IAIABC CLAIMS RELEASE 3 STANDARDS: UPON REQUEST (UR) ELEMENT REQUIREMENT TABLE INSTRUCTIONS

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1 Introduction: IAIABC CLAIMS RELEASE 3 STANDARDS: UPON REQUEST (UR) ELEMENT REQUIREMENT TABLE INSTRUCTIONS This table was designed to provide a tool to communicate a Receiver's business data element requirements for each UR (Upon Request) data call. When completing the requirement table, consideration should be given to the point in time when the data was required by statute, rule or current version of EDI. If a data element has not always been required to be reported, but is required now, it should be listed as Mandatory Conditional (MC) on the table, and the condition should identify that from X date this data element is mandatory, but prior to that date, the data element is Not Applicable (NA). Data elements intended to be used to match a transaction to the jurisdiction s database should be expressed as Mandatory, with consideration given to changes to Match Data values. Refer to Match Data Rules. When a jurisdiction makes a data call, the jurisdiction should make every attempt to give affected Claim Administrators ample notice to allow for programming. See Upon Request (UR) Processing Rules in Section 4 for transaction processing rules for data requirements, limitations and expected population of data elements that may change during the life of a claim. When completing UR requirements for legacy claims or acquired claims, special consideration should be given to availability of the data. See Legacy Claims Processing and Acquired Claims Processing in Section 4 prior to completion of the element requirements. Usage: This table should be completed when the jurisdiction deems a data call is necessary. The IAIABC Release 3 UR Element Requirement table contains worksheets to be completed for each report UR type and its related conditions that apply to the jurisdiction s reporting requirements: UR FROI (Upon Request First Report of Injury) UR FROI Conditions (UR First Report of Injury applicable condition restrictions) UR SROI (Upon Request Subsequent Report) UR SROI Conditions (UR Subsequent Report applicable condition restrictions) Element Requirement Table Layout: Rec (Record) - This column indicates in which record the data element must be populated for Release 3 (See Record Layouts for details). DN# (Data Element Number) This column indicates the assigned Data Element Number. The Data Dictionary in Section 6 provides descriptions of the element. SROI the Benefits segment of the UR SROI Element Requirement table is blocked out and contains references to R3 standards to acquaint jurisdictions and senders with standard population of the segment. These references should not be removed. Some cells are pre-populated with Requirement Code Values. The Requirement rules defined below apply. Data elements indicated with a value of F (Fatal Technical) cannot be changed by the jurisdiction because they are necessary for technical processing. Some conditional values have been indicated by a character and apply only if the defined condition exists (see below for exceptions). These conditions are defined in the Conditional section for the UR report type. Rev of 3

2 IAIABC CLAIMS RELEASE 3 STANDARDS: UPON REQUEST (UR) ELEMENT REQUIREMENT TABLE INSTRUCTIONS A Requirement Code Value must be entered at each cell marked by the intersection of FROI/SROI UR MTC column and a Data Element row. Those cells that do not contain a value are open to jurisdictions to assign a valid requirement code. Special characters must be replaced with valid requirement codes. Conditional Requirements: Each time an MC (Mandatory/Conditional) or EC (Expected/Conditional) requirement value is assigned by the jurisdiction on the FROI or SROI UR, the conditional data element number, data element name and the applicable condition(s) should be described on the related Conditional requirement tab in addition to the pre-populated values. Special conditions such as jurisdiction rule effective date(s) that are dependent on date of injury, etc. should be included in the described condition, when applicable. Each Conditional requirement tab is pre-populated with suggestions and/or limitations defined in the Release 3 standard. Once conditions have been defined for all applicable data elements, modify the table presentation as follows: 1. Delete rows containing Data Elements that will not be collected or where conditions do not apply in your jurisdiction 2. Delete columns A (Req Code) and B (Rec) from the table 3. Sort the table by Data Element Number Standard Requirement Code Values: M = Mandatory. The data element must be present and must be a valid format or the transaction will be rejected. MC = Mandatory/Conditional. The data element becomes mandatory under conditions established by the receiver. If the defined condition exists, the data element becomes mandatory and mandatory rules apply (the data element must be present and must be a valid format or the transaction will be rejected). For example, if the Benefit Type Code indicates death benefits, then the Date of Death becomes mandatory. The receiver must provide senders with the specific circumstances, which cause an element to become mandatory. E = Expected. The data element is expected on the MTC, yet the transaction will be accepted with errors should it fail any edit. If an E is designated, the transaction will not be rejected if it is the only edit failure. EC = Expected/Conditional. The data element becomes expected under conditions established by the receiver. The receiver must provide senders with a document describing the specific circumstances, which cause an element to become expected. The transaction would be accepted with errors should it fail any edit. IA = If Applicable/Available. Data should be sent if available. The data may or may not be populated. If present, may be edited for valid value and/or format. Jurisdiction may or may not return an error on validity edits. NA = Not Applicable. The data element is not applicable to the jurisdiction s requirements for the MTC and may or may not be sent; edits must not be applied. Systems/Processing Requirement Codes: These are standards designations only; the codes cannot be used by a jurisdiction or be changed: F = Fatal Technical. Data elements that are essential for a transmission/transaction to be accepted into a jurisdictions workers compensation administration database or acknowledgment back to the claim administrator. 2 of 3

3 IAIABC CLAIMS RELEASE 3 STANDARDS: UPON REQUEST (UR) ELEMENT REQUIREMENT TABLE INSTRUCTIONS Exceptions: These characters represent Requirement Codes that must be changed by the jurisdiction. You must assign either a valid requirement code or change to NA if not used. # = Only If Applicable/Available (IA) or Not Applicable (NA) are valid Requirement codes for these = Only Mandatory/Conditional (MC), Expected/Conditional (EC), or Not Applicable (NA) are valid Requirement codes for these elements. See the Conditional Requirements for the report type (FROI, SROI) for those rules that apply. > = Only Mandatory/Conditional (MC) or Not Applicable (NA) are valid Requirement codes for these elements. See the Conditional Requirements for the report type (FROI, SROI) for those rules that apply % = Only Mandatory/Conditional (MC), Expected/Conditional (EC), or Not Applicable (NA) are valid Requirement codes for these elements. See Data Population Rules in the Data Dictionary (Section 6). & = See Conditional requirements tab for specifications/restrictions on use. Legend for Requirement Code/Application Acknowledgement Code: There is a relationship between the Requirement Code assigned to a data element and DN0111- Application Acknowledgment Code that is returned on the Acknowledgment Record (AKC). The Edit Matrix is designed to convey which data elements have edits applied to them and to provide standard error messages to use in association with these edits. Error messages are communicated in the Acknowledgement Record in the form of error messages using DN0115-Element Number, DN0116- Element Error Number, DN0117-Variable Segment Number and DN0291-Element Error Text. The severity of applied edits (Application Acknowledgment Code: TR, TE, TA), if not passed, is determined by referencing the Jurisdiction s completed Element Requirement Table. The Application Acknowledgment Code field on the AKC is based on the Requirement Code assigned to the data element as outlined in the table below, where the application acknowledgment code applies to the most severe edit failure for the transaction. Requirement Code M (Mandatory) MC (Mandatory/Conditional) E (Expected) EC (Expected/Conditional) IA (If Applicable/Available) NA (Not Applicable) F (Fatal) Result of Failed Element Requirement Edit TR (Transaction Rejected) TR (Transaction Rejected) TE (Transaction Accepted with Errors) TE (Transaction Accepted with Errors) TA (Transaction Accepted) OR TE (Transaction Accepted with Errors) * TA (No error messages may be applied) TR (Transaction Rejected) * The result depends on whether the jurisdiction chooses to apply edits to the IA data 3 of 3

4 IAIABC Claims Release 3 Instructions Instructions: Double click image above to open Claims R3 Requirements: Population Legend Symbols below including blank cells should be changed by the jurisdiction on the applicable tables. The color shading provides the ability to identify the initial symbol defined by the Should be changed by - Only Mandatory/Conditional (MC), Expected/Conditional (EC), If Applicable/Available (AA, AE, AR), or Not Applicable (NA) are valid requirement codes for these elements. # Should be changed by Jurisdiction # - Only If Applicable/Available (AA, AE, AR) or Not Applicable (NA) are valid requirement codes for these elements. & Should be changed by Jurisdiction & - See Conditional requirements tab for specifications/restrictions on use. > Should be changed by Jurisdiction > - Only Mandatory/Conditional (MC) or Not Applicable (NA) are valid r equirement codes for these elements.? Should be changed by Jurisdiction? - Only Mandatory/Conditional (MC), Expected/Conditional (EC), or Not Applicable (NA) are valid requirement codes for these SROI Payment segment elements + Should be changed by Jurisdiction + - Only If E (Expected), (EC) Excepted Conditional), Applicable/Available (AA, AE, AR) or Not Applicable (NA) are valid requirement codes for these elements. % Should be changed by Jurisdiction % - Only Mandatory/Conditional (MC), Expected/Conditional (EC), If Applicable/Available (AA, AE, AR),elements. or Not Applicable (NA) are valid requirement codes ^ Should be changed by Jurisdiction Only Mandatory/Conditional (MC), Restricted (R), or Restricted/Conditional (RC) are valid requirement codes VariableSegment Population Rules Benefits Segment (Section 4). tab. * Should be changed by Jurisdiction * - Only Mandatory/Conditional (MC), Expected/Conditional (EC), or Not Applicable (NA) are valid See requirement codes for these SROI Event Benefits segment elements. Blank Should be changed by Jurisdiction Blank -Cells that do not contain a value are open to jurisdictions to assign any valid requirement code. Symbols below should not be changed by the jurisdiction on the applicable tables. The color shading provides the ability to identify the initial symbol defined by the IAIABC. Prefilled Req Code Should not be changed by Jurisdiction IAIABC defined requirements, requirement code (s) should not be changed by Jurisdiction $ Should not be changed by Jurisdiction $ - Limited to the requirements applicable to the original underlying MTC being corrected Legend for Requirement Code (Description) = resulting Application Acknowledgment Code F (Fatal Technical) = TR (Transaction Rejected) M (Mandatory) = TR (Transaction Rejected) MC (Mandatory/Conditional) = TR (Transaction Rejected) AA (If Applicable/Available Item Accepted) = TA (Transaction Accepted) AE (If Applicable/Available Item Accepted with Errors) = TE (Transaction Accepted with Errors) AR (If Applicable/Available Item Rejected) = TR (Transaction Rejected) N/A (Not Applicable) = TA (Transaction Accepted) (No error messages are applied) X (Exclude Not Applicable to the transaction)= TA (Transaction Accepted) (No error messages applied) EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev Instructions

5 IAIABC Claims Release 3 Change Log WorkSheet Changed Change Description Change Reason/Purpose IAIABC Release Publication Date Change Number Revision Date Earliest Implemen tation Date EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev IAIABC Change Log

6 [Jurisdiction] Change Log Jur Revision Date Jur Published Date Jur Implementaion Date Jur Change Number WorkSheet Changed Row or Column Updated Change Description: Previous Requirement Change Description: New Requirement Change Reason/Purpose IAIABC Change Number (if applicable) EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev {Jur} Change Log

7 IAIABC Claims Release 3 FROI UR Element Requirement Table E (Expected) IAIABC Defined M # MC (Mandatory/Conditional) &? EC (Expected/Conditional) > IA (If Applicable/Available) + NA (Not Applicable) F (Fatal Technical) Claim Administrator Postal Code (DN0014) and related address fields should be populated with: Mailing or Physical REC DN# DATA ELEMENT NAME FORMAT FROI UR Transaction Set ID 3 A/N F Maintenance Type Code 2 A/N F Maintenance Type Code Date DATE F Jurisdiction Code 2 A/N F Jurisdiction Claim Number 25 A/N Insurer FEIN 9 A/N F Claim Administrator City 15 A/N Claim Administrator State Code 2 A/N Claim Administrator Postal Code 9 A/N F Claim Administrator Claim Number (Key Match) 25 A/N F Employer FEIN 9 A/N Employer Physical City 15 A/N Employer Physical State Code 2 A/N Employer Physical Postal Code 9 A/N Industry Code 6 A/N Insured Location Identifier 15 A/N Policy Number Identifier 18 A/N Policy Effective Date DATE Policy Expiration Date DATE Date of Injury DATE Time of Injury HHMM Accident Site Postal Code 9 A/N Nature of Injury Code 2 A/N Part of Body Injured Code 2 A/N Cause of Injury Code 2 A/N Initial Treatment Code 2 A/N Date Employer Had Knowledge of the Injury DATE Date Claim Administrator Had Knowledge of Injury DATE Employee First Name 15 A/N Employee Mailing City 15 A/N Employee Mailing State Code 2 A/N Employee Mailing Postal Code 9 A/N Employee Date of Birth DATE Employee Gender Code 1 A/N Employee Marital Status Code 1 A/N Employee Number of Dependents 2 N Initial Date Disability Began DATE Employee Date of Death DATE Employment Status Code 2 A/N Manual Classification Code 4 A/N Employee Date of Hire DATE Wage $ Wage Period Code 2 A/N Number of Days Worked Per Week 1 N EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR FROI

8 IAIABC Claims Release 3 FROI UR Element Requirement Table REC DN# DATA ELEMENT NAME FORMAT FROI UR Initial Date Last Day Worked DATE Full Wages Paid for Date of Injury Indicator 1 A/N Initial Return to Work Date DATE R Transaction Set ID 3 A/N F R Maintenance Type Correction Code 2 A/N X R Maintenance Type Correction Code Date DATE X R Denial Rescission Date DATE R Jurisdiction Branch Office Code 2 A/N R Claim Administrator Claim Number 25 A/N F R Claim Administrator FEIN 9 A/N F R Claim Administrator Name 40 A/N R Claim Administrator Information/Attention Line 50 A/N R Claim Administrator Primary Address 40 A/N R Claim Administrator Secondary Address 40 A/N R Claim Administrator Country Code 3 A/N R Employee ID Type Qualifier 1 A/N R21 * Employee ID *One of the following Employee ID types may be populated in positions Employee SSN 15 A/N > 0152 Employee Employment Visa 15 A/N > 0153 Employee Green Card 15 A/N > 0154 Employee ID Assigned by Jurisdiction 15 A/N > 0156 Employee Passport Number 15 A/N > R Employee Last Name Suffix 4 A/N R Employee Authorization to Release Medical Records Indicator 1 A/N R Employee Social Security Number Release Indicator 1 A/N R Employee Last Name 40 A/N R Employee Middle Name/Initial 15 A/N R Employee Mailing Primary Address 40 A/N R Employee Mailing Secondary Address 40 A/N R Employee Mailing Country Code 3 A/N R Employee Phone Number 15 A/N R Death Result of Injury Code 1 A/N R Type of Loss 2 A/N R Return to Work with Same Employer Indicator 1 A/N R Return to Work Type Code 1 A/N R Physical Restrictions Indicator 1 A/N R Insured FEIN 9 A/N R Insured Name 40 A/N R Insured Type Code 1 A/N R Insured Report Number 25 A/N R Work Week Type Code 1 A/N R Work Days Scheduled Code 7 A/N R Injury Severity Type Code 1 A/N R Insurer Name 40 A/N R Insurer Type Code 1 A/N R Insolvent Insurer FEIN 9 R Claim Administrator Alternate Postal Code 9 A/N R Employee Security ID 15 AN R Accident Premises Code 1 A/N R Accident Site County/Parish 20 A/N R Accident Site Location Narrative 50 A/N EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR FROI

9 IAIABC Claims Release 3 FROI UR Element Requirement Table REC DN# DATA ELEMENT NAME FORMAT FROI UR R Accident Site Organization Name 50 A/N R Accident Site City 15 A/N R Accident Site Street 40 A/N R Accident Site State Code 2 A/N R Accident Site Country Code 3 A/N R Date Employer Had Knowledge of Date of Disability DATE R Agreement to Compensate Code 1 A/N R Employer Name 40 A/N R Employer UI Number 15 A/N & R Employer Physical Primary Address 40 A/N R Employer Physical Secondary Address 40 A/N R Employer Physical Country Code 3 A/N R Employer Contact Business Phone Number 15 A/N R Employer Contact Name 40 A/N R Employer ID Assigned by Jurisdiction 15 A/N R Manual Classification Sub-Code 2 A/N R Employer Mailing Information/Attention Line 50 A/N R Employer Mailing City 15 A/N R Employer Mailing Country Code 3 A/N R Employer Mailing Postal Code 9 A/N R Employer Mailing Primary Address 40 A/N R Employer Mailing Secondary Address 40 A/N R Employer Mailing State Code 2 A/N R Occupation Description 50 A/N R Full Denial Effective Date DATE R Claim Status Code 1 A/N R Claim Type Code 1 A/N R Late Reason Code 2 A/N R Employer Paid Salary in Lieu of Compensation Indicator 1 A/N Variable Segment Counters R Number of Accident/Injury Description Narratives 2 N R Number of Denial Reason Codes 2 N R Number of Denial Reason Narratives 2 N R Number of Managed Care Organizations 2 N R Number of Witnesses 2 N Variable Segments Accident/Injury Description Narratives R Accident/Injury Description Narrative 50 A/N Full Denial Reason Codes R Full Denial Reason Code 2 A/N Full Denial Reason Narratives R Denial Reason Narrative 50 A/N Managed Care Organizations R Managed Care Organization Code 2 A/N R Managed Care Organization Name 50 A/N R Managed Care Organization Identification Number 40 A/N Witnesses R Witness Name 40 A/N R Witness Business Phone Number 15 A/N EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR FROI

10 IAIABC Claims Release 3 First Report of Injury Conditional Requirements Req Code FROI DATA ELEMENT DN# DATA ELEMENT NAME BUSINESS CONDITION(S) TECHNICAL CONDITION(S) 0005 Jurisdiction Claim Number Must be Conditional (MC, EC), IA (If Applicable/Available) or NA (Not Applicable) based on availibility from the jurisdiction. % 0016 Employer FEIN Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable based on Full Denial Reason code % 0028 Policy Number Identifier Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable based on Full Denial Reason code % 0029 Policy Effective Date Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable based on Full Denial Reason code % 0030 Policy Expiration Date Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable based on Full Denial Reason code > 0042 Employee SSN When DN 0270 Employee ID Type Qualifier = S, then mandatory & 0052 Employee Date of Birth May be M, E or Conditional (MC, EC) if the jurisdiction's Match Data table includes Employee Date of Birth & 0056 Initial Date Disability Began If the jurisdiction event table accepts claims that do not have lost time (notice, medical, etc.) then the DN requirement should be conditional based on if there was a compensable disability 0057 Employee Date of Death Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on ability to recognize a death payment/report. If the jurisdiction must make this field mandatory, it is crucial that they provide a way for the claim administrator to get the JCN directly from the jurisdiction. See Data Population Rules in the Dictonary. See Data Population Rules in the Dictonary. See Data Population Rules in the Dictonary. See Data Population Rules in the Dictonary. This DN is populated in the Employee ID field. See Record Layout for positioning. The jurisdiction needs to define the conditions that would make this Mandatory or Expected. (Death Result of Injury Code, etc.) & 0063 Wage Period Code When DN 0063 Wage Period Code is M, MC, E, or EC, then 0062 Average Wage must be the same requirement code or a more severe 0068 Initial Return to Work Date When DN 0224 Physical Restrictions Indicator is populated, then DN 0068 Initial Return to Work Date can be 0077 Late Reason Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on ability to recognize late 0146 Death Result of Injury Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on ability to recognize a death payment/report. > 0152 Employee Employment Visa When DN 0270 Employee ID Type Qualifier = E, then mandatory > 0153 Employee Green Card When DN 0270 Employee ID Type Qualifier = G, then mandatory > 0154 Employee ID Assigned by Jurisdiction When DN 0270 Employee ID Type Qualifier = A, then mandatory % 0155 Employee Mailing Country Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on comparison to employee mailing state code. > 0156 Employee Passport Number When DN 0270 Employee ID Type Qualifier = P, then mandatory % 0164 Employer Physical Country Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on comparison to employer physical state code. % 0166 Employer Mailing Country Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on comparison to employer mailing state code. % 0178 Initial Medical Provider Physical Country Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on comparison to initial medical provider physical state 0186 Jurisdiction Branch Office Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the ability to recognize a prior acknowledged report. Must be Conditional (MC, EC) or Not Applicable based on ability to recognize a RTW. The jurisdiction needs to define the conditions that would make the payment/report late. The jurisdiction needs to define the conditions that would make the indicator Mandatory or Expected. (Date of Death, etc.) This DN is populated in the Employee ID field. See Record Layout for positioning. This DN is populated in the Employee ID field. See Record Layout for positioning. This DN is populated in the Employee ID field. See Record Layout for positioning. See Data Population Rules in the Dictonary. This DN is populated in the Employee ID field. See Record Layout for positioning. See Data Population Rules in the Dictonary. See Data Population Rules in the Dictonary. See Data Population Rules in the Dictonary. EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR FROI Conditional Requiremnts

11 IAIABC Claims Release 3 First Report of Injury Conditional Requirements Req Code FROI DATA ELEMENT DN# DATA ELEMENT NAME BUSINESS CONDITION(S) TECHNICAL CONDITION(S) 0189 Return to Work Type Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the presence of a RTW 0224 Physical Restrictions Indicator When DN 0068 Initial RTW Date or DN 0072 Current RTW Date is populated, then only MC, EC, IA (If Applicable/Available) or NA can be 0228 Return to Work with Same Employer Indicator Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable based on the presence of a RTW date. % 0280 Accident Site Country Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on comparison to accident site state 0292 Insolvent Insurer FEIN Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable & 0329 Employer UI Number If this data element is required, the jurisdiction should furnish effective procedures for providing the information to the carriers. Can only use Conditional (MC, EC) or Not Applicable Requirement Codes. When using a Conditional requirement code, this can only be conditional if RTW Date is required. See Data Population Rules in the Dictonary. See limitations of use in the Data Population Rules in the Dictionary EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR FROI Conditional Requiremnts

12 E (Expected) IAIABC Defined M # MC (Mandatory/Conditional) & & EC (Expected/Conditional) >? IA (If Applicable/Available) + NA (Not Applicable) F (Fatal Technical) Claim Administrator Postal Code (DN0014) and related address fields should be populated with: Mailing or Physical REC DN# DATA ELEMENT NAME FORMAT SROI UR A Transaction Set ID 3 A/N F A Maintenance Type Code 2 A/N F A Maintenance Type Code Date DATE F A Jurisdiction Code 2 A/N F A Insurer FEIN 9 A/N F A Claim Administrator Postal Code 9 A/N F A Employee Number of Dependents 2 N F A Pre-existing Disability Code 1 A/N A Initial Date Disability Began DATE A Date of Maximum Medical Improvement DATE & A Current Return to Work Date DATE A Employee Date of Death DATE A Wage Period Code 2 A Number of Days Worked Per Week 1 N & A Date of Injury DATE A Insured Report Number 25 A/N M A Claim Administrator Claim Number 25 A/N # A Jurisdiction Claim Number 25 A/N F A Claim Status Code 1 A/N A Claim Type Code 1 A/N A Agreement to Compensate Code 1 A/N A Date Claim Administrator Notified of Employee Representation DATE A Late Reason Code 2 A/N Variable Segment Counters A Number of Permanent Impairments 2 N F A Number of Death Dependent/Payee Relationships 2 N F

13 REC DN# DATA ELEMENT NAME FORMAT SROI UR Variable Segments Permanent Impairments A Permanent Impairment Body Part Code 3 A Permanent Impairment Percentage 3.2 N Death/Dependent/Payee Relationships A Dependent/Payee Relationship Code 2 R Transaction Set ID 3 A/N F R Maintenance Type Correction Code 2 A/N X R Maintenance Type Correction Code Date DATE X R Date Claim Administrator Knew Disability Exceeded the Waiting Period DATE R Jurisdiction Branch Office Code 2 A/N R Claim Administratoristrator Claim Number 25 A/N F R Claim Administrator FEIN 9 A/N F R Claim Administrator Name 40 A/N R Claim Administrator Claim Representative Name 40 A/N R Claim Administrator Claim Representative Business Phone Number 15 A/N R Claim Administrator Claim Representative Address 80 A/N R Claim Administrator Claim Representative Fax Number 10 A/N R Employee ID Type Qualifier 1 A/N M R22 * Employee ID *One of the following Employee ID types may be populated in positions Employee SSN 15 A/N > 0152 Employee Employment Visa 15 A/N > 0153 Employee Green Card 15 A/N > 0154 Employee ID Assigned by Jurisdiction 15 A/N > 0156 Employee Passport Number 15 A/N > R Employee Last Name 40 A/N R Employee First Name 15 A/N R Employee Middle Name/Initial 15 A/N R Employee Last Name Suffix 4 A/N R Employee Date of Birth DATE R Employee Marital Status Code 1 A/N R Employee Education Level 2 N R Employee Number of Entitled Exemptions 2 N R Anticipated Wage Loss Indicator 1 A/N R Reduced Benefit Amount code 1 R Employee Tax Filing Status Code 1 A/N R Death Result of Injury Code 1 A/N R Insured FEIN 9 A/N R Insolvent Insurer FEIN 9 R Employer FEIN 9 A/N R Employer Physical Postal Code 9 A/N R Return to Work with Same Employer Indicator 1 A/N R Date Employer Had Knowledge of Date of Disability DATE R Non-Consecutive Period Code 1 A/N R Estimated Gross Weekly Amount Indicator 1 A/N R Current Date Last Day Worked DATE R Current Date Disability Began DATE R Initial Date Last Day Worked DATE R Return to Work Type Code 1 ID R Physical Restrictions Indicator 1 A/N R Suspension Effective Date DATE R Full Denial Effective Date DATE

14 REC DN# DATA ELEMENT NAME FORMAT SROI UR R Denial Rescission Date DATE R Partial Denial Code 1 A/N R Calculated Weekly Compensation Amount $9.2 R Wage Effective Date DATE R Discontinued Fringe Benefits $9.2 R Type of Loss Code 2 A/N R Employment Status Code 2 A/N R Permanent Impairment Minimum Payment Indicator 1 A/N R Initial Return to Work Date DATE R Full Wages Paid for Date of Injury Indicator 1 A/N R Lump Sum Payment/Settlement Code 2 A/N R Employer Paid Salary in Lieu of Compensation Indicator 1 A/N R Average Wage $9.2 R First Day of Disability After the Waiting Period DATE R Award/Order Date DATE R Claim Administrator Alternate Postal Code 9 A/N R Employer Paid Salary Prior to Acquisition Code 1 A/N R Work Week Type Code 1 A/N R Work Days Scheduled Code 7 A/N R Employee Security ID 15 A/N R Injury Severity Type Code 1 A/N

15 REC DN# DATA ELEMENT NAME FORMAT SROI UR Variable Segment Counters R Number of Benefits 2 N F R Number of Payments 2 N F R Number of Other Benefits 2 N F R Number of Benefit ACR 3 N F R Number of Recoveries 2 N F R Number of Reduced Earnings 2 N F R Number of Concurrent Employers 2 N F R Number of Full Denial Reason Codes 2 N F R Number of Denial Reason Narratives 2 N F R Number of Suspension Narratives 2 N F Variable Segments Benefits R Benefit Type Code 3 A/N R Maintenance Type Code 2 A/N R Gross Weekly Amount $9.2 R Gross Weekly Amount Effective Date DATE R Net Weekly Amount $9.2 R Net Weekly Amount Effective Date DATE R Benefit Period Start Date DATE R Benefit Period Through Date DATE R Benefit Type Claim Weeks 4 N R Benefit Type Claim Days 1 N R Benefit Type Amount Paid $9.2 R Benefit Payment Issue Date DATE Payments Requirements on UR reports are based on "Sweep" Benefits Segment Rules in Variable Segment Population Rules (see Section 4) R Payment Reason Code 3 A/N X R Payee 40 A/N X R Payment Amount $9.2 X R Payment Covers Period Start Date DATE X R Payment Covers Period Through Date DATE X R Payment Issue Date DATE X Other Benefits R Other Benefit Type Code 3 R Other Benefit Type Amount $9.2 Benefit ACR - Segment contains Adjustments, Credits or Redistributions R Benefit Adjustment Code 4 R Benefit Adjustment Start Date DATE R Benefit Adjustment End Date DATE R Benefit Adjustment Weekly Amount $9.2 R Benefit Credit Code 4 R Benefit Credit Start Date DATE R Benefit Credit End Date DATE R Benefit Credit Weekly Amount $9.2 R Benefit Redistribution Code 4 R Benefit Redistribution Start Date DATE R Benefit Redistribution End Date DATE R Benefit Redistribution Weekly Amount $9.2 Recoveries Jurisdictions must require DN Recovery Code if any of the following Recoveries data elements are requested

16 REC DN# DATA ELEMENT NAME FORMAT SROI UR R Recovery Code 3 A/N R Recovery Amount $9.2 Reduced Earnings Jurisdictions must require DN Reduced Earnings Week Number if any of the following Reduced Earnings data elements are requested R Reduced Earnings Week Number 2 N R Actual Reduced Earnings $9.2 R Deemed Reduced Earnings $9.2 Concurrent Employers Jurisdictions must require DN Concurrent Employer Name if any of the following Concurrent Employers data elements are requested R Concurrent Employer Name 40 A/N R Concurrent Employer Contact Business Phone 15 A/N R Concurrent Employer Wage $9.2 Denial Reason Codes R Full Denial Reason Code 2 A/N

17 REC DN# DATA ELEMENT NAME FORMAT SROI UR Denial Reasons R Denial Reason Narrative 50 A/N Suspension Narratives R Suspension Narrative 50 A/N

18 IAIABC Claims Release 3 Subsequent Report of Injury Conditional Requirements Req Code SROI DATA ELEMENT DN# DATA ELEMENT NAME BUSINESS CONDITION(S) TECHNICAL CONDITION(S) NOTE & 0016 Employer FEIN > 0042 Employee SSN When DN 0270 Employee ID Type Qualifier = S, then mandatory This DN is populated in the Employee ID field. See Record Layout for positioning. & 0052 Employee Date of Birth May be M, E or Conditional (MC, EC) if the jurisdiction's Match Data table includes Employee Date of 0055 Employee Number of Dependents May be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable & 0056 Initial Date Disability Began If the jurisdiction event table accepts claims that do not have lost time (notice, medical, etc.) then the DN requirement should be conditional based on if there was a compensable disability 0057 Employee Date of Death Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable based on ability to recognize a death payment/report. The jurisdiction needs to define the conditions that would make this Conditional. (Death Benefit, CD MTC, Death Result of Injury Code, etc.) & 0063 Wage Period Code When DN 0063 Wage Period Code is M, MC, E, or EC, then 0062 Average Wage must be the same requirement code or a more severe 0064 Number of Days Worked Per Week May be Conditional (MC, EC) IA (If Applicable/Available) or Not 0065 Initial Date Last Day Worked May be Conditional (MC, EC) IA (If Applicable/Available) or Not 0066 Full Wages Paid for Date of Injury Indicator May be Conditional (MC, EC) IA (If Applicable/Available) or Not 0068 Initial Return to Work Date When DN 0224 Physical Restrictions Indicator is populated, then DN 0068 Initial Return to Work Date can be required. Must be Conditional (MC, EC) or Not Applicable based on ability to recognize a 0070 Date of Maximum Medical Improvement Must be Conditional (MC, EC) or IA (If Applicable/Available) or Not Applicable. The jurisdiction needs to define the conditions that would make this Conditional. (Benefit Type Code, MTC, 0072 Current Return to Work Date Must be Conditional (MC, EC) or IA (If Applicable/Available) or Not Jurisdiction must define the condition. Applicable based on ability to recognize a 0074 Claim Type Code May be Conditional (MC, EC) IA (If Applicable/Available) or Not 0077 Late Reason Code Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable Must be Conditional (MC, EC) or Not Applicable based on ability to recognize a late 0083 Permanent Impairment Body Part Code Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Jurisdiction must define the condition. Applicable based on ability to recognize a Permanent Impairment 0084 Permanent Impairment Percentage Must be Conditional (MC, EC) IA (If Applicable/Available) or Not Applicable based on ability to recognize a Permanent Impairment benefits Jurisdiction must define the 0092 Benefit Adjustment Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0289 Number of Benefit ACR. The DN should be used when adjustments to benefits are made. DN 0126 Benefit Credit Code, DN 0130 Benefit Redistribution Code, and DN 0092 Benefit Adjustment Code are used in the same field in the record layout depending upon what code is being 0093 Benefit Adjustment Weekly Amount Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Adjustment 0094 Benefit Adjustment Start Date Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Adjustment 0097 Dependent/Payee Relationship Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on ability to recognize a death 0124 Actual Reduced Earnings Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0285 Number of Reduced Earnings >0, and/or benefit segment = RE MTC or transaction MTC = 0125 Benefit Adjustment End Date Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Adjustment 0126 Benefit Credit Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0289 Number of Benefit ACR. The DN should be used when credits to benefits are made. The jurisdiction needs to define the conditions that would make this Conditional. (Death Benefit, CD MTC, Death Result of Injury Code, etc.) The jurisdiction may expect Actual Reduced Earnings (DN 0124) or Deemed Reduced Earnings (DN 0147), whichever applies, but not both. DN 0126 Benefit Credit Code, DN 0130 Benefit Redistribution Code, and DN 0092 Benefit Adjustment Code are used in the same field in the record layout depending upon what code is being reported. EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR SROI Conditional Requiremnts

19 IAIABC Claims Release 3 Subsequent Report of Injury Conditional Requirements Req Code SROI DATA ELEMENT DN# DATA ELEMENT NAME BUSINESS CONDITION(S) TECHNICAL CONDITION(S) 0127 Benefit Credit Start Date Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Credit 0128 Benefit Credit End Date Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Credit 0129 Benefit Credit Weekly Amount Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Credit 0130 Benefit Redistribution Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0289 Number of Benefit ACR. The DN should be used when redistribution to benefits are 0131 Benefit Redistribution Start Date Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Redistribution 0132 Benefit Redistribution End Date Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on whether the segment is reporting Benefit Redistribution 0133 Benefit Redistribution Weekly Amount Must be Conditional (MC, EC), IA or Not Applicable based on whether the segment is reporting Benefit Redistribution 0141 Concurrent Employer Name Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0275 Number of Concurrent Employers 0142 Concurrent Employer Contact Business Phone Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0275 Number of Concurrent Employers 0143 Concurrent Employer Wage Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0275 Number of Concurrent Employers 0144 Current Date Disability Began Must be Conditional (MC, EC) IA (If Applicable/Available) or Not 0145 Current Date Last Day Worked Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the ability of the jurisdiction to recognize that this is a subsequent period of disability and that there was a RTW period. (Example: MTC = RB preceeded by a 0146 Death Result of Injury Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on ability to recognize a death 0147 Deemed Reduced Earnings Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on the value of DN 0285 Number of Reduced Earnings >0 DN 0126 Benefit Credit Code, DN 0130 Benefit Redistribution Code, and DN 0092 Benefit Adjustment Code are used in the same field in the record layout depending upon what code is being reported. This data may not always be available. Jurisdictions should not require a segment be present since there isn't always a concurrent employer. This data may not always be available. Jurisdictions should not require a segment be present since there isn't always a concurrent employer. This data may not always be available. Jurisdictions should not require a segment be present since there isn't always a concurrent employer. This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 4. Note: This may represent the Initial Date Last Day Worked if there have been no RTW periods or non-consecutive lost days. This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 4. The jurisdiction needs to define the conditions that would make this Conditional. (Death Benefit, CD MTC, Employee Date of Death, etc.) This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 4. The jurisdiction may expect Actual Reduced Earnings (DN 0124) or Deemed Reduced Earnings (DN 0147), whichever applies, but not both. ^ 0152 Employee Employment Visa When DN 0270 Employee ID Type Qualifier = E, then mandatory This DN is populated in the Employee ID field. See Record Layout for positioning. > 0153 Employee Green Card When DN 0270 Employee ID Type Qualifier = G, then mandatory This DN is populated in the Employee ID field. See Record Layout for positioning. > 0154 Employee ID Assigned by Jurisdiction When DN 0270 Employee ID Type Qualifier = A, then mandatory This DN is populated in the Employee ID field. See Record Layout for positioning. > 0156 Employee Passport Number When DN 0270 Employee ID Type Qualifier = P, then mandatory This DN is populated in the Employee ID field. See Record Layout for 0189 Return to Work Type Code Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on ability to recognize a current or initial RTW date. See Data Population Rules in the dictionary. This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 0196 Full Denial Rescission Date Must be Conditional (MC, EC), IA (If Applicable/Available) or Not Applicable based on ability to recognize a previous denial of benefits (FROI-04, SROI-04). To be used with MTC's that start or reinstate benefits after a full denial has been sent. This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 4. EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR SROI Conditional Requiremnts

20 IAIABC Claims Release 3 Subsequent Report of Injury Conditional Requirements Req Code SROI DATA ELEMENT DN# DATA ELEMENT NAME BUSINESS CONDITION(S) TECHNICAL CONDITION(S) 0202 Reduced Benefit Amount Code Must be Conditional (MC, EC), IA or NA based on the jurisdiction s ability to recognize a missing Benefits segment or the value of DN0086 Benefit Type Amount Paid less than previously 0215 Other Benefit Type Amount Must be Conditional (MC, EC), IA or Not Applicable based the requirement or presence of DN 0216 Other Benefit Type 0216 Other Benefit Type Code Must be Conditional (MC, EC), IA or Not Applicable based on whether other benefits on the jurisdiction exception table have been paid. Refer to the definition of the Reduced Benefit Amount Code in the Data Dictionary (Section 6) Note: May be edited on the presence of the Variable Segment counter or on valid other benefit type codes accepted by the 0224 Physical Restrictions Indicator Must be Conditional (MC, EC) IA or Not Applicable This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 0228 Return to Work with Same Employer Indicator May be Conditional (MC, EC), IA or Not Applicable This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 0242 Reduced Earnings Week Number Must be Conditional (MC, EC), IA or Not Applicable based on the value of DN 0285 Number of Reduced Earnings >0, and/or benefit segment = RE MTC or transaction MTC = 0256 Wage Effective Date Must be Conditional (MC, EC) IA or Not Applicable This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 4. & 0273 Employer Paid Salary in Lieu of Compensation Indicator If the jurisdiction event table accepts claims that do not have lost time (notice, medical, etc.) then the DN requirement should be conditional based on if there was a compensable disability period. This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 0290 Type of Loss Code Must be Conditional (MC, EC) IA or Not Applicable This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 4. % 0292 Insolvent Insurer FEIN This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 0297 First Day of Disability After the Waiting Period Must be Conditional (MC, EC) IA or Not Applicable This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 0298 Date Claim Administrator Knew Disability Exceeded the Waiting Period Must be Conditional (MC, EC), IA or Not 0299 Award/Order Date Must be Conditional (MC, EC), IA or Not Applicable based on ability to recognize that an Award/Order applies to benefits being reported. This data element can be required on acquired claim (AP) reporting the first payment on the claim - refer to Acquired Claims Processing Rules in Section 4. The jurisdiction needs to define the conditions that would make this Conditional. (Permanent Impairment percentage being reported, etc.) EDI-Claims-R3_UR-Element-Requirement-Table_Pub _Rev UR SROI Conditional Requiremnts