paid (Payment Adjustment Code = 010 or 510); Must be a valid date CCYYMMDD.

70 Date of Maximum Medical Improvement 71 Return to Work Qualifier

72 Date of Return/Release to Work 57 Employee Date of Death

Wage 62 Wage 63 Wage Period 64 Number Of Days Worked 67 Salary Continued Indicator Accident 31 Date Of Injury 26 Insured Report Number 15 Claim Administrator Claim Number 5 Agency Claim Number Claim Status 73 Claim Status 74 Claim Type 75 Agreement to Compensate Code Must be a valid date CCYYMMDD. Must be a valid code. Required if Disability is > 7 days, or, if DN 56, Date of Disability is completed; else, N/A. Must be either Y or N

Must be a Valid Code. Must be a Valid Code.

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Subsequent Report of Injury Requirements
76 Date Of Representation Payments 77 Late Reason Code Must be a valid code. Required if has Legal Rep., else N/A. Must be a valid date CYYMMDD.

Variable Segment Counters 78 Number of Permanent Impairments 79 Number of Payment/Adjustments 80 Number of Benefit Adjustments 81 Number of Paid to Date/Reduced Earnings/Recoveries 82 Number of Death Dependent/Payee Relationships Variable Segments Permanent Impairment Occurs M if 78 > 0, else N/A. 83 Permanent Impairment Body Must be in a Valid Code Part Code 84 Permanent Impairment Must be valid percentage Percent Payment/Adjustments Occurs Number of Payment/Adjustment Times 85 Payment/Adjustment Code Required if payment made, else N/A 86 Payment/Adjustment Paid To Required if DN 79 > 0, else N/A. Date 87 Payment/Adjustment Weekly Required if DN 79 > 0, else N/A. Amount 88 Payment/Adjustment Start Required if DN 79 > 0, else N/A. Date Must be a valid date; CCYYMMDD. 89 Payment/Adjustment End Required if DN 79 > 0, else N/A. Date Must be a valid date CCYYMMDD. 90 Payment/Adjustment Weeks Required if DN 79 > 0, else N/A. Paid 91 Payment/Adjustment Days Required if DN 79 > 0, else N/A. Paid Benefit Adjustments Occurs Number of Benefit Adjustments Times 92 Benefit Adjustment Code Required if payment made, else N/A. 93 Benefit Adjustment Weekly Required if DN 80 > 0, else N/A. Amount 94 Benefit Adjustment Start Date Required if 80 > 0, else N/A. Must be a valid date CCYYMMDD. Paid To Date /Reduced Earnings /Recoveries occurs Paid To Date/Reduced Earnings /Recoveries Times 95 Paid To Date / Reduced Required if payment made, else N/A. Earnings / Recoveries Code 96 Paid To Date / Reduced Required if DN 81 > 0, else N/A. Earnings / Recoveries Amount Death Dependent/Payee Relationships Occurs Death Dependent/Payee Relationship Times 97 Dependent/Payee Required if fatal payment/adjustment type code Relationship DN 85 = 010 or 510, else N/A.

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SROI Crosswalk Table - NJ Forms to NJ Benefit Status Letter and IAIABC Flat File
SROI Information in New Jersey NJ WC-3 Form Presence of WC-3 Form 1. Injured Worker’s name 1. Injured Worker’s Home address New Jersey Benefit Status Jurisdiction Employee’s name Employee Address Line 1 Employee Address Line 2 Employee City Employee State Employee Postal Code 2. Age 3a. Social Security No. 3. Date of accident 4. Probable date of recovery No 5. Did injury cause death No 6. Employer name 6. Employer address No Soc. Security Number Date of injury No Report effective date (Date of Notice) Date of death No Employer name Employer’s address Line 1 Employer’s Address Line 2 Employer City Employer State Employer Postal Code 6. Employer FEIN or NJTIN No 7. Agreement to compensate signature No 8. Did injury require medical aid 9. Medical aid to be paid by employer or carrier 9a. Cost of medical aid rendered by carrier or employer No No No No No No No No (not needed) DN – 26 conditional DN – 75 mandatory DN – 77 conditional No (not needed) No (not needed) DN – 95 conditional— required if payments made With code = 350, 360 or 370 and with paid amount in DN 96 per code No (not needed) DN – 42 mandatory DN – 31 mandatory No (not needed) DN – 3 mandatory DN – 57 conditional DN – 2 mandatory No (not needed) No (not needed) EDI-SROI DN – 4 mandatory No (not needed) No (not needed)

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10. Output earning/daily average 11. Output by day/wages per pay 12. Output by hour/hourly rate 13. Number of hours worked per day 14. Number of days in a reg. work week No No 15. Amount of weekly wages No No 16. Were board and lodging furnished 17. Name and Address of physician Date form prepared 18. Detailed X-ray findings 19. Detailed diagnosis of physician

No No No No No No No Average Weekly Wage No No No No Date of Notice No No States get this directly from provider & not carrier (3415-100)

No (not needed) No (not needed) No (not needed) No (not needed) DN – 64 conditional DN – 67 mandatory DN – 63 mandatory DN – 62 mandatory No (not needed) DN – 87 conditional No (not needed) No (not needed) DN – 3 mandatory No (not needed) No

20a. General X-ray findings 20b. Total number of treatments 20c. Date of discharge 21. General diagnosis 22. Is worker capable of doing same work 23. Date disability began No No No No No No No No

No No No No No From Date Through Date No No No No No No No

No (not needed) No (not needed) No (not needed) No (not needed) No (not needed) DN – 56 conditional No DN – 69 conditional DN – 76 conditional DN – 78 mandatory DN – 79 mandatory DN – 80 mandatory DN – 81 mandatory DN – 82 mandatory

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Payments
No No No 24. Date payments began No No No Payment Type Code No Amount Paid to Date Paid from-date Paid through-date # Weeks paid # Days paid DN – 85 conditionalcomplete if Payment Made DN – 87 conditional DN – 86 conditional DN – 88 conditional DN – 89 conditional DN – 90 conditional DN – 91 conditional

Benefit Adjustments
Yes Yes Yes No No No DN – 92 conditional DN – 93 conditional DN – 94 conditional

Paid To Date
Yes Yes No No No No No DN – 95 conditional Actual = Code 600 – 624 Deemed + Code 650 – 674 No No DN – 95 conditional 600-675 Code No No No (not needed) DN – 95 conditional DN – 96 conditional

Recoveries
Yes No DN–95 conditional Code = 800-840 Yes No DN – 96 conditional for DN 95 (800 - 840)

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Claim Administration
1. Self Insurer or Carrier Name No No No No No Yes Yes 25. Date injured returned to work No No No No Applicable to Formals only 26. Total time unable to work weeks/months Insurer name (if Claim Administrator) No TPA name (if assigned) No Claim Adm. Claim Number Claim Adm. Address (Postal Zip Code) No No Date returned to work No No No No Agency Claim Number No but can be calculated by (Date Return to work – date from) 27. Did any perm. injury result from accident 28. If yes describe fully, giving % of member involved 29. Amount of weekly compensation 30. No. of weeks / amt. pd. for temp. disability Weeks $$ No No ---------DN – 83 conditional DN – 84 conditional No Payment Type # Weeks Paid Amount Paid to Date DN – 87 conditional DN – 85 conditional (Code 050, 070) DN – 90 conditional DN – 91 conditional DN – 86 conditional 31. Number of weeks to be paid for amputation 32. Number of weeks to be paid for other permanent injuries # Weeks Paid # Weeks Paid DN – 90 conditional DN – 90 conditional No (not needed) DN – 6 mandatory No (not needed) DN – 8 conditional DN – 15 mandatory DN – 14 mandatory DN – 73 mandatory DN – 74 mandatory DN – 72 conditional DN – 71 conditional DN – 71 conditional DN – 71 conditional DN – 71 conditional DN – 5 conditional Can be calculated by (DN 72 – DN 56)

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33. Total amount of compensation for permanent injuries

Payment Type Amount Paid to Date

DN – 85 conditional (Code 030, 040, 530, 540) DN – 86 conditional

34. Was there an informal hearing NJ WC-3A Name of Employer Employer FEIN # or NJTIN 40. Date of preparation 41. Cost of Employer or Carrier

No NJ Benefit Status Letter Employer Name No Date of Notice Payment Type # Weeks Paid Amount Paid to Date

No (not needed) EDI SROI No (not needed) No (not needed) DN – 3 mandatory DN – 85 conditional (code 010 or 510) DN – 90 conditional DN – 86 conditional

42. Name each dependent Name Date of Birth Relationship to deceased

No No No No

No (not needed) No (not needed) No (not needed) DN – 97 conditional (based on code)

Physically or mentally deficient (Y or N) No 43. Amount of compensation paid prior to death

No

DN – 97 conditional Code = 7

Date of MMI Payment Type # Weeks paid Amount Paid to Date

DN – 70 conditional DN – 85 conditional (Code other than 010, 510) DN – 90 conditional DN – 86 conditional

44. Specify dependents which are physically or mentally deficient

No

DN – 97 (not needed) relationship value in first position, if handicapped, will equal “7” DN – 31 (not needed) No (not needed) DN – 42 (not needed) No (not needed) No (not needed) No (not needed)

Date of accident Name of deceased employee Social Security Number Name of principal dependent Address 45. Weekly comp rate paid to each dependent:

Date of injury Employee Name Soc. Security Number No No No

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Rate: Weeks: Amount: 46. Total compensation paid & to be paid dependents 47. Total cost of burial paid by employer/carrier

No No No Amount Paid to Date Paid to Date (PTD) Type

No (not needed) No (not needed) No (not needed) DN – 86 conditional DN – 95 conditional (Code = 300)

PTD Amount Agreement to compensate dependents – signature Agreement to accept compensation by principal dependent – signature No No

DN – 96 conditional No (not needed) No (not needed)

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EDI Reports and Related Events
The industry standards for State Reporting considered state oversight and compliance objectives and how they are achieved in the claim administrator claim handling processes. As such, the standards relate state EDI Reporting requirements to claim processing events. Each report or transaction, is labeled with a code to identify the claim event it represents: Initial Payment, Change of Benefits, Denial, Suspensions, Partial Suspensions, Reinstatements, Acquired Claim, etc. The Event codes have taken the American National Standards Institute (ANSI) technical name of Maintenance Type Codes (MTC). Release 1 is comprised of approximately 40 business events (MTCs). NJCRIB State Reporting only uses ten of the available MTCs: 1. Original First Report of Injury (00), 2. Denial (04), 3. Acquired (AU) for FROI Reports, 4. Change FROI (02) 5. Cancel FROI (01) 6. Correction FROI (CO) 7. Semi-Annual (SA) SROI Report 8. Denial SROI (04) 9. Change SROI (02), and 10. Correction SROI (CO). The data required to be reported is based on the business event. Date Requirements are often referred to and expressed as MCOs: Mandatory, Conditional, or Optional. Conditional data elements require the situation be specified when that data element is “Mandatory” or “Optional.” Mandatory indicates the data element is required or else the transaction is incomplete and will be rejected. Mandatory data includes data that is necessary to process the claim from a technical or business standpoint. A claim missing a Claim Administrator Claim Number or Insurer FEIN will not allow the claim to be matched to the NJCRIB database, or matched to the Insurer database or trading partner table. Missing Date of Injury, Nature of Injury, or Part of Body codes may render statistical analysis invalid. Two tables are provided to identify NJCRIB FROI MTC Report Data Requirements and SROI MTC Data Requirements. A third table, the NJCRIB Event Table, defines the business situation that will cause a Report (MTC) to be required, such as, either an Original First Report of Injury or a Denial First Report of Injury (if claim is being denied at the time it is being reported) must be submitted to NJCRIB FROI if: • • An accident or occupational exposure results in lost work days, Medical treatment or care by a medical provider other than first aid administered at the site of accidence or occurrence.

At the time, the insurance carrier, third party administrator, self-insured employer, or statutory non-insured employer has knowledge of one of the following events, a SROI must be reported. When the injured employee has: • • • • Recovered so as to be able to return to work, or Reached maximum medical improvement (MMI), or Is deceased, or The claim is 26 weeks after the date of accident on a medical only claim.

Review the details of the NJCRIB Event table to determine which nine specified business events occur and when a report is required.

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FROI Requirements Table
Maintenance Type Code (MTC) values: 00 04 01 02 CO AU Original Denial Cancel Change Correction Acquired Unallocated
Groupings Elements No Data Name Transaction 1 Transaction Set Id 2 Maint. Type Code 3 Maint. Type Code Date Jurisdiction 4 Jurisdiction 5 Agency Claim Number Fmt. 3 A/N 2 A/N DATE MTCs Beg End 00 04 01 02 CO AU Edits 1 4 6 3 5 13 M M M M M M M M M M M M M M M M Must Be 148, A49, AK1, HD1 or TR1 M Must Be 00, 04, 01, 02, CO, or AU M Must Be a Valid Date CCYYMMDD M Must be "NJ" C AU: Required if previously assigned and available M M C Required if TPA is reporting C Required if TPA is reporting M O M M M M M O M M O M M M M Must be either Y or N (Yes or No) M O O

2 A/N 14 25 A/N 16

15 40

M O

M M

M M

M M

M M

Claim Admin. 6 Insurer FEIN 9 A/N 41 49 M M M M M 7 Insurer Name 30A/N 50 79 M M M M M 8 TPA FEIN 9 A/N 80 88 C C C C C 9 TPA Name 30 A/N 89 118 C C C C C 10 Claim Admin. Address Line 1 30 A/N 119 148 M M M M M 11 Claim Admin. Address Line 2 30 A/N 149 178 O O O O O 12 Claim Admin. City 15 A/N 179 193 M M M M M 13 Claim Admin. State 2 A/N 194 195 M M M M M 14 Claim Admin. Postal Zip 9 A/N 196 204 M M M M M 15 Claim Admin. Claim Number 25 A/N 205 229 M M M M M Insured 16 Employer FEIN 9 A/N 230 238 M M M M M 17 Insured Name 30 A/N 239 268 O O O O O 18 Employer Name 30 A/N 269 298 M M M M M 19 Employer Address Line 1 30 A/N 299 328 M M M M M 20 Employer Address Line 2 30 A/N 329 358 O O O O O 21 Employer City 15 A/N 359 373 M M M M M 22 Employer State 2 A/N 374 375 M M M M M 23 Employer Postal Code 9 A/N 376 384 M M M M M 24 Self Insured Indicator 1 A/N 385 385 M M M M M 25 SIC Code 6 A/N 386 391 M M M M M 26 Insured Report Number 10 A/N 392 401 O O O O O 27 Insured Location Number 15 A/N 402 416 O O O O O Policy (Policy Fields are only Mandatory for Insured Employers) 28 Policy Number 30 A/N 417 446 C C C C C

C N/A if Self-Insured; Required If insured.

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Groupings Elements No Data Name 29 Policy Effective Fmt. DATE MTCs Beg End 00 04 01 02 CO AU Edits 447 454 C C C C C C N/A if Self-Insured; required if insured. Must Be a Valid Date CCYYMMDD, and Must Be < or = Date of Injury. 455 462 C C C C C C N/A if Self-Insured; required if insured. Must Be a Valid Date CCYYMMDD, and Must Be > or = Date of Injury. Injury. 463 470 M M M M M M Must be< or = Date Reported to Employer and Must Be a Valid Date CCYYMMDD. M M M Must be a valid code Y or N M Must be a valid Code M Must be a valid Code M Must be a valid Code M M Must be a valid Code M Must Be a Valid Date CCYYMMDD and Must Be > or = Date of Injury. O Must Be a Valid Date CCYYMMDD M M M O M O M M M O M M C C C

30 Policy Expiration

DATE

Accident 31 Date of Injury

DATE

32 33 34 35 36 37 38

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

39 Initial Treatment Code 40 Date Reported to Employer

HHMM 9 A/N 1 A/N 2 A/N 2 A/N 2 A/N 150 A/N 2 A/N DATE

471 475 484 485 487 489 491

474 483 484 486 488 490 640

M M M M M M M M M

M M M M M M M M M

M O O M M M M O M

M M M M M M M M M

M M M M M M M M M

641 642 643 650

41 Date Reported to Claims Admin. Employee 42 Social Security Number 43 Employee Last Name 44 Employee First Name 45 Employee Middle Initial 46 Employee Address Line 1 47 Employee Address Line 2 48 Employee City 49 Employee State 50 Employee Postal Code 51 Employee Phone 52 Employee Date of Birth 53 Gender Code 54 Marital Status Code 55 Number of Dependents 56 Date Disability Began

DATE

651 658

O

O

O

O

O

9 A/N 30 A/N 15 A/N 1 A/N 30 A/N 30 A/N 15 A/N 2 A/N 9 A/N 10 A/N DATE 1 A/N 1 A/N 2N DATE

659 668 698 713 714 744 774 789 791 800 810

667 697 712 713 743 773 788 790 799 809 817

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

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

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

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

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

818 818 819 819 820 821 822 829

57 Employee Date of Death

DATE

830 837

C

C

C

C

C

C

Must be a valid date; Must be < or = to Date of Injury Must be a valid Code Required If Date of Death completed Must Be Numeric and Required If date of death completed Must Be a Valid Date CCYYMMDD and required if lost time is => one day and if DN 65 Date Last Day Worked completed. Required If death claim; else N/A. Must Be a Valid Date CCYYMMDD and Must be > or = Date of Injury.

Employment 58 Employment Status Code 59 Class Code

2 A/N 4 A/N

838 839 840 843

O M

O M

O O

O M

O M

O If present must be a valid code M

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Groupings Elements No Data Name 60 Occupation Description 61 Date of Hire 62 Wage 63 Wage Period 64 Number of Days Worked 65 Date Last Day Worked MTCs Fmt. Beg End 00 04 01 02 CO AU Edits 30 A/N 844 873 M M O M M M DATE 874 881 O O O O O O Must Be a Valid Date CCYYMMDD $9.2 882 892 M M M M M M 2 A/N 893 894 M M M M M M Must be a valid code 1N 895 895 C C C C C C Required if DN 56 Completed; Must Be Numeric (1 – 7) DATE 896 903 C C C C C C Required If Loss OF Time From Work or if DN 56 Date Disability Began completed; Must Be a Valid Date CCYYMMDD. 1 A/N 904 904 O O O O O O If present must be Y or N 1 A/N DATE 905 905 906 913 M C M O O O M C M C M Must be either Y or N C Required if employee able to return to regular duties. Must Be a Valid Date CCYYMMDD.

66 Full Wages Paid for Date of Injury Indicator. 67 Salary Continued Indicator 68 Date of Return To Work

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SROI Requirements Table
Maintenance Type Code (MTC) values: SA 04 02 CO Semi-Annual Denial Change Correction
MTCs SA 04 02 CO M M M M M C M M C C C M M M M M C M M C C C M M M M M C M M C C C M M M M M C M M C C C Edits Occ.

Grouping No. Transaction 1 Transaction Set Id 2 Maint. Type Code 3 Maint. Type Code Date Jurisdiction 4 Jurisdiction Claim Admin. 6 Insurer FEIN 8 TPA FEIN 14 Claim Admin. Postal Zip Employee 42 Social Security Number 55 Number Of Dependents 69 Pre-Existing Disability 56 Date Disability Began

Must be 148, A49, AK1, HD1 or TR1. Must be SA, 04, 02, or CO. Must be a valid date CCYYMMDD. Must be "NJ.”

1 1 1 1 1 1 1 1 1 1 1

Required if TPA is reporting; Must be same as previous 00 or AU, whichever is latest FROI.

70 Date of Maximum Medical Improvement 71 Return to Work Qualifier

C C

C C

C C

C C

72 Date of Return/Release to Work 57 Employee Date of Death

C C

C C

C C

C C

Required if Death benefits paid (Payment/Adjustment Code = 010 or 510). Must be either Y (for Yes) or N (for NO). Required if Lost time => 1 day or if DN 64, Last Day Worked is completed. Must be a valid date CCYYMMDD. Required if Max Med Improvement has been reached; Must be a valid date CCYYMMDD. Required if DN 72, Date of Return/Release to Work completed. Must be a valid date CCYYMMDD. Required if release or if returned to work, else N/A. Must be a valid date CCYYMMDD. Required if Death or fatal benefits paid (Payment/Adjustment Code = 010 or 510). Must be a valid date CCYYMMDD.

1 1

1 1

Wage 62 Wage 63 Wage Period 64 Number Of Days Worked 67 Salary Continued Indicator Accident 31 Date Of Injury 26 Insured Report Number 15 Claim Administrator Claim Number 5 Agency Claim Number Claim Status 73 Claim Status 74 Claim Type 75 Agreement to Compensate Code

M M C M M O M M M M M

M M C M M O M M O O M

M M C M M O M M O O M

M M C M M O M M O O M

Must be a valid code. Required if Disability = > than 7 days or if DN 56 Completed. Must be either Y (yes) or N (No) Must be a valid date CCYYMMDD.

1 1 1 1 1 1 1 1

Must be a Valid Code. Must be a Valid Code. Must be a Valid Code.

1 1 1

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Grouping No. 76 Date Of Representation Payments 77 Late Reason Code Variable Segment Counters 78 Number of Permanent Impairments 79 Number of Payment/Adjustments 80 Number of Benefit Adjustments 81 Number of Paid to Date/Reduced Earnings/Recoveries 82 Number of Death Dependant/Payee Relationships Variable Segments 83 Permanent Impairment Body Part Code 84 Permanent Impairment Percent Payment/Adjustments 85 Payment/Adjustment Code 86 Payment/Adjustment Paid To Date 87 Payment/Adjustment Weekly Amount 88 Payment/Adjustment Start Date 89 Payment/Adjustment End Date 90 Payment/Adjustment Weeks Paid 91 Payment/Adjustment Days Paid Benefit Adjustments 92 Benefit Adjustment Code

MTCs SA 04 02 CO C C C C

Edits Required if employee has Legal Rep., else N/A. Must be a valid date CCYYMMDD. Must be a valid code.

Occ. 1

C M M M M

C M M M M

C M M M M

C M M M M

1 1 1 1 1

M

M

M

M

Required if Fatal or Death benefits paid (Payment/Adjustment Code = 010 or 510)

1

C C

C C

C C

C C

Required if DN 78 > 0, else N/A. Must be a Valid Code Must be valid percentage Required if DN 79 > 0; else N/A M if payment made, else N/A M if 79 > 0, else N/A. M if 79 > 0, else N/A. M if 79 > 0, else N/A. Must be a valid date CCYYMMDD. M if 79 > 0, else N/A. Must be a valid date CCYYMMDD. M if 79 > 0, else N/A. M if 79 > 0, else N/A. Not Applicable Not Applicable to NJ Subsequent Reports of Injury Not Applicable to NJ Subsequent Reports of Injury Not Applicable to NJ Subsequent Reports of Injury Required if DN 95 is completed Required if payment made, else N/A. Required if 81 > 0, else N/A.

6 1 1 10 1 1 1 1 1 1 1 10 1 1 1 25 1 1

C C C C C C C

C C C C C C C

C C C C C C C

C C C C C C C

93 Benefit Adjustment Weekly Amount 94 Benefit Adjustment Start Date Paid to Date/RE/Recoveries 95 Paid To Date / Reduced C Earnings / Recoveries Code C 96 Paid To Date / Reduced Earnings / Recoveries Amount Dependent Payee Relationships 97 Dependent/Payee C Relationship

C C

C C

C C

C

C

C

Required if DN 82 is > 0 Required if fatal or death benefits payment made, (Payment/Adjustment Code = 010 or 510)

12 1

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NJCRIB FROI & SROI Event Tables

NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU FIRST AND SUBSEQUENT REPORTS OF INJURY EVENT TABLE
MTC
00

MTC Description
Original First Report of Injury

Report Trigger
Due 21 days from Receipt of Claim. NOTE: No First Report of Injury is required for a work related injury that resulted only in first aid treatment. Due Immediately at Time Jurisdiction Change noted by Claim Administrator. Due Immediately at the time any data element previously reported is updated in Claim Administrator’s system. Send the FROI 04 if sending as a follow up to “00, Original First Report of Injury” or “AU” Acquired Claim First Report and no SROI report has been sent. The 04 as a follow up to the 00 is due immediately upon denying the claim. If appropriate to correct the outstanding error, the CO is due the day following receipt of the AK1 Acknowledgement of a prior FROI with a status of “TE.” Due within 21 days of date current claim administrator assumed claim-handling responsibilities. One Semi-Annual report is due within twenty-six weeks or 6 months after the date when the claimant has returned to work, reached MMI, or is deceased. For medical only claims, due within twenty-six weeks or 6 months following the date of accident. Note only one SA report is due for each claim. Do not send an SA if the claim is cancelled or if the claim is denied unless monies have been paid on the denied claim. Send the SA within 26 weeks of the date of denial. Due immediately at the time the Claim Administrator denies the claim. Send if any payments have been issued. Due immediately at the time any SROI data element previously sent on the SA, 04 SROI, or CO SROI is updated in the Claim Administrator’s system. If appropriate to correct the outstanding error, the CO is due the day following receipt of the AK1 Acknowledgement to a prior SROI with a status of TE.

01 02

Cancel First Report of injury Change First Report of Injury Denial First Report of Injury

04

CO

Correction First Report of Injury Acquired Claim, First Report of Injury Semi-Annual Subsequent Report of Injury

AU SA

04 02

Denial Subsequent Report of Injury Change Subsequent Report of Injury Correction to Subsequent Report of Injury

CO

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Approved EDI Formats
NJCRIB approves the use of IAIABC or ANSI technical formats. Both use the IAIABC data standards for State Reporting. These formats were chosen to standardize, simplify, and reduce the costs of exchanging data. Each meets the requirements of state reporting but also possesses characteristics that may make one format more suitable to your needs. The IAIABC format is a flat file format. Each IAIABC format data element is identified by its physical position in the file. All data must be included. Missing or partially filled fields must be filled by blanks or zeros as per the data type it represents. The Release 1 Flat File Format is relatively simple and the technology is well known and suited for in-house development. Some translators process IAIABC Flat Files. Release 1 includes five flat files: First Report (FROI), Subsequent Report (SROI), Acknowledgement (AK1), and Header (HD1) and Trailer (TR1) files. The ANSI format is a coded format. Each ANSI format data element is identified by a code and sequence scheme. This scheme does not require State Optional data to be omitted. Field delimiters eliminate the need to zero or blank fill a field to flat file field lengths. The ANSI format was developed to meet OSHA, BLS, Drs. Reports, and also contains data typically exchanged between a claim administrator and policy/contract holders. The ANSI format provides for hierarchical representation of the data and is therefore is fitted for and economical for transmitting huge amounts of claims. Because of its complexity, most organizations purchase a commercial translator and simply, using translator tools, map their data names to the standard reports. The ANSI Format uses two transactions: 148 Report of Injury or Illness, and 824 Acknowledgement. These transactions include Header and Trailer conventions. ANSI transmission capabilities include grouping and additional addressing functionality. ANSI transactions are mandated for Health Care Insurance under the HIPAA Act. The IAIABC and ANSI Format is detailed in the IAIABC Release 1 EDI Implementation Guide. An updated ANSI Format and examples are available in the appendix of this Guide.

NJCRIB Data Edits
The industry state reporting standards include a process that enables a claim administrator to relate a generic edit to data used in any state report. Two charts are provided. The first identifies edits applied to NJCRIB FROI and SROI reports. The second identifies edits applied to Header and Trailer transactions. All Reports submitted to NJCRIB are edited against the appropriate chart.

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IAIABC DN

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 First Report Transaction Trigger = Within 21 days Transaction Set ID Maint. Type Code Maint. Type Code Date Jurisdiction Agency Claim Number Insurer FEIN Insurer Name TPA FEIN TPA Name Claim Admin. Address Line 1 Claim Admin. Address Line 2 Claim Admin. City Claim Admin. State Claim Admin. Postal Zip Claim Admin. Claim Number IAIABC Data Element Name Mandatory Field Not Present Number of Days Worked must be 0-7 Must be Numeric 0 - 9 Must be a valid date (CCYYMMDD) Must be A-Z, 0-9 or spaces
030 001

NJ CRIB EDI Implementation Guide TR TR TR TR TRC TR TR TRC TRC TR TR TR TR TR
018 028 029

New Jersey Edit Matrix Table

Error Messages

Page 70

TR TR TR TR TE TE TE TE TE TE TR TRC TE TRC TR TR TR TR TR TR TR

Must be a vaild time (HHMM) Must be <= Date of Injury Must be >=Date of Injury Must be >= Date Disability Began
037 031 033 034 035

Must be <= Maintenance Type Code Date Must be => Start Date No Match on NJCRIB Database All Digits Cannot be the Same Must be <= Current Date Not Statutorily Valid No Matching Subsequent Rpt (A49) No Matching FROI (148) TR TR Must be <= Date of Hire Duplicate Transmisson / Transaction TR TR TR TR TR TR TR TR Code / ID Invalid
058

038 039 040 041 042 050 053 055 057

May 15, 2002

TR TRC TE TR

Value not consistant with previous rpt Invalid Record Count Must Be >= Policy Effective Date Must be <= Policy Expiration date No Leading or Embedded Spaces TR TR
059 066 067 068 100

Error Messages
Value not consistant with previous rpt Number of Days Worked must be 0-7 Duplicate Transmisson / Transaction Must be <= Maintenance Type Code Date Must be => Start Date No Matching Subsequent Rpt (A49) Must be a valid date (CCYYMMDD) Must be >= Date Disability Began Must Be >= Policy Effective Date No Leading or Embedded Spaces TR TE TE TR TR TR TRC TRC TR TR TR TR
May 15, 2002

No Match on NJCRIB Database

All Digits Cannot be the Same

Must be a vaild time (HHMM)

Mandatory Field Not Present

Must be A-Z, 0-9 or spaces

Must be <= Date of Injury

Must be <= Current Date

Must be >=Date of Injury

No Matching FROI (148)

Must be <= Date of Hire

Must be Numeric 0 - 9

IAIABC DN 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

IAIABC Data Element Name Employer FEIN Insured Name Employer Name Employer Address Line 1 Employer Address Line 2 Employer City Employer State Employer Postal Code Self Insured Indicator SIC Code Insured Report Number Insured Location Number Policy Number Policy Effective Policy Expiration Date of Injury Time of Injury Postal Code of Injury Site Employers Premise Indicator Nature of Injury Code Part of Body Injured Code Cause of Injury Code

001

018 028 029

030

031 033 034 035

037

038 039 040 041 042 050 053 055 057

058

059 066 067 068 100

TR TR TR TR TR TR TR TR

TR TE TE TE TE TE TR TRC TE TE TE TE TR TR TR

TR

TR TRC TR

TRC TRC TRC TR TR TR TR TR TR TR

TR TR TE

Invalid Record Count

Not Statutorily Valid

Code / ID Invalid

TR TE TE

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Must be <= Policy Expiration date TR

Error Messages
Value not consistant with previous rpt Number of Days Worked must be 0-7 Duplicate Transmisson / Transaction Must be <= Maintenance Type Code Date Must be => Start Date No Matching Subsequent Rpt (A49) Must be a valid date (CCYYMMDD) Must be >= Date Disability Began Must Be >= Policy Effective Date No Leading or Embedded Spaces Must be <= Policy Expiration date

No Match on NJCRIB Database

All Digits Cannot be the Same

Must be a vaild time (HHMM)

Mandatory Field Not Present

Must be A-Z, 0-9 or spaces

Must be <= Date of Injury

Must be <= Current Date

Must be >=Date of Injury

No Matching FROI (148)

Must be <= Date of Hire

Must be Numeric 0 - 9

IAIABC DN 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59

IAIABC Data Element Name Accident Description / Cause Initial Treatment Code Date Reported to Employer Date Reported to Claims Admin. 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

001

018 028 029

030

031 033 034 035

037

038 039 040 041 042 050 053 055 057

058

059 066 067 068 100

TR TR TR TR TR TR TR TR TR TR TR TR TR TRC TRC TRc

TE TR TE TR TE TE TE TE TE TE TR TE TR TE TR TR TR TE
May 15, 2002

TR TE

TR TE TR TR

TR TE TE

TRC TE TR TE TE

TR TRC TRC TR TE TE TR TE TE TE TE TE

TR

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Invalid Record Count

Not Statutorily Valid

Code / ID Invalid

Error Messages
Value not consistant with previous rpt Number of Days Worked must be 0-7 Duplicate Transmisson / Transaction Must be <= Maintenance Type Code Date Must be => Start Date No Matching Subsequent Rpt (A49) Must be a valid date (CCYYMMDD) Must be >= Date Disability Began Must Be >= Policy Effective Date No Leading or Embedded Spaces Must be <= Policy Expiration date

No Match on NJCRIB Database

All Digits Cannot be the Same

Must be a vaild time (HHMM)

Mandatory Field Not Present

Must be A-Z, 0-9 or spaces

Must be <= Date of Injury

Must be <= Current Date

Must be >=Date of Injury

No Matching FROI (148)

Must be <= Date of Hire

Must be Numeric 0 - 9

IAIABC DN 60 61 62 63 64 65 66 67 68 1 2 3 4 6 8 14 42 55 69 56 70

IAIABC Data Element Name Occupation Description Date of Hire Wage Wage Period Number of Days Worked Date Last Day Worked Full Wages Pd for Date of Injury Ind. Salary Continued Indicator Date of Return To Work Subsequent Report Transaction Transaction Set ID Maint. Type Code Maint. Type Code Date Jurisdiction Insurer FEIN TPA FEIN Claim Admin. Postal Zip Social Security Number Number Of Dependents Pre-Existing Disability Date Disability Began Date of Maximum Medical Improvement

001

018 028 029

030

031 033 034 035

037

038 039 040 041 042 050 053 055 057

058

059 066 067 068 100

TR TE TR TR TR TRC TR TR TRC TR TR TE TR TR TR TR TR TRC TR TR TRC TRC

TE TE TE TR TE TE TE TE TR TE TE TR TR TR TR TR TR TR TR TR TR TR TR TR TR TR TR TR TR TRC TR TR TR TR TR TR TR TR TR TR
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TR TR TR TR TR

TRC TE

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Invalid Record Count

Not Statutorily Valid

Code / ID Invalid

Error Messages
Value not consistant with previous rpt Number of Days Worked must be 0-7 Duplicate Transmisson / Transaction Must be <= Maintenance Type Code Date Must be => Start Date No Matching Subsequent Rpt (A49) Must be a valid date (CCYYMMDD) Must be >= Date Disability Began Must Be >= Policy Effective Date No Leading or Embedded Spaces TR Must be <= Policy Expiration date

No Match on NJCRIB Database

All Digits Cannot be the Same

Must be a vaild time (HHMM)

Mandatory Field Not Present

Must be A-Z, 0-9 or spaces

Must be <= Date of Injury

Must be <= Current Date

Must be >=Date of Injury

No Matching FROI (148)

Must be <= Date of Hire

Must be Numeric 0 - 9

IAIABC DN 71 72 57 62 63 64 67 31 26 15 5 73 74 75 76 77 78 79 80 81 82

IAIABC Data Element Name 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 Perminant Impairments Number of Payment/Adjustments Number of Benefit Adjustments Number of Paid to Date/Reduced Earnings/Recoveries Number of Death Dependant/Payee

001

018 028 029

030

031 033 034 035

037

038 039 040 041 042 050 053 055 057

058

059 066 067 068 100

TRC TRC TR TRC TR TR TR TR TR TR TE TR TR TR TR TR TR TR TR TR TR TR TR TR TR
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TE TR TR TR TR TR TR TR TE TR TR TE TE TE TR TR TR TR TR TR TE TR TE TR TR TR TE TRC TRC TRC TRC TRC
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Invalid Record Count

Not Statutorily Valid

Code / ID Invalid

TE TE TE

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Error Messages
Value not consistant with previous rpt Number of Days Worked must be 0-7 Duplicate Transmisson / Transaction Must be <= Maintenance Type Code Date Must be => Start Date No Matching Subsequent Rpt (A49) Must be a valid date (CCYYMMDD) Must be >= Date Disability Began Must Be >= Policy Effective Date No Leading or Embedded Spaces Must be <= Policy Expiration date

No Match on NJCRIB Database

All Digits Cannot be the Same

Must be a vaild time (HHMM)

Mandatory Field Not Present

Must be A-Z, 0-9 or spaces

Must be <= Date of Injury

Must be <= Current Date

Must be >=Date of Injury

No Matching FROI (148)

Must be <= Date of Hire

Must be Numeric 0 - 9

IAIABC DN

IAIABC Data Element Name

001

018 028 029

030

031 033 034 035

037

038 039 040 041 042 050 053 055 057

058

059 066 067 068 100

83 84 85 86 87 88 89 90 91 92 93 94 95 96

Relationships Permanent Impairment Occurs Number of Permanent Impairment Times Permanent Impairment Body Part Code TRC Permanent Impairment Percent TRC TE Payment/Adjustments Occurs Number of Payments/Adjustment Times Payment/Adjustment Code TRC Payment/Adjustment Paid To Date TRC TR Payment/Adjustment Weekly Amount TRC TR Payment/Adjustment Start Date TRC TR TE TE TE C Payment/Adjustment End Date TR TR TE TE TE TE Payment/Adjustment Weeks Paid TRC TR Payment/Adjustment Days Paid TRC TR TR Benefit Adjustments Occurs Number of Benefit Adjustment Times Benefit Adjustment Code Benefit Adjustment Weekly Amount Benefit Adjustment Start Date Paid To Date/Reduced Earnings/Recoveries Occurs Paid To Date/Reduced Earnings/Recoveries Times Paid To Date /Reduced Earnings TRC /Recoveries Code Paid To Date /Reduced Earnings TRC TR /Recoveries Amount Death Dependant/Payee Relationship Times

TE

TR TR TE TE

TR

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Invalid Record Count

Not Statutorily Valid

Code / ID Invalid

NJ CRIB EDI Implementation Guide IAIABC IAIABC Data Element Name DN 97 Dependant/Payee Relationship Header & Trailer Records (HD1 & TR1) 98 Sender ID 99 Receiver ID 100 Date Transmission Sent 101 Time Transmission Sent 104 Test / Production Indicator 105 Interchange Version ID 106 Detail Record Count Mandatory Field Not Present
001

TRC

TR TR TR TR TR TR TR

Error Messages
Number of Days Worked must be 0-7 Must be Numeric 0 - 9 Must be a valid date (CCYYMMDD) TR Must be A-Z, 0-9 or spaces
030 018 028 029

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TR TR TR TR TR TR TR

Must be a vaild time (HHMM) Must be <= Date of Injury Must be >=Date of Injury Must be >= Date Disability Began
037 031 033 034 035

Must be <= Maintenance Type Code Date Must be => Start Date No Match on NJCRIB Database All Digits Cannot be the Same Must be <= Current Date Not Statutorily Valid No Matching Subsequent Rpt (A49) No Matching FROI (148) Must be <= Date of Hire Duplicate Transmisson / Transaction Code / ID Invalid
058

038 039 040 041 042 050 053 055 057

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TR

TR TR TR

Value not consistant with previous rpt Invalid Record Count Must Be >= Policy Effective Date Must be <= Policy Expiration date No Leading or Embedded Spaces
059 066 067 068 100

Conditional Data Elements/Edits
IAIABC DN

IAIABC Data Element Name First Report of Injury Agency Claim Number TPA FEIN TPA Name Claim Admin. Postal Zip

Condition Required if MTC (DN 2) is not either Original, 00 or Acquired/Unallocated, AU. Send if available on Acquired/Unallocated (AU). If either DN 8 or 9 present, the other is required. Must match prior FROI (00 or AU, whichever is latest dated FROI). If either DN 8 or 9 present, the other is required. If DN 13, Claim Administrator State is a valid USA state code, error message 028 and 058 are applied; else error message 030 is applied. 058 refer to length of zip not to validity of the code. If Employer State Code (DN 22) is a valid USA state code, error message 028 and 058 are applied; else error message 030 is applied. Error message code 058 refers to length of zip not to validity of the code Required if DN 24 = N or if DN 29 or 30 is present; else does not apply. Required if DN 24 = N or if DN 28 or 30 is present; else does not apply. Required if DN 24 = N or if DN 28 or 29 is present; else does not apply. If Employer Premises Indictor (DN 34) = Y and Employer State (DN 32) is a valid US State then error message 028 and 058 apply; else error message 030 is applied. Error Message 058 refers to length of zip not to validity of the code. If Employee State Code (DN 49) is a valid USA state code, error message 028 and 058 are applied; else error message 030 is applied. Error message code 058 refers to length of zip not to validity of the code. Error Message 058 refers to the acceptable length --either 7 or 10 numerics Required if DN 57, Date of Death present. Required if DN 57, Date of Death present. Required if DN 64, Number of Days Worked is completed. Required If DN 55, Date Disability Began is completed. If DN 56, Date Disability Began completed, then DN 65 required If DN 8 present on FROI, DN 8 required on SROI; Must match prior FROI (00 or AU, whichever is latest dated FROI). Required if DN 57, Date of Death present; else does not apply.

5 8 9 14

23

Employer Postal Code

28 29 30 33

Policy Number Policy Effective Policy Expiration Postal Code of Injury Site

50

Employee Postal Code

51 54 55 56 64 65 8 55

Employee Phone Marital Status Code Number of Dependents Date Disability Began Number Of Days Worked Date Last Day Worked Subsequent Report Transaction TPA FEIN Number Of Dependents

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Conditional Data Elements/Edits
IAIABC DN

IAIABC Data Element Name Date Disability Began Number of Days Worked Return to Work Qualifier Date of Return/Release to Work Employee Date of Death Number of Perminant Impairments Number of Payment/Adjustments Number of Benefit Adjustments Number of Paid to Date/Reduced Earnings/Recoveries Number of Death Dependant/Payee Relationships Permanent Impairment 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 /Reduced Earnings /Recoveries Code Paid To Date /Reduced Earnings /Recoveries Amount Dependant/Payee Relationship

Condition Required If DN 74 is L or I; else is optional. Required if DN 74 is L or I; else is optional. Required if DN 72, Date of Return/Release to work present; else does not apply. Required if DN 71, Return to Work Qualifier present; else does not apply. Required if DN 85 = 010 or 510; else does not apply. Error Message 058 refers to the number of valid occurrences (may be 0 – 6) Error Message 058 refers to the number of valid occurrences (may be 0 – 10) Error Message 058 refers to the number of valid occurrences (must be 0) Error Message 058 refers to the number of valid occurrences (may be 0 – 25) Error Message 058 refers to the number of valid occurrences (may be 0 – 12) If either DN 83 or 84 present the other is required If either DN 83 or 84 present the other is required Required if either Payment/Adjustment Paid to Date Amt (DN 086) or Weekly Amt (DN 087) or Start Date (DN 88) or End Date (DN 89), Weeks Paid (DN 90) or Days Paid (DN 91) are present. If DN 85 present and if DN 85 is other than 240 or 500, required If DN 85 present and if DN 85 is other than 240 or 500, required If DN 85 present and if DN 85 is other than 240 or 500, required If DN 85 present and if DN 85 is other than 240 or 500, required If DN 85 present and if DN 85 is other than 240 or 500, required If DN 85 present and if DN 85 is other than 240 or 500, required Does Not apply to NJ SROI Does Not Apply to NJ SROI Does Not Apply to NJ SROI If either DN 96, PTD/RE/Recoveries Amt or DN 95 PTD/RE/Recoveries is present then both are required If either DN 96, PTD/RE/Recoveries Amt or DN 95 PTD/RE/Recoveries is present then both are required At least one iteration of DN 97 is required if DN 86 = 010 or 510.

56 64 71 72 57 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97

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Acknowledgement and Correction Process
The industry standard for State Reporting includes a process where the State edits and acknowledges each report it receives. The Acknowledgement will show the status of each report as either: • • • Transaction Accepted (TA), Transaction (accepted with) Errors (TE), or Transaction Rejected (TR).

A status of TA requires no response. A TE Acknowledgement will list the code of each data element that failed editing, and the code of the edit that detected the error. Also, a status of TE requires that a Correction transaction (FROI or SROI) record, as appropriate, be submitted with correct values for the reported data errors. A status of TR requires that the report be resubmitted.

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Transaction Sequence Requirements
First Reports
The first transaction that NJCRIB receives on a claim must be an Original (00), Acquired/Unallocated (AU), or a Denial (04). Only one Original or Denial transaction is permitted per claim. Only one Acquired/Unallocated transaction per claim administrator is permited per claim. A Cancel (01) or Change (02) requires that an Original, Acquired/Unallocated, or Denial was previously submitted and accepted by NJCRIB. A Correction (CO) is a response to an NJCRIB Acknowledgement with errors. NJCRIB will edit all transactions it receives and notify the reporting administrator if a report was rejected, accepted, or accepted with errors. Only transactions accepted with or without error by NJCRIB will be considered as meeting NJCRIB reporting requirements. A transaction that is accepted without errors satisfies that NJCRIB reporting requirement. A transaction that is rejected by NJCRIB must be resent. The date of accepted transactions with or without errors is used to measure reporting compliance. However, transactions accepted with errors require correction, even though the date originally received will be used to measure reporting compliance.

Subsequent Reports
NJCRIB requires that a First Report, Original, Acquired/Unallocated, or Denial was previously submitted and accepted by NJCRIB before a subsequent Semi-Annual (SA) or Denial (04) transaction will be accepted. A Subsequent Change (02) transaction requires that a Semi-Annual (SA) or Denial (04) transaction was previously accepted. A Subsequent Correction requires that an Acknowledgement had already been received on a SemiAnnual (SA), Denial (04), or Change Transaction (02).

NOTE: Please refer to the IAIABC Release 1 Specifications for report transaction
(Maintenance Type Codes, e.g. SA, 04, 02, etc.) definitions and Transaction Sequence Requirements.

IMPORTANT IMPLEMENTATION NOTE: The IAIABC EDI Reporting Process was
developed to meet diverse jurisdiction reporting requirements. Therefore the specifications include numerous reports (MTCs) and the Transaction Sequence Requirements must account for all possible transactions. Other jurisdictions that require the Semi-Annual Transaction (SA) also require the Initial Payment (IP) or Full Salary (FS). Administrators who report to these states probably apply the IAIABC Transaction Sequence rule before submitting a SA. The absence of aN NJCRIB requirement of an IP or FS transaction may be problematic for these administrators.

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NJCRIB encourages claim administrators to recognize that other states will not require every transaction and that similar perceived Transaction Sequence conflicts will arise. It is suggested that administrators revisit their EDI process and augment it as follows. Program your system with IAIABC requirements. When a claim event, such as issuance of an Initial Payment (IP) occurs, perform it as scheduled. However, before submitting the corresponding Transaction (MTC), check the jurisdiction’s report requirements. If the Report (MTC) is required, send it and continue processing as per the acknowledgement it yields. If the Report (MTC) is not required, post your EDI management system so that the requirement has been satisfied and allow any Transaction Sequence Rules dependent on previous submission of that Report to function normally for all states.

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Reporting Process Functions and Options
A comparison of the NJCRIB EDI Requirements with your manual and computer system processes may identify both manual and technical deficiencies. The previous section provided the NJCRIB requirements. This section depicts the State EDI Reporting Processes at a high level. It is followed by a section of EDI Products that may be built in-house or acquired commercially. The objective of this section is to increase your awareness of the process and potential solutions. It should be used in conjunction with your organization’s formal project development plan. The State EDI Reporting Process includes: • • • • • • Managing State Reporting Requirements. Capturing State Report Data. Editing for Data Content and Quality. Translating Data into or from IAIABC or ANSI Formats. Managing Communications (Report Transmissions). Managing Acknowledgements, Replacement Reports, and Corrections.

Manage State Reporting Requirements
State Reporting has typically been performed through the combined efforts of the Claim Adjuster and Administration staff. EDI reporting provides the potential to replace Claim Adjuster report monitoring by automated process based on claim system data or claim adjuster actions. The receipt of Acknowledgements can initiate computer or claim adjuster responses. The level of sophistication can range greatly between administrator processes.

Capture State Report Data
A common dilemma for Claim Administrators is the capture and electronic storage of data required by State’s implementing EDI Reports. Although creating national standard data elements simplifies claims administrator and state reporting, there is often a void between a State’s reporting data requirements and data available through the claim administrator’s claim handling computer system. How do you resolve the difference? If the missing data falls within the category of “Optional,” no immediate fix may be required. If the missing data involves “Conditional” or “Mandatory” data an immediate solution is in order. Missing data solutions vary and are dependent on several factors, such as claim volume, age and flexibility of your claim handling computer system, as well as priority of other business objectives and projects. Solutions fall into three basic categories: 1. Modify your claim handling computer system and claim process to capture the missing data. 2. Supplement your claim handling computer system with an additional data entry and storage application for the missing data. 3. Use a combination of computer system and manually captured data sources.

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Data Entry Products
A Data Entry Product is a software product that augments an existing claim handling system. Such systems usually contain the generic state reporting standard data and provide the capability to apply a state’s report and data requirements. These products import data from the Claim Administrator’s system and allow one or more staff to enter the missing Mandatory, Conditional, or Optional data. Complexity of this application, cost, number of states to be implemented, and frequency of requirement changes should be considered as part of a make/buy decision. NJCRIB and NJDWC have provided an Internet data entry solution for statutory non-insured. An important aspect of the NJCRIB EDI State Reporting implementation is to improve the data quality of the Reports NJCRIB and NJDWC receives. Attaining and sustaining “Production” status and avoiding possible fines requires maintaining NJCRIB Data Quality minimum requirements. All NJCRIB reports should be edited and corrected prior to submission to NJCRIB.

Data Content and Quality Editing Products
A data content and quality editing product is a software product that edits Claim Administrator state report data against a state’s requirements. Such systems usually contain specific edits for state reporting data content and business requirements. Data entry and data content and quality editing features are often found in the same product.

Translate Data into or from IAIABC or ANSI formats
Claim Administrator Systems data is usually stored in a proprietary format that is not readily exchangeable between organizations. Translation to specific technical data requirements and structuring the data in a standard format such as IAIABC flat file or ANSI X12 148 transaction is required to make the report easily received and processed by others.

Translator Products
A translator is a software product that converts data from one format to another. It may serve the purpose of converting proprietary claim administrator computer system data into either IAIABC Flat File or ANSI X12 transactions. Conversely, it is used to convert IAIABC Flat File and ANSI Transactions into proprietary claim administrator computer system data. Translators typically contain the capability to process one or more sets of related transactions. For example, a translator will typically do all the Workers Compensation transactions. Some may also include the ability to do health care, purchase orders, etc. They typically include the ability to recognize versions of a transaction. For example, a translator may meet IAIABC Release 1 and Release II requirements. To achieve these capabilities, the user is required to “map” their computer system data names to the desired IAIABC or ANSI transactions. Translators vary greatly in capability and the platforms on which they run. Some require a mainframe environment while others only require personal computer (PC) capabilities. Claim Administrators with large mainframe claim management applications have effectively used a PC translator to satisfy multiple state EDI reporting. Translators often combine communication capabilities for processing internal or external sources of data. In-house technical staff will be required to install and operate a translator.

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Manage Communications/Transmissions
Success of State EDI Reporting is dependent on the technical ability to pass data between organizations. Data transfer may occur directly between organizations or through intermediaries. Data transfer interruptions may occur and data could be lost. This process includes: • • • • Managing trading Partner electronic addresses Scheduling transmission sends and receives (24 hours a day) Recording the success or failure of each attempted send and receive Backing up transmission data for a specific period follows a successful send or receive.

This process is a combination of automated software applications and technical operator review of daily transmission results and intervention to identify technical difficulties or reinitiate transmission or recovery operations.

Communications Management Products
These products consist of software and hardware components. The software component is used to manage the movement of the data and to operate the associated communications hardware. These products are likely to have certain limitations. Applications and sophistication of the software/hardware may vary greatly.

VANs
A Value Added Network (VAN) is a facility used to exchange electronic files between organizations. A VAN can be viewed as a huge community “hard drive” that contains separate storage (Mail Boxes) for its subscribers. It provides a place for the Claim Administrator to send State Reports to and a place to pick up acknowledgements from the states. Such facilities run 24 hours a day and provide “Federal Quality” data security, reliable backup, and reliable data transfer with communication level acknowledgement. It relieves each subscriber from considerable hardware, software, and personnel investments and virtually extends your organization’s hours of operation. Unless EDI Volume is very large, or an Organization has excess capacity, VANs probably provide a significant cost advantage. Some protocol differences exist between the major VANS, but once established, VANs provide expansive connectivity to States and Claim Administrators, Employers, and Medical Providers.

E-Mail Address
With the proliferation of Internet Access and E-mail accounts, E-mail could be used to pass attached files (IAIABC or ANSI) much like a VAN stores EDI transmissions. This usage in a State Reporting context is relatively new and feedback on its success is limited. Possible concerns with sending State Reports via E-mail are file capacity limits, data security, and lack of communication acknowledgements. When used between two trading partners, such as a Claim Administrator and Vendor it may be a very viable solution. An experienced EDI Vendor providing connectivity to NJCRIB may include this type of communication between your organization and the Vendor. At present, NJCRIB will not accept EDI claims transactions via e-mail.

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Manage Acknowledgements, Replacement Reports, and Corrections
EDI is the reciprocal transfer of data between organizations. In State Reporting, the state responds to each submitted report with an acknowledgement that the report was accepted, accepted with errors, or rejected. It is the responsibility of the claim administrator to replace rejected reports with acceptable reports and correct data on reports accepted with errors. A rejected report is not considered filed until it has been corrected, retransmitted, and accepted with or without errors. Whereas some reports require the prior acceptance of another report, failure to replace rejected reports can cause other reports to be rejected and therefore to be late. This process involves review of state Acknowledgements one or more times a day, to initiate correction. Failure to receive an acknowledgement of acceptance may be used to stop additional reports on that claim until corrections are made.

Manage Acknowledgements, Replacement Reports, and Corrections Products
This functionality may be built as an in-house product or acquired commercially. This function is typically a feature within a multifeature product.

Submitting Options to Consider
A review of the NJCRIB Reporting Requirements and your current capabilities is a prerequisite to evaluating the various solutions presented below. Products range from specific EDI functions to integration with your existing system to meet all your state EDI reporting requirements. Make/buy cost comparison, frequency of reporting criteria changes, maintenance, and available lead-times are a few of the criteria that you should evaluate. The viability of any of these product types depends on your specific needs. This IG and the options presented in it should be part of a formal process that includes management, claim, and technical staff participation.

Workers Compensation EDI Reporting Products
State Reporting Products vary and may include several to all of the following features: • • • • • • Managing State Reporting Requirements. Capturing State Report Data. Editing for Data Content and Quality. Translating Data into or from IAIABC or ANSI formats. Managing Communications (report transmissions). Managing acknowledgements, replacement reports, and corrections.

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Stand Alone and Server-Based Workers Compensation EDI Reporting Products
Workers Compensation EDI reporting products are available in stand-alone and server-based versions. A stand-alone version is a single workstation that can be used to process the entire organization’s state reports. A server-based system allows multiple users so that EDI state reporting data entry or management can be distributed to many workstations. Claim volume or number of locations, and whether the claims system is centralized or distributed may affect the type and number of EDI products needed. These solutions are probably best suited for moderate to high volume claim systems. These services may include or specify a VAN or other communication method as part of the process. These systems can be used by employers to report to claim administrators or for claim administrators to report to states.

Web-based Data Entry & EDI Reporting Services
Web-based worker’s compensation products allow an organization to meet its reporting requirements through totally external processes. With this type of product, a designated claim person signs on to a web site application, selects a state or claim administrator, and enters the data for the claim. The user would log on later to receive the acknowledgement that the claim was accepted, accepted with errors, or rejected and respond accordingly. Because this process requires manual data entry and does not allow for loading data directly from a claim system process it is probably best suited to low volume users. Expect the unit per claim charge to be higher than high volume solutions but requires little commitment or investment. These systems can be used by employers to report to claim administrators or for claim administrators to report to States.

Claim EDI Reporting Services
Several claim administrators have created or contracted with claim reporting services. These services may accept claims reported by telephone, fax, or E-mail. When they serve as your EDI submitter, they will perform the equivalent of the EDI reporting features 1 through 6 noted above. The details of each service should be worked out with that particular vendor. These systems can be used by employers to report to claim administrators or for claim administrators to report to States.

In-house Vs. Vendor Products and Services
Implementing EDI is a complex process. EDI knowledge and experience is of major value and consideration to avoid the major pitfalls associated with developing and implementing EDI. Most EDI implementations are a combination of in-house and EDI vendor products and services. Consider both short term and long term EDI Objectives. Your success will depend on knowing which to use for what purpose. The involvement of vendors may simplify and reduce the analysis effort required by claim administrators and ultimately lower implementation and operation costs. Many products include specialized automated routines that require in-depth knowledge of EDI standards, protocols, and each state’s requirements. Off-the-shelf products may avoid consuming talents from high priority projects, cost less, and be available in the time allowed. Dedicated services and products may allow your organization to focus on providing claim services instead of EDI reporting. NJ CRIB EDI Implementation Guide

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Each organization should analyze its capabilities, weaknesses, and Plan of Operation to decide upon the best mix of in-house and vendor services. Questions to consider when choosing an EDI Vendor Product or Service: • • • • • • • • • • • • Are they an experienced IAIABC standards vendor? How much IAIABC participation and knowledge of the EDI standards do they have? How much EDI experience and knowledge do they have? How much workers compensation experience and knowledge do they have? Are they in EDI production and in how many states? Do they have a strong client base? Do they provide dedicated customer & technical support? Do they provide EDI and software training? What experience do they have with the IAIABC flat files and ASC (ANSI) X12 record layouts? Are they committed to quality assurance in data submission and software testing? Are they financially secure? How do their clients evaluate their products and services?

What can an Experienced EDI Vendor or Service Provider do for you?
There are EDI Vendors experienced with the IAIABC standards that can provide EDI software packages, Web based claim-reporting services, paper processing to EDI Services, value added networks (VANs) service, Internet services and EDI consulting services. The IAIABC can provide a list of vendors that are experienced in EDI technology and workers' compensation requirements.

Some of the Services and Products Vendors can Provide (but not limited to) Include:
• • • • • • • • • • Software to submit data electronically Data editing prior to transmission to the state Return acknowledgement processing Management tools and reports to ensure quality data is reported to the state Web-based claim form submission Liaison between the carrier/trading partner and the state Training and orientation in EDI, state requirements, software, etc Help with EDI testing and implementation Provide business and technical support Consulting services, analysis of your needs and system requirements

NOTE: NJCRIB does not recommend or advise against the products or services of any
vendor. NJCRIB suggests that NJCRIB EDI participants carefully review experienced vendor products and claims as well as contacting customers and other participants to benefit from their experience. NJ CRIB EDI Implementation Guide
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NJCRIB EDI Trading Partner Process
The usual steps taken to becoming a NJCRIB Trading Partner are given in this section. Some of these steps involve tasks that have been explained in prior sections and are offered here as reminders. You should note also that your business environment might dictate you take supplemental steps between those being suggested below. Or, as an experienced EDI partner, trading with other jurisdictions, you may find it unnecessary to repeat some of these steps to become a trading partner with the NJCRIB. We do, however, emphasize that we require that you formally comply with Steps 1, 5, 6, and 8 listed below. More information expanding on each step follows. When forms are referenced in these steps, how to find instructions for completing the forms is also included. If, after reviewing the steps you would like to discuss them further, please call the NJCRIB EDI Test Coordinator at 1-800-240-0088.

1. Contact the IAIABC/Purchase the IAIABC EDI Release I Implementation Guide
A clear understanding of the IAIABC definitions and standards is required to be a successful EDI Trading Partner in New Jersey. Visit their web site http:\\www.iaiabc.org, or call them at (608) 2771479 to obtain a copy of their Implementation Guide and other publications that may assist you in implementing New Jersey requirements. New Jersey Division of Workers Compensation and the New Jersey Compensation Rating & Inspection Bureau’s EDI Implementation Guide (this Guide) provides supplemental, NJ-specific, information to that provided in the IAIABC EDI Release I Implementation Guide.

2. Appoint an EDI Coordinator
Once NJCRIB has received the completed NJCRIB EDI Questionnaire, NJCRIB will pass the information to the NJCRIB EDI Test Coordinator who will be expecting you to send in the Trading Partner Agreement and Trading Partner Profile. Once the Trading Partner Agreement and Profile have been received, the NJCRIB EDI Test Coordinator will contact you to develop and agree upon a testing and implementation plan and schedule. During this initial contact, our EDI Test Coordinator will ask for the name and contact information for your EDI Implementation Coordinator. Our expectations is your EDI Implementation Coordinator will be a person knowledgeable about • • • • Your source data, How to retrieve it, Your business process and systems that support it, And be empowered to speak on behalf of your organization.

NJCRIB expects continuing implementation contacts will be handled through your EDI Implementation Coordinator.

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We recommend that your EDI Implementation Coordinator attend all NJCRIB informational meetings, become involved in the IAIABC EDI committees, and other organizations that will assist your company in becoming knowledgeable in the EDI standard processes. NJCRIB does not endorse nor will we financially assist you in any of these endeavors. These are suggestions and recommendations that you may find of assistance to you.

3. Review NJ EDI Data Requirements and Claim Events that Require Reporting
Refer to Steps to Implement EDI and review the Report and Data Requirements and EDI Reports and Related Events sections. From your review of this detail section your EDI Implementation Coordinator will have a list of data elements (which use the IAIABC name and numbers defined in the IAIABC Release 1 Implementation Guide) and the business events or situations that trigger specific EDI transaction to be filed with NJCRIB.

4. Examine your NJ WC Business Processes to Determine how NJ EDI Requirements Fit with them
Review how the data elements NJCRIB requires on its EDI reports are: • • • Captured in your claim data source system. How you will supplement your system’s data capture routines. How you will build the EDI transactions for transmission to NJCRIB.

5. Complete and Return the NJ EDI Trading Partner Agreement
NJCRIB requires that the Trading Partner Agreement form be completed by the business entity that is the source for the claim data. The source is usually the Claim Administrator handling the claim but the source may be the insurance carrier or a self insured or non-insured if a Third Party Administrator is handling the claim on their behalf. Complete the Trading Partner Agreement immediately and send the Agreement to the NJCRIB EDI Test Coordinator (either via fax or e-mail). A sample Agreement form follows on the next page for illustrative purposes only. Note that it portrays a partnership agreement between NJCRIB and a fictitious carrier. A blank NJCRIB EDI Trading Partner Agreement for your use is included following the illustrative sample. You may remove it from the Guide or you may photocopy it from the Guide and use the photocopy. Or, a blank form can be downloaded from the NJCRIB web site, printed and used for the same purpose. If the NJCRIB EDI Test Coordinator has not received a signed and dated Agreement two weeks prior to your mandatory scheduled test date the Test Coordinator will contact you to determine the status of your Trading Partner Agreement. If you have applied for a variance, please inform the EDI Test Coordinator of that status and forward a copy of the variance petition and grant so that we may schedule your test at an appropriate time.

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NJCRIB EDI Project Agreement Sample
NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU ELECTRONIC DATA INTERCHANGE (EDI) PROJECT 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: New Jersey Compensation Rating and Inspection Bureau (hereafter NJCRIB); and The ABC Insurance Company of Newark, New Jersey_ (Partner Company) and all other companies within the (Partner Company) authorized to write WC insurance or provide insurance related services (hereafter Reporter). 2. 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 and Subsequent Report of Injury to the NJCRIB. The Objective is to initiate, implement, and maintain First Reports of Injury and Subsequent Reports of Injury through electronic filing. 3. Both agree that the Objective is lawful and performance hereunder shall be deemed complete performance 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 NJCRIB or any related governmental entity for permission to file information electronically. 4. Exhibit A, 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 the data transmissions from the Reporter, including original submissions and corrections or resubmissions as needed (data transmissions). b. The test and implementation plan and schedule under which the parties will prepare to send and receive data from each other. c. The schedule, form, including data element definitions, and format of data transmissions from the NJCRIB, including acknowledgments, notices of error or notices of acceptance as applicable (data transmissions).

d. The Value Added Network (VAN) or other carrier that will be used to transmit and receive data transmissions. e. The allocation of data transmission costs between the parties. 5. Each party shall retain the content of data transmissions in confidence to the extent required by law. Agreed this 12th day of June 2000 for the parties by their duly authorized or lawfully empowered representatives. J. Paul Jones (signature) J. Paul Jones (name) Branch Claim Manager (title)
ABC Insurance Company of Newark

P.T. Administrator (signature) P.T. Administrator (name) Director (title)
New Jersey Compensation Rating & Inspection Bureau

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NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU
A.1. The Reporter and NJCRIB agree to use the national EDI standards for First and Subsequent Reports of Injury, Release I, established by the International Association of Industrial Accident Boards and Commissions, in any available format (i.e. flat file or ANSI X12). The Project will commence with the transmission of the version of the First Report Injury defined per paragraph C3 below on _July 1, 2002_________. During the testing phase, the Reporter will be required to file paper forms in addition to the electronic transmission of records. Once the testing requirements are met, the Reporter will no longer be required to file paper forms with the NJDWC. If the Reporter’s customers are required to file a paper copy of the First Report, the NJCRIB agrees to waive the requirement for all reports made to the NJCRIB 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 80% of all electronic first reports (a) meet or pass all technical requirements for the test period, which shall be no longer than four (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.) data dictionary as it is today and as amended from time to time and approved by the I.A.I.A.B.C. or as otherwise agreed between the parties in writing. The transmission of data will occur on Tuesday of each week from the Reporter or as otherwise agreed and will be received by the NJCRIB 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 NJCRIB, but not greater than five (5) business days. Transmission will be accomplished via the Value Added Network (VAN) or web as agreed between the parties from time to time. The Reporter shall pay transmission cost for all reports being sent to the NJCRIB. NJCRIB shall not bear the costs of any transmissions to the Reporter; Reporter shall pay transmission costs for all reports sent by NJCRIB to the Reporter.

B.1.

B.2.

C.1.

C.2. C.3.

C.4. D.1. E.1.

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Trading Partner Agreement
NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU ELECTRONIC DATA INTERCHANGE (EDI) PROJECT 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 n 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: New Jersey Compensation Rating and Inspection Bureau (hereafter NJCRIB); and _________________________________ _ (Partner Company) and all other companies within the (Partner Company) authorized to write WC insurance or provide insurance related services (hereafter Reporter). 2. 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 and Subsequent Report of Injury to the NJCRIB. The Objective is to initiate, implement and maintain First Report of Injury and Subsequent Report of Injury through electronic filing. 3. Both agree that the Objective is lawful and performance hereunder shall be deemed complete performance 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 NJCRIB or any related governmental entity for permission to file information electronically. 4. Exhibit A, 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 the data transmissions from the Reporter, including original submissions and corrections or re submissions as needed (data transmissions). b. The test and implementation plan and schedule under which the parties will prepare to send and receive data from each other. c. The schedule, form, including data element definitions, and format of data transmissions from the NJCRIB, including acknowledgments, notices of error or notices of acceptance as applicable (data transmissions).

d. The Value Added Network (VAN) or other carrier that will be used to transmit and receive data transmissions. e. The allocation of data transmission costs between the parties. 5. Each party shall retain the content of data transmissions in confidence to the extent required by law. Agreed this ____ day of _________ 2002 for the parties by their duly authorized or lawfully empowered representatives.

(signature) (name) (title)

(signature) (name) (title)
New Jersey Compensation Rating & Inspection Bureau

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NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU
A.1. The Reporter and NJCRIB agree to use the national EDI standards for First and Subsequent Reports of Injury, Release I, established by the International Association of Industrial Accident Boards and Commissions, in any available format (i.e. flat file or ANSI X12). The Project will commence with the transmission of the version of the First Report Injury defined per paragraph C3 below on ______________________. During the testing phase, the Reporter will be required to file paper forms in addition to the electronic transmission of records. Once the testing requirements are met, the Reporter will no longer be required to file paper forms with the NJDWC. If the Reporter’s customers are required to file a paper copy of the First Report, the NJCRIB agrees to waive the requirement for all reports made to the NJCRIB 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 80% of all electronic first reports (a) meet or pass all technical requirements for the test period, which shall be no longer than four (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.) data dictionary as it is today and as amended from time to time and approved by the I.A.I.A.B.C. or as otherwise agreed between the parties in writing. The transmission of data will occur on of each week from the Reporter or as otherwise agreed and will be received by the NJCRIB 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 NJCRIB, but not greater than five (5) business days. Transmission will be accomplished via the Value Added Network (VAN) or web as agreed between the parties from time to time. The Reporter shall pay transmission cost for all reports being sent to the NJCRIB. NJCRIB shall not bear the costs of any transmissions to the Reporter; Reporter shall pay transmission costs for all reports sent by NJCRIB to the Reporter.

B.1.

B.2.

C.1.

C.2. C.3.

C.4. D.1. E.1.

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6. Complete and Return the Sender’s Trading Partner Profile
The sender of the EDI transaction is required to complete the Trading Partner Profile. The sender may or may not be the same business entity that is the source or owner of the data, otherwise referred to as the data Reporter. The sender may be the Third Party Administrator or the sender may be the insurance carrier or the self-insured, self-administered employer. However, the data Reporter must advise the NJCRIB EDI Coordinator ofthe name and contact information for the sender of the data if the sender is other than the Reporter who signed the Trading Partner Agreement forms (see #6 above). The Sender ID is required on the Trading Partner Profile. A Sender ID is composed of the sender’s Master FEIN and physical address postal code. A separate Trading Partner Agreement form for each Sender ID (identification) is required. For example: One Trading Partner Profile is required if a sender is forwarding the EDI information for more than one company, from its same location (postal code). The sender may choose which FEIN it designates as the master FEIN. Multiple Trading Partner Profiles are required if a sender has more than one location (postal code) from which it will be forwarding data. A separate Trading Partner Profile is required for each unique FEIN/location (postal code) originating data transfers. Further, if one company has a centralized computer location from which it is sending data for more than one claim office then only one Sender Trading Partner Profile is required (all data transfers are originating from the same FEIN and location). However, if one company is sending data from many different offices each originating a data transfer from its decentralized computers, then separate profiles are required for each sender location even though all are for the same company. In summary, the administrator or organization acting on behalf of the administrator (to compile, transmit, and correct reports required by NJCRIB) must complete this form as part of the preimplementation requirements. The Trading Partner Profile form follows on the next page. You may copy the form from the Guide or you may download a copy of the form from the NJCRIB web site. Complete the copy of the form and send it to the NJCRIB EDI Test Coordinator. Detail instructions for completing the form follow the pages with the blank form.

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New Jersey Trading Partner Profile Application and Confirmation Form
Form Data Entry Requirements: (M) Mandatory (C) Conditional (O) Optional
Purpose: [ ] Submit [ ] Change [ ] Delete
[ [ [ [ [

Trading Partner

A. (M) Trading Partner Name: B. (M) Trading Partner Type:

C. (M) In Production Status with other IAIABC State(s): D. (M) Plan to use NJ Web Claim Data Entry Option (C) If yes, enter anticipated monthly volume: E. Trading Partner (Sender) ID 1. (M) FEIN: 2. (O) TP 3 digit ID (If allowed by State): 3. (M) Postal Code: F. Trading Partner Physical Address 1. (M) Street Address: 2. (M) City: 3. (M) State: 4. (M) Postal Code: G. Trading Partner Mailing Address 1. (O) Street Address: (If Different) 2. (O) City: 3. (O) State: 4. (O) Postal Code: H. EDI Business Contact Info. 1. (M) Name: 2. (M) Title: 3. (M) Phone: 4. (M) E-mail Address (preferred): or Fax ) Fax: Complete Section I if using a Vendor’s Data Entry Service or Web data entry EDI solution and skip J & K. I. Vendor Information 1. (M) Vendor Name: 2. (M) Vendor Contact Name: 3. (M) Vendor Contact Phone Number: 4. (O) Vendor Contact E-mail Address: Complete Section J if your Information Technology Staff operates your EDI system, or Imports or Exports Transactions to Client State. J. EDI Trading Partner’s Information 1. (M) Name: Technology Contact Information 2. (M) Title: 3. (M) Phone: 4. (M) E-mail (preferred): or Fax: Complete Section J if your organization controls the File Type or Network used. K. EDI Communication Information 1. (M) EDI File Type: IAIABC Flat File R1 [ ] R2 [ ] R3 [ ] ANSI 148/824 Version (3041) [ ] TBD [ ] 2. (M) Network: [ ] AT&T [ ] Transmitter User ID: [ ] Advantis Mailbox ID: Account ID Message Class:

] Insurer [ ] Third Party Administrator ] Self Insured Self Administrated ] Statutory Noninsured ] No [ ] Yes ] No [ ] Yes (Statutory Noninsured Only)

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NJCRIB Trading Partner Information A. Trading Partner: New Jersey Compensation Rating and Inspection Bureau B. EDI Requirements: 1. Implementation Requirements Release 1 Optional EDI Implementation Date: Release 1 Mandatory EDI Implementation Date: Release II Optional EDI Implementation Date: Release II Mandatory EDI Implementation Date: 2. File Format Requirements a. IAIABC R1 Flat Files Record Delimiter: carriage return line feed b. ANSI 148 & 824 Version (3041) Segment Terminator: ~ ISA T/P Information: Test/Production Data Element Separator: * Sub Element Separator: > ID: Use Master FEIN + extension if needed Acknowledge 824 Transmissions? Yes Acknowledge 997 Transmissions? Yes C. Communication Information 1. NJCRIB (RECEIVER) ID: FEIN: 226000325 Filler: Blank Postal Code: 071025511 2. Network: (Use one of the following) AT&T: Mailbox ID: NJWCEDI Transmitter: User ID: NJ Advantis Mailbox ID: WCST032 Message Class: N/A Account ID: WCST D. Business Contact Information 1. 2. 3. 4. 5. Business Contact Name: EDI Coordinator Business Contact Address: P.O. Box 381, Trenton, NJ 08625-0381 Business Contact Phone Number: (609) 292-2515 Business Contact E-mail Address: DWCEDI@DOL.STATE.NJ.US General Information: MIS@NJCRIB.COM 04/15/2002 07/05/2002 None at this time None at this time

E. EDI Coordinator & Technical Contact Information 1. 2. 3. 4. IT Contact Name: Sharon Marion IT Contact Phone Number: (800) 240-0088 IT Contact E-mail Address: NJEDI@HNC.COM IT Contact Fax Number: 949-655-3375

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Instructions for Completing the New Jersey Trading Partner Profile Application and Confirmation Form
Each Sender completes New Jersey Trading Partner Profile Application and Confirmation Form parts A through K. The NJCRIB Trading Partner Information section provides Receiver information which your vendor or organization will require to submit claim reports to and receive acknowledgements from NJCRIB. You may use a copy of this form from the NJCRIB IG or obtain a copy preprinted from the NJCRIB Web Site. The completed form is to be faxed or e-mailed to the NJCRIB EDI Coordinator. TRADING PARTNER PROFILE APPLICATION AND CONFIRMATION FORM (SENDER’S) INFORMATION: Purpose: Check one: Submit, Change, or Delete. Check Submit to establish your NJCRIB account, which is required of all NJCRIB Trading Partners. Check Change to revise any previously submitted contact information or vital processing information such as Trading Partner ID, Vendor, Van, File Type, etc. Check Delete to terminate a Trading Partner Account.

NOTE: The NJCRIB EDI Coordinator may contact you to verify information.
The NJCRIBEDI Coordinator will contact you if you have submitted vital processing information changes to discuss the potential impact and make the associated EDI Trading Partner migration/processing plans as necessary.

Sections A-G
Please enter all Mandatory Information. Definitions are provided to assist you. Failure to complete or submit this form may affect your implementation schedule and place your organization in an out of compliance status with New Jersey requirements. Please contact the NJCRIBEDI Coordinator if questions arise or you need assistance. Trading Partner Name: The name of the business entity that is reporting a New Jersey Workers’ Compensation Claim Trading Partner Type: The type of Claim Administrator reporting a New Jersey Workers’ Compensation Claim In Production Status with other IAIABC State(s): Indicates if the NJCRIB Trading Partner applicant has attained production status using IAIABC standards in other states. Plan to use NJ Web Claim Data Entry Option: Indicates if a NJCRIB Statutorily Noninsured Trading Partner applicant will test using the NJ Web Claim Date Entry option. This option is only available to New Jersey Statutory Non-Insureds. If yes, enter anticipated monthly volume: The number of Claims/Transactions a NJCRIB Statutorily Noninsured Trading Partner applicant using the NJ Web Claim Date Entry option expects to exchange per month. Trading Partner (Sender) ID: FEIN: The Federal Employer’s Identification Number of the Trading Partner. TP 3-digit ID (If allowed by State): An optional 3-digit ID that may be used by the Trading Partner to manage its EDI distribution process. Postal Code: The 9-position ZIP code (ZIP+4) for the trading partner’s physical location address.

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Trading Partner Physical Address: Street Address: The street address of the trading partner’s physical location address. It will represent where materials may be received when using delivery services other than the U.S. Postal Service P.O. Box address regarding “this” trading partner. City: The city of the trading partner’s physical location address. State: The 2-character standard state abbreviation for the trading partner’s physical location address. Postal Code: The 9-position ZIP code of the street address. The ZIP code combined with the trading partner’s FEIN is used to identify the sender. Trading Partner Mailing Address (If Different): The mailing address used to receive deliveries via the U. S. Postal Service. If this address is the same as the physical address, indicate “Same as above.”

Sections H-J
Trading Partner Contact Information In this section, include the information about those individuals we may contact regarding your EDI filings. There are three types of contacts and each addresses a different areas of EDI processing when issues are encountered and your organization’s assistance is needed to resolve the issue. Though unusual, one person may serve as all three types. Please read the definitions below and include the names and information as appropriate for your firm. Business Contact: The individual most familiar with the overall data 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 respond to any issues that may arise from other than the actual process of transferring the data from your business to the NJCRIB’s receipt. Please provide the following information: Name: The name of the contact. Title: A descriptive term for the duties that the contact person performs. Phone: The telephone number where the contact can be reached during normal business hours. E-mail Address (preferred): If the contact has an e-mail address, please include the exact address where the NJCRIB EDI Coordinator may reach him/her. FAX: If a FAX is available, please include the telephone number of the FAX maching. Vendor Contact: The Vendor to be contacted if transmission or product/services issues arise.
Complete Section I if using a Vendor’s Data Entry Service or Web data entry EDI solution and skip J & K. This

individual will be the point of contact for the appropriate product technical or business specialist. Please note that compliance and data quality issues are referred to the Trading Partner and not to the vendor. Please provide the following information: Vendor Name: The name of the contact. Vendor Contact Name: The name of the contact person at the vendor location. Title: A descriptive term for the duties that the contact person performs. Phone: The telephone number where the contact can be reached during normal business hours. E-mail Address (preferred): If the contact has an e-mail address, please include the exact address where the NJCRIB EDI Coordinator may reach him/her. FAX: If a FAX is available, please include the telephone number of the FAX machine.

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Technical Contact: The individual within your organization that is to be contacted if issues regarding technical or transmission process arise. Complete Section J if your Information Technology Staff operates your EDI system, or Imports or Exports Transactions to Client State. This individual may be a telecommunications specialist, computer operator, etc. If your organization uses a vendor product where “all” report information is keyed directly into that product, this type of contact does not apply to your organization. Name: The name of the contact. Title: Descriptive term for duties performed. Phone: The telephone number where that contact can be reached during normal business hours e-mail Address: If the contact has an email address please include the exact address at which the NJCRIB EDI Coordinator may reach him/her. FAX: If FAX facilities are available, please include the telephone number of the FAX machine.

Section K
EDI Communication Information
Complete Section K if your organization controls the File Type or Network used. Please enter all Mandatory Information. Definitions are provided to assist you. Please contact the NJ EDI Coordinator if questions arise or you need assistance. Failure to complete or submit this form may affect your implementation schedule and put your organization out of compliance with New Jersey Requirements.

A Value Added Network (VAN) will be used to exchange data; the trading partner will specify the electronic mailbox to which data can be transmitted. Separate mailbox information may be provided for transmitting production versus test data. EDI FILE TYPE: Check the appropriate File Format(s) NETWORK: Three VAN options are included on the profile. Complete the box for the VAN you will be using. Leave the others blank. USER ID: Identifies a trading partner’s VAN mailbox/services. (Transmitter Only) ACCT ID: Identifies a trading partner’s VAN mailbox/services. (Advantis Only) MESSAGE CLASS: Enter the message class if appropriate. (Advantis Only)

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NJCRIB Trading Partner Profile
Trading Partner: The receiver is the New Jersey Compensation Rating & Inspection Bureau (NJCRIB).

EDI Requirements Implementation Requirements
Release 1 Optional EDI Implementation Date: The first date that a Trading Partner MAY submit IAIABC R1 EDI Files under Production EDI transactions to NJCRIB Release 1 Mandatory EDI Implementation Date: The date on which a Trading Partner MUST submit IAIABC R1 EDI Files under Production EDI transactions to NJCRIB to be in compliance with New Jersey Law. File Format Requirements: The IAIABC Release that applies and the acceptable File Format types and versions. Receiver’s Flat File Record Delimiter: This character used by Trading Partners (claims administrators) to indicate the end of each physical record when submitting flat file transactions formatted according to the IAIABC proprietary standards.

Receiver’s ANSI X12 Transmission Specifications
Segment Terminator: A character that indicates the end of a segment. ISA T/P Information: Used to identify a transaction as Test or Production to prevent the inappropriate posting of data to test or production systems. Data Element Separator: A character that separates data elements. Sub Element Separator: A character that separates data elements within compound data elements. ID: Identifies the trading Partner Acknowledge 997: Indicates that a transmission will or will not be acknowledged in regard to complete and structurally correct exchange of data. Acknowledge 824: Indicates that a batch or transaction will or will not be acknowledged in regard to business data content requirements and specific business deficiencies.

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EDI Communication Information
This section specifies NJCRIB’s Value Added Network (VAN) mailboxes, to which claims administrators can transmit EDI transactions to NJCRIB. FEIN/Postal Code: The Federal Employer’s Identification Number and 9-position ZIP code (ZIP+4), of NJCRIB that uniquely identifies NJCRIB as a trading partner. Network: The name of the VAN service on which the NJCRIB’s mailbox can be accessed. Network Mailbox Acct ID: The name of the NJCRIB mailbox on the specified VAN. Network User ID: This is the identifier of the NJCRIB’s entity to the VAN. Contact Information: This section identifies individuals assigned by NJCRIB to address EDI Claim Reporting issues. EDI Coordinator: This is the individual who is assigned to handle all Trading Partner Submissions, Changes, or Deletions and route all TECHNICAL issues. Business Contact: This is the individual assigned to address all business and New Jersey Compliance questions. All other inquires may be addressed to General Information.

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7. Schedule Changes to your Internal Business Processes and Systems
Complete any changes to your internal business processes and systems prior to creating test transactions. The test criterion requires that you compile the test transactions from “actual” NJ workers compensation claims that originate from your source system. This test data must be transmitted to NJCRIB through whatever reporting and “sending” systems you will use once you are approved to send “production” or live data to us.

8. Contact the NJCRIB EDI Test Coordinator to Review Schedule Testing
Following receipt of the executed Trading Partner Agreement and the Trading Partner Profile (due at least 2 weeks prior to your scheduled test date), we will prepare to accept test data from you. We will review your Agreement and Profile to determine whether you may be exempted from part or all of the mandatory testing and the test schedule if you have petitioned for and been granted a variance to implement EDI at a date later than July 5, 2002.

Exemptions from Testing
If your organization or vendor has successfully passed previous New Jersey EDI connectivity testing or demonstrated EDI competency in other IAIABC EDI jurisdictions, the EDI Coordinator will advise you that your testing requirements have been waived or reduced accordingly. If your vendor has not demonstrated EDI competency in other IAIABC EDI Jurisdictions, the first scheduled test use of that service/product will apply to all users of that product. The New Jersey EDI Coordinator will advise known users of the vendor of the scheduled test date. On successful completion of vendor testing, subsequent Trading Partner Profile applications will advise the Trading Partner that they may immediately move to production status. Trading Partner’s will be notified if the vendor is unable to meet testing requirements within 2 weeks of the scheduled test date or two weeks prior to the mandatory July 5, 2002 EDI Reporting date.

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Test Status Advisory
The acknowledgement of your Trading Partner Profile and Agreements from the NJCRIB EDI Test Coordinator will advise you of your test requirements by indicating how your Test/Production indicator is to be set. You will be advised to set your Test/production status indicator to: Production and begin sending production transactions to NJCRIB at any time (but no later than the mandate date of July 5, 2002) if you are exempted from the test. Test and to participate in the scheduled test during your assigned test period if you are not exempted from testing. Therefore, it is important to complete the Trading Partner Agreement and Trading Partner Profile immediately to determine your test status in a timely fashion. If you do not complete testing and are not approved to move into production status by the end of your assigned test period, you may not be able to complete the required testing prior to the mandated implementation date and be exposed to out-of-compliance sanctions from the New Jersey Division of Workers Compensation.

9. Schedule Training and Implementation for your Staff
Training of your staff in the NJCRIB requirements is your responsibility. Please feel free to use any of the information contained in this Guide or to make and provide as many photocopies of this Guide as may be needed to assist you in your training. The NJCRIB EDI Implementation Guide is not copyrighted or protected by copyright. It is provided to assist you in the planning and implementation of our reporting requirements. You may also find it helpful to contact others to identify training service providers. NJCRIB does not endorse or require that you use any specific certified providers or follow any specific training regimine. We offer these suggestions to assist you in planning your implementation. NJCRIB will be holding a training session in April 2002 and you may find that session helpful to your EDI Training coordinator.

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NJCRIB Test and Production Process
Purpose
The purpose of the Test Period is to make certain that each Claim Administrator’s transmission meets NJCRIB’s technical requirements and data quality standards. If granted a variance, testing will still be required on the same basis as described herein but at a later time than the Scheduled Test Period. The goals of the testing phase are to assure each trading partner demonstrates technical and business competencies. Technical Competence – extends to both the ability to communicate electronically and the ability to use the file structure used is appropriate. Technical competence is demonstrated by the ability of each trading partner to transmit and receive state reports in either the IAIABC flat file or ANSI 148 format. Specifically, whether the Claim Administrator can successfully connect to and transmit the FROI and SROI andwhether the NJCRIB can connect to and transmit the “Acknowledgement” to the Claim Administrator. Business Competence – examines the data content to determine if it meets the quality standards of the NJCRIB. Business competence is demonstrated by the ability of the FROI and SROI to pass the NJCRIB EDI System’s edits for data content and values.

NJCRIB Test Schedule – Test Plan Development
All NJCRIB trading partners are randomly placed in the tiered NJCRIB Test Schedule and required to complete the full test program with the following exceptions: • • • Trading Partners who are using a vendor experienced in other jurisdictions with the IAIABC standards are not required to participate in the NJCRIB Test Schedule. Trading Partners who volunteered to participate in the 2001 pre-law passage testing are not required to participate in the 2002 NJCRIB Test Schedule. Trading Partners who are in Production status with another jurisdiction prior to implementing with NJCRIB are required to participate only in a limited connectivity test. If the limited test is successful then no further testing for the NJCRIB implementation is required.

If an exception applies to you and your firm’s name appears on the NJCRIB Test Schedule, you must notify the NJCRIB EDI Test Coordinator immediately or testing will be assumed and required. All other NJCRIB EDI Trading Partners are required to complete the Test Plan during their assigned Test Plan Scheduled period unless the Trading Partner has been granted a variance. However, testing will be required of all Trading Partners. Those with variances must complete a test prior to their variance agreement’s implementation date. Two weeks prior to the first day of the scheduled test period, the trading partner or vendor must complete and submit the Trading Partner Agreement and the Sender Trading Partner Profile to the NJCRIB EDI Test Coordinator. You may contact NJCRIB Test Coordinator in either of the following manners. • • • Via e-mail at njedi@hnc.com or By telephone at (800) 240-0088. By fax at (949) 655-3375

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You must contact the NJCRIB EDI Test Coordinator prior to sending any Test transaction(s): • • • If you have any questions about the test, To confirm your testing readiness, or If you have not heard from the NJCRIB EDITest Coordinator the week before your scheduled test period begins.

Test documentation required before the test begins is the completed and signed Trading Partner Agreement and the Trading Partner Profile, and if applicable, a copy of any variance petitions granted by the Workers’ Compensation Court System. Though not required, every Trading Partner may benefit by a pretest review of the NJCRIB edits for each data element. Having a “test plan” does not mean or require that a formal, testing document be exchanged between the participants. Rather, a discussion of a test plan is intended to take place and result in an understanding of the procedures and the processes involved.

Test Plan Procedures
Different testing procedures apply depending upon the transmission mode you will be using to send data to NJCRIB, see below description for Web Users and VAN Mailbox Users. New Jersey Division of Workers Compensation will not accept reports on paper on or after July 5, 2002 unless the trading partner has applied for and was granted a variance to N.J.S.A. 34:15-96-99 by the New Jersey Division of Workers’ Compensation. Therefore, all testing regardless of the transmission mode, you choose must be completed prior to July 5, 2002 for you to be in compliance with the EDI legislation.

Test Overview for WEB Users
The NJCRIB Web Site is provided as an alternative for the low transaction volume reporter (15 or less transactions per month) to enter each transaction’s data manually. Claim Administrators using the web site data entry as the transmission mode need only test that they can access the NJCRIB web data entry site with their user name and password. The user name and password are specified in the Acknowledgement of the Trading Partner Profile. Reporter/Sender need only successfully enter a single record of one “real New Jersey workers’ compensation claim. The “real” claim may be an open or closed claim – a claim with either status is acceptable. The entry of one claim is sufficient and needs to be done only once for First Reports and once for Subsequent Reports. The web site will automatically perform data format and validation edits and will only accept data in the correct format.

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Test Overview for VAN Mailbox Users
During the testing process and until notified otherwise by NJCRIB’s EDI Test Coordinator, Claim Administrators and their employer clients must continue to provide the NJ Workers’ Compensation Division the appropriate First and Subsequent report paper report forms. No paper reporting process is to be discontinued until the Claim Administrator has received written approval to specifically discontinue paper-reporting processes. Any premature discontinuance by either the Employer or the Claim Administrator could result in penalties and fines for improper reporting. There are six steps in the NJCRIB testing process, as follows. 1. Pretesting Requirements 2. Technical Capability Test 3. Business Content Test File (First Reports of Injury) 4. NJ Test Completion (First Reports of Injury) 5. Business Content Test File (Subsequent Reports of Injury) 6. NJ Test Completion (Subsequent Report of Injury) Testing will continue until the Claim Administrator meets NJ data quality requirements as detailed following in Step 3. Continuing the testing may require additional test documents from those described in the following steps may be required should the tester not pass a given level of testing.

Step 1: Pretest Requirements
Each Test submitter is required to consult the NJCRIB Test Schedule to determine the test time period assigned to it. Once the test time frame is established, each Claim Administrator must prepare for the test by completing and submitting a Trading Partner Profile and Trading Partner Agreement. These forms and instructions for completing them can be found on preceding pages If a variance has been granted, complete the two documents and forward them to the EDI Test Coordinator along with a copy of your variance petition and grant. Once NJCRIB EDI Test Coordinator has received and acknowledged the Trading Partner Profile and Trading Partner Agreement, the NJCRIB EDI Test Coordinator will contact you to review testing guidelines, address any questions you may have, and confirm the scheduled time frame for each Claim Administrator to submit Test files. Test transactions are required to be submitted on actual or “real” New Jersey open or closed workers compensation claims, chosen by the Claim Administrator.

Step 2: Technical Capability Test File
The first test is the technical capability test. Once received, NJCRIB will process and acknowledge the test file (the claim administrator’s technical capability). During this phase of the test procedure, the sender transmits a file of one Original First Reports of Injury to the NJCRIB. The test file must consist of the following transactions: • • • Header record (with the Test/Production indicator (DN 104) set to “T,” One “00,” Original First Report of Injury transaction, Trailer Record.

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While five days are allowed for the test, on the first day of the scheduled test period, the Claim Administrator forwards the Technical Capability Test File. Once the file is sent, the Claim Administrator must notify NJCRIB the file has been sent. The advisory may be sent to NJCRIB EDI Test Coordinator via e-mail at njedi@hnc.com or by telephone at (800) 240-0088. Include the following information in the advisory: • • Date and time the test file was sent The identity of the VAN and mailbox address to which the test transaction was sent

In response to the Claim Administrator’s advisory, NJCRIB will process the test file through the NJCRIB EDI System’s edit processes and will return an AK-1 Acknowledgement, to the Claim Administrator. The acknowledgement to a Technical Capability Test File is a batch acknowledgement and does not include a detail transaction edit response. Expect the Acknowledgement to contain errors resulting from data edits. If the file is technically acceptable, the test for business edits begins. If there are data content edits found in the technical capability test of the First Report of Injury, they will not be corrected through a “CO” transaction. There is no need to do so since data content is not being examined in this portion of the test.

Follow Up Procedures
Responses are electronically created. Therefore: • If NJCRIB does not receive a recognizable test file within 48 hours of receipt of the e-mail or phone call, the NJCRIB Test Coordinator will contact the Claim Administrator to investigate the status of Claim Administrator’s test file. If the Claim Administrator does not receive an AK-1 batch acknowledgment within three days of sending the test file, contact the NJCRIB EDI Test Coordinator at the E-mail or phone number above.

When Step 2 has been completed, the NJCRIB Test Coordinator will advise the Claim Administrator to proceed to Step 3 below.

Step 3: Business Content Test File
After NJ’s acknowledgement that the Technical Capability Test File has been received and the NJCRIB EDI Test Coordinator has approved the capability portion of the test, the Claim Administrator will forward the first of two business content test files of First Reports of Injury to NJCRIB. NJCRIB requires that the two business content test files be sent in two separate batch transmissions sent on two different dates during the claim administrator’s assigned test period. Each Business Content Test File’s First Report of Injury transaction must meet the following conditions: • • • Must be sent from the Claim Administrator’s production EDI system. Must contain data from “actual claims” handled by the Claim Administrator, which may either be open or closed claim files. Must reflect the full spectrum of required FROI reports (some of which are “00” Original First Report of Injury and at least one “AU” Acquired/Unallocated First Report of Injury and one “04” Denial First Report of Injury).

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The business content test file must contain the following transactions, in the proper sequence: • • • Header Record (with DN 104, Test/Production Indicator, set to “T”) Ten First Reports of Injury Trailer Record

The Claim Administrator may not send a second or follow up batch Business Content Test file until it has received the acknowledgements from the previous batch of First Reports of Injury. Send the second test file batch immediately after receiving the acknowledgement from the first test batch file. The second test file batch must contain no more than 10 transactions and include the transactions with the following MTCs. • • • “CO” transactions for each previous transaction acknowledged with errors (assigned a TE status code. “02” transactions for transactions previously sent with a change to one data element previously sent. An “01” transaction canceling a transactions previously sent.

If the Claim Administrator has not received an acknowledgement to the Business Content Test File within three days following the date it sent the file, contact the NJCRIB Test Coordinator by phone at (800) 240-0088 or by e-mail at njcrib@hnc.com to determine the test file status.

Data Quality Requirements for Business Content Test Files
Upon receipt of a Business Content Test File, NJ will process the file through the NJCRIB EDI system’s edit process and will return the AK-1 (or ANSI 824) detailed Acknowledgement. The Claim Administrator must review the detailed acknowledgement and implement corrective claim handling and technology solutions for each error on transactions assigned either a TE or TR status. • • TE status will be returned for each transaction accepted with error(s). TR status will be assigned to a transaction rejected for not passing requirements.

The testing and evaluation process continues until two consecutive batches of Business Content Test Files are processed and acknowledged and on which the Claim Administrator has met the NJCRIB data quality requirements. NJCRIB Business Content Test Files data quality requirements are: • • A minimum of 80% are accepted with a TA or TE status No more than 20 % are rejected with a TR status

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Step 4: NJ Test Completion (First Report of Injury)
At the time the Claim Administrator successfully completes the FROI Business Content Testing, the NJCRIB Test Coordinator will provide approval to move to the “Production” status for First Reports of Injury. Congratulations – Partial Production Status Achieved! When partial production status has been achieved, FROI testing will be discontinued. At this time, the NJCRIB EDI Test Coordinator and the Claim Administrator (and Claim Administrator’s Reporter if using a vendor) must agree and clearly establish a date, no later than July 5, 2002, when the Claim Administrator will begin sending FROIs in the Production status. It is extremely important that the Claim Administrator continues reporting using the New Jersey First Report of Injury paper report form until the Claim Administrator begins sending the EDI reports. Once testing has been completed and the claim administrator achieves “production” status designation, the claim administrator may voluntarily begin sending EDI reports in the “production” status immediately or at any date prior to the mandate date of July 5, 2002 as agreed upon by the EDI Test Coordinator. However, the Claim Administrator must begin sending “production” EDI reports no later than July 5, 2002, unless the trading partner has applied for and was granted a variance to N.J.S.A. 34:15-96-99 by the New Jersey Division of Workers’ Compensation. At the time the Claim Administrator begins sending all First Reports of Injury via EDI it may also cease sending the paper First Report of Injury to NJDWC on that date as well.

Step 5: Business Content Test File (Subsequent Reports of Injury)
When the Claim Administrator has completed testing of First Reports of Injury and has been approved to move into production status with the testing of Subsequent Reports of Injury begins. It is important to complete both the First Report of Injury testing and the Subsequent Report of Injury testing during the scheduled test period assigned to each claim administrator and prior to the mandate date of July 5, 2002.

Order of MTCs for Subsequent Report of Injury Testing
NJCRIB requires the Claim Administrator to have achieved the “production” status with FROI reports before beginning the testing of SROIs. The Claim Administrator is to send Subsequent Report test transactions that match the claims on which the First Report of Injury test transactions were previously sent. (Otherwise, the Subsequent Report test transaction(s) will fail the edit that requires a FROI to be present on the NJCRIB database prior to the acceptance of a SROI.). NJCRIB accepts the “SA,” “04,” “02,” and “CO” SROI “MTCs.” Any SROI MTCs other than SA, 04, 02, or CO sent will be rejected as not jurisdictionaly valid. SROI MTC Data Element requirements, which include the mandatory data element, and Agency Claim Number (assigned to the First Report of Injury during the FROI test cycle), are outlined in the preceding section for each Subsequent Report type or MTC.

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Test File Submission
All SROI test file submissions require the following: • • • Each SROI test file transaction must match to a previously transmitted FROI. SROI Business Content Test File transactions within a transmission are required to be in the logical MTC sequence as follows (either an 04 or SA must precede the 02 or CO). Two SROI tests will be required. Do not send the second batch of SROI test files until the acknowledgements from the first SROI test have been received.

SROI Test File Batch #1
Limit the combination of Subsequent Report MTCs (either on the same or a different FROI) in the first batch of SROI Business Content Test Filess to SROI MTCs of Semi-Annual (SA) or Denial (04). Send at least one SROI record with a code value error in one field so that it will result in a TE or Accepted with Errors acknowledgment. The first batch file must contain: • • • Header (with the Test/Production indicator [DN 104] set to T) Minimum of ten SROI transactions with MTC of either 04 or SA Trailer

It is not necessary to either e-mail or telephone the NJ EDI Test Coordinator that you have sent the SROI Business Content Test File. When received by NJCRIB, the SROI test file will be processed through the NJCRIB EDI system, edits applied, and the Acknowledgement returned.

NOTE: If you have not received the AK1 Acknowledgement within three
working days, contact the NJCRIB EDI Test Coordinator at (800) 240-0088 or e-mail to njedi@hnc.com.

SROI Test File Batch #2
Once the first SROI Business Content Test File has been acknowledged and batch #1’s test transactions have been assigned either a TE or TA status, send a second Business Content Test File with the SROI “02” and “CO” MTC records. If any transactions were acknowledged with a “TR” (Transaction Rejected) status, correct the error and resend the rejected transaction(s) in the second SROI batch. At least one of each “02” and “CO” SROI MTC code must be included. However, there is no other batch minimum or maximum number of transactions. To send the “CO” a previously acknowledged SROI transaction must have been assigned a TE (Accepted with Errors) status. If no SROI transaction from the first batch of test files was assigned a “TE” status, send a test SROI SA transaction in the second batch with at least one data element with a value that does not match the NJCRIB transaction requirements. Doing so should produce a “TE” status on the acknowledgement. Send the “CO” correction in a third SROI batch on the next business day to complete the testing. If you are uncertain about which data element or entry to send to cause the “TE” status response, contact the NJCRIB EDI Test Coordinator for assistance by phone at (800) 240-0088 or by e-mail at njedi@hnc.com.

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SROI Data Quality Requirements
As with the First Report of Injury testing, the SROI Business Content Testing will continue until the Claim Administrator has met the NJCRIB Data Quality requirements. Refer to Data Quality Requirements (page 108) for a review of NJCRIB Requirements. When Step 5 testing is completed, the NJCRIB Test Coordinator will notify the Claim Administrator that SROI Testing is complete. If you do not receive acknowledgements from the last batch of SROIs sent within three days, contact the NJCRIB EDI Test Coordinator immediately.

Step 6: NJ Test Completion (Subsequent Report of Injury)
Reaching Step 6 means that the Claim Administrator has successfully completed both First Report of Injury and Subsequent Report of Injury testing with the NJCRIB as advised by the NJCRIB test coordinator. Congratulations – Full Production Status has been achieved. Once the testing process for SROI reporting has been completed and acknowledged as such by the NJCRIB EDI Test Coordinator, the Claim Administrator may then begin sending “production” SROI reports on “actual” new EDI claims. Two reminders: 1. Remember to change the Test/Production indicator in the header record on Subsequent Reports to “P” for Production before sending “actual” new claims. 2. All Subsequent reports require that a First Report on the same claim be sent previously and acknowledged with a “TA” or “TE” status and an Agency Claim Number assigned to it. Do not send an EDI SROI report on a claim where the First Report of Injury was sent on paper unless you first send a FROI. Continue with the “P” indicator unless informed by the NJCRIB that the data quality of Subsequent Reports of Injury no longer meets NJ requirements, see Data Quality Requirements for Business Content Test Files (page 108) for a review of these requirements.

Ongoing Monitoring of Production Status
NJCRIB will continue to monitor EDI data quality for every Claim Administrator through the test process and will continue to do so throughout the Trading Partner relationship. If the Claim Administrator’s data quality falls below the NJCRIB data quality requirements for five (5) consecutive transmissions, NJCRIB requires the Claim Administrator to submit to the following: • • • Paper reports will not be resumed and the Employer/Sender may be out of compliance with the New Jersey EDI legislation’s mandate. Increasingly higher Data Quality requirements may be imposed to correct problems and to avoid excessive submissions and the continuing review of the Administrator’s written responses. The Claim Administrator is required by NJCRIB to submit a written report to the NJCRIB EDI Coordinator. The written report is to include the cause and corrective action taken by the Employer/Sender for each error noted on the AK-1 Acknowledgement for the last five transmissions.

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Communication Requirements
Claim information must be transmitted to NJCRIB through IAIABC Release I FROI and Release IA SROI EDI in either Flat File format with appropriate header and trailer records, or the ANSI 148 format. This Guide must be used in conjunction with the IAIABC Release 1 EDI Implementation Guide. The IAIABC Guide, which includes data element definitions, file formats, ANSI X12 requirements, etc., may be purchased by contacting the IAIABC at (608) 277-1479. Experienced vendor services will include at a minimum responsibility for report transmissions and acknowledgements between the Sender and NJCRIB EDI System via NJCRIB recognized Value Added Networks (VANs) of Advantis and AT&T. Vendor services and products often include the highly recommended features of pretransmission data quality editing and management of EDI transmissions and acknowledgements. Administrators who do not contract with a vendor for part or all of these functions will be expected to perform those services. In this regard direct connects to NJCRIB will only be considered for large claim volume Administrators and Vendors who provide compelling cost and efficiency reasons. Vendors or Administrators seeking direct connection to the NJCRIB EDI System should refer to the NJCRIB Connect policy which imposes stringent technical competency requirements, data security, and application interoperability requirements.

New Jersey Policy for the Addition of External Connections
New Jersey supports an open Electronic Data Interchange (EDI) environment and opposes artificial barriers to competition among EDI vendors. To promote and facilitate EDI between State Workers Compensation Jurisdictions, Claim Administrators, Employers, Providers, and Reporting Service Vendors, the New Jersey vendor will add the ability for Vendors to Directly Connect to the NJCRIB EDI System. The request must be authorized by NJCRIB. A one time fee based on programming and specific Connect related requirements will apply per connection. Technical capability requirements assure Jurisdiction EDI system users of reliable high quality data transfer and processes. Organizations wishing to establish a “Connect” with the NJCRIB EDI System must certify that they meet the following Network, Application, and Process requirements, and that they will adhere to the Restrictions. A thirty-day period will be allowed to test and establish reliable connectivity with each new Connect. Technical assistance is available from NJCRIB. At the discretion of NJCRIB, a Connect may be disconnected for failure to meet requirements such as transmission quality, customer complaints, etc. NJCRIB reserves the right to suspend a Connect temporarily, when that Connect degrades the NJCRIB EDI System or associated processes performance or connectivity.

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Network Requirements
• • • • • • • • • • Ability to communicate via modem (analog dial on POTS line) or Internet connection. Use verifiable file transmission protocols such as FTP or FMODEM/XMODEM, etc. Identify individual user accounts and provide at least password protection for account access. Route files to multiple receivers. Hold files for pickup by a receiver. Provide logging of file transmissions. Provide archive of file transmissions. Provide redelivery of files for at least two weeks after original transmission date. Ability to route X12 files based on ISA information. Provide reliable service (less than 3% down time during service hours).

Application Software Requirements
The VAN Vendor must provide software to connect to their service. NJCRIB will deliver transactions to the Vendor software either through a programmatic interface or by placing files in common directories. The Vendor software is completely responsible for delivery of the transactions to the Vendor’s Network. The Vendor software must provide/perform the following: • • • • • • • Provide a communications module callable from the NJCRIB EDI System that will perform connection, file transfer, and delivery verification without intervention. Communications with the Vendor Network and transfer of files does not require manual intervention. Provide adequate documentation for integration with the NJCRIB EDI System. If encryption is provided, include modules to perform encryption and decryption without intervention. If encryption is provided, use industry standard encryption methods, with the Vendor bearing the cost of licensing. Must be compatible with the NJCRIB EDI System operating environment (32 bit Windows). Must not interfere with NJCRIB EDI System or associated Jurisdiction system operations. (e.g. must not crash or unnecessarily load the system.)

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Processing Requirements
• • • • • • • • Send and receive multiple files within a single connection session. Provide an outbound queue where the NJCRIB EDI System can place transactions before sending. Provide an inbound queue where the NJCRIB EDI System can pick up transactions after receiving. Provide logging information on communications status to the NJCRIB EDI System, including success/failure notification. Identify sent files to prevent duplicate transmissions. Identify received files to prevent the NJCRIB EDI System from reprocessing them. Identify interrupted or failed transmissions and notify the NJCRIB EDI System. Recover from interrupted or failed transmissions and resend or rereceive files without creating duplicate transmissions and without intervention.

Restrictions
• • Vendor software will not perform any additional or unanticipated processing such as validation of Acknowledgements, on the NJCRIB EDI System or other Jurisdiction systems. Vendor data will not be archived on the NJCRIB EDI Systems.

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Appendices
Appendix 1 - Transaction Examples

First Report of Injury – Scenario
Employee John Jones was injured at 10:15 AM on 7/5/02 when he ran into a six foot stack of crates of paper plates with the fork lift he was driving. The stack of cardboard crates fell onto Jones, who complained of pain in his neck, back and right leg. Supervisor called to scene of accident. John Jones was taken by ambulance to St. Vincent’s Hospital, where his broken leg was placed in a cast, a neck brace applied and was put on bed rest for one week. He is not expected to return to work for 3 weeks. The following information was taken from Mr. Jones’ personnel file and on 7/6/02 Jones’ employer, Knox Paper Suppliers, sent a First Report of Injury to Manufacturers Insurance Company (MIC) of Newark who assigned the claim to Smith Adjusting Service on 7/7/02. Smith Adjusting Service forwarded the Original First Report of Injury to NJCRIB on 7/9/02.

IAIABC Flat Files
Header Record – Claim Administrator to NJCRIB
Data Element Number 0001 0098 Data Element Name Transaction Set ID Sender ID (25) FEIN (9) Filler (7) Postal Code (9) Receiver ID (25) FEIN (9) Filler (7) Postal Code (9) Date Transmission Sent Time Transmission Sent Original Date Transmission Sent Original Time Transmission Sent Test/Production Indicator Interchange Version ID Data Entry For Report HD1 379876543 ------071021102 226000325 ------071025511 20020709 173000 Blank Blank P 14801 Comment

0099

Header (Composed of 25 characters in 3 subparts) No hyphen (Blanks) No hyphen or spaces (Composed of 25 characters in 3 subparts) No hyphen (Blanks) No hyphen or spaces

0100 0101 0102 0103 0104 0105

(Sent at 5:30 PM – converted to Military Time)

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First Report of Injury – 00 Transaction – Claim Administrator to NJCRIB
Data Element Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 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 SIC Code Insured Report Number Insured Location Number Policy Number Policy Effective Policy Expiration Date of Injury Time of Injury Postal Code of Injury Site New Jersey Requirement Mandatory Mandatory Mandatory Mandatory Blank – Not Applicable Mandatory Mandatory Conditional Conditional Mandatory Optional Mandatory Mandatory Mandatory Mandatory Mandatory Optional Mandatory Mandatory Optional Mandatory Mandatory Mandatory Mandatory Mandatory Optional Optional Optional Optional Optional Mandatory Mandatory Mandatory SWC145632 1-1-02 (sent as 20020101) 1-1-03 (sent as 20030101) 7-5-02 (sent as 20020705) 1015 AM (sent as 1015) 07004 Trenton NJ 07004-2710 (sent w/o hyphen) N (for No) 5113SC Newark NJ 07102-1102 (sent w/o hyphen) SAS78904 26-23457800 (sent w/o hyphen) New Jersey Paper and Cardboard Suppliers Knox Paper Suppliers 3710 Tennessee Ave Data Entry for Report

148 00 (Original First Report of Injury) 7/9/02 sent as 20020709 NJ Mandatory on all transactions except first FROI. 15-0089764 (sent w/o hyphen) Manufacturers Ins Co of Newark 37-9876543 (sent w/o hyphens) Smith Adjusting Service 22 Park Place, Suite 105

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Data Element Number 34 35 36 37 38

Data Element Name Employers Premises Indicator Nature of Injury Code Part of Body Injured Cause of Injury Code Accident Description/ Cause Initial Treatment Code 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 if Hire Wage Wage Period Number of Days Worked Date Last Day Worked Full Wages Paid for Date of Injury Indicator Salary Continued Indicator Date of Return to Work

New Jersey Requirement Mandatory Mandatory Mandatory Mandatory Mandatory

Data Entry for Report

Y (for Yes) 90 90 46 EE drove forklift into stack of crates (paper plates). Resulted in broken right leg, back and neck pain. 3 7-5-02 (sent as 20020705) 7-7-02 (sent as 20020707) 261-46-8762 (sent w/o hyphens) Jones John Q 3701 First Street Apt 4B

39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68

Mandatory Mandatory Optional Mandatory Mandatory Mandatory Optional Mandatory Optional Mandatory Mandatory Mandatory Optional Mandatory Mandatory Conditional Optional Conditional Conditional Optional Mandatory Mandatory Optional Mandatory Mandatory Mandatory Conditional Optional Mandatory Conditional

Trenton NJ 07012-3215 (sent w/o hyphen) (213) 876-1211 3-15-72 (sent as 19720315) M U

7-6-02 (sent as 20020706)

5210 Warehouseman II

$950.00 (sent as 000095000) 1 5 7-5-02 (sent as 20020705) Y (yes) N (no)

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Trailer Record – Claim Administrator ot NJCRIB
Data Element Number 0001 0106 Data Element Name Transaction Set ID Detail Record Count Data Entry For Report TR1 000000001 Comment

Trailer One transaction between header & trailer

Acknowledgement to First Report of Injury Scenario
Upon receiving the First Report of Injury, the NJCRIB edited the transaction and returned the following Acknowledgement to Smith Adjusting Company noting the Agency Claim Number assigned to this claim by NJCRIB. The First Report was acknowledged with no errors. The Agency Claim Number of 00001001 is now required on all reports/transactions following for this claim.

Header Record – NJCRIB to Claim Administrator
Data Element Number 0001 0098 Data Element Name Transaction Set ID Sender ID (25) FEIN (9) Filler (7) Postal Code (9) Receiver ID (25) FEIN (9) Filler (7) Postal Code (9) Date Transmission Sent Time Transmission Sent Original Date Transmission Sent Original Time Transmission Sent Test/Production Indicator Interchange Version ID Data Entry For Report HD1 379876543 ------071021102 226000325 ------071025511 20020710 083000 Blank Blank P 1481A Comment

0099

Header (Composed of 25 characters in 3 subparts) No hyphen (Blanks) No hyphen or spaces (Composed of 25 characters in 3 subparts) No hyphen (Blanks) No hyphen or spaces

0100 0101 0102 0103 0104 0105

(Sent at 8:30 AM – converted to Military Time)

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Acknowledgement Transaction – NJCRIB to Claim Administrator
Data Element Number 1 107 108 109 6 14 8 110 111 27 15 5 2 3 112 113 114 Error Code 115 116 117 Data Element Name Data Returned by New Jersey CRIB

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 Acknowledgement Code Insured Report Number Claim Administrator Claim Number Agency Claim Number Maintenance Type Code (From original transaction) Maintenance Type Code Date (From original transaction) Request Code (purpose) Free Form Text Number of Errors Variable Segment (if Errors) Error Code Occurs Number of Error Times Element Number Element Error Number Variable Segment Number

AK1 000000001 7-10-02 (sent as 20020710) 2:15 AM (sent as 021500) 15-0089764 (sent w/o hyphen) 07102-1102 (sent w/o hyphen) 37-9876543 (sent w/o hyphen) 148 TA SAS78904 00001001 00 7-9-02 (sent as 20020709)

00 00 0000 000 0

Trailer Record – NJCRIB to Claim Administrator
Data Element Number 0001 0106 Data Element Name Transaction Set ID Detail Record Count Data Entry For Report TR1 000000001 Comment

Trailer One transaction between header & trailer

Subsequent Report of Injury (NJCRIB “Final” or SA Report) Scenario
Mr. Jones returned to work at full duty and full pay on 8/15/02 with no permanency. The Semi-Annual report or final EDI report, due to NJCRIB on 2/15/03, was sent by Smith Adjusting Company on 2/14/03 as follows. Payments of Temporary Total Disability, doctor, hospital and other medical bills was included along with Return to Work date, return to work qualifier and MMI date per NJCRIB requirements.

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Header Record – Claim Administrator to NJCRIB
Data Element Number 0001 0098 Data Element Name Transaction Set ID Sender ID (25) FEIN (9) Filler (7) Postal Code (9) Receiver ID (25) FEIN (9) Filler (7) Postal Code (9) Date Transmission Sent Time Transmission Sent Original Date Transmission Sent Original Time Transmission Sent Test/Production Indicator Interchange Version ID Data Entry For Report HD1 379876543 ------071021102 226000325 ------071025511 20030214 113001 Blank Blank P A491A Comment

0099

Header (Composed of 25 characters in 3 subparts) No hyphen (Blanks) No hyphen or spaces (Composed of 25 characters in 3 subparts) No hyphen (Blanks) No hyphen or spaces

0100 0101 0102 0103 0104 0105

(Sent at 11:30:01 AM – converted to Military Time)

Subsequent Report of Injury Transaction – Claim Administrator to NJCRIB
Data Element Number 1 2 3 4 6 8 14 42 55 69 56 70 71 72 57 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 New Jersey Requirement Mandatory Mandatory Mandatory Mandatory Mandatory Conditional Mandatory Mandatory Conditional Conditional Conditional Conditional Conditional Conditional Conditional Data Entry for Report

A49 SA (Semi Annual) {NJ Final} 2/14/03 (sent as 20030214) NJ 15-0089764 (sent w/o hyphen) 37-9876543 (sent w/o hyphen) 07102-1102 261-46-8762 (sent w/o hyphens) Blank (Mandatory if Death Claim) N (No) 7-6-02 (sent as 20020706) 8-31-02 (sent as 20020831) 1 8-15-02 (sent as 20020815)

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Data Element Number 62 63 64

Data Element Name Wage Wage Period Number of Day Worked

New Jersey Requirement Mandatory Mandatory Conditional

Data Entry for Report

67 31 26 15 5 73 74 75 76 77 78 79 80 81

82

83 84 85 86 87 88 89 90 91 92 93 94 95 96

Salary Continued Indicator Date of Injury Insured Report Number Claim Administrator Claim Number Agency Claim Number Claim Status Claim Type Agreement to Compensate Code Date of Representation Late Reason Code Number of Permanent Impairments Number of Payment/Adjustments Number of Adjustments Number of Paid to Date/Reduced Earnings/ recoveries Number of Death Dependent/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/Reduced Earnings/Recoveries Code Paid to Date/Reduced Earnings/Recoveries Amount
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Mandatory Mandatory Optional Mandatory Mandatory Mandatory Mandatory Mandatory Conditional Conditional Mandatory Mandatory Mandatory Mandatory

$950.00 (sent as 000095000) 1 5 (Mandatory since this is a disability claim of greater than 1 week) N (No) 7-5-02 (sent as 20020705) SAS78904 00001001 C I L

00 01 00 03

Mandatory

00

Conditional Conditional Conditional Conditional Conditional Conditional Conditional Conditional Conditional Optional Conditional Conditional Conditional Conditional

Segment not sent Segment not sent 050 $3673.37 (sent as 000367337) $633.34 (sent as 000063334) 7-6-02 (sent as 200220706) 8-14-02 (sent as 20020814) 5 4 Segment not sent Segment not sent Segment not sent 350 (payments to doctors) $757.39 (sent as 000075739)

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Data Element Number 95 96 95 96 97

Data Element Name Paid to Date/Reduced Earnings/Recoveries Code Paid to Date/Reduced Earnings/Recoveries Amount Paid to Date/Reduced Earnings/Recoveries Code Paid to Date/Reduced Earnings/Recoveries Amount Dependednt Payee Relationship

New Jersey Requirement Conditional Conditional Conditional Conditional Conditional

Data Entry for Report

360 (payments to hospitals) $1015.89 (sent as 000101589) 370 (other medical payments) $112.32 (sent as 000011232) Blank (Mandatory only if death benefits payment made)

Trailer Record – Claim Administrator to NJCRIB
Data Element Number 0001 0106 Data Element Name Transaction Set ID Detail Record Count Data Entry For Report TR1 000000001 Comment

Trailer One transaction between header & trailer

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