Workers Compensation Automation and Integration System (WCAIS)

Transcription

1 Workers Compensation Automation and Integration System (WCAIS) EDI Forms Solution September 2016

2 Agenda 2 Overview and Objectives EDI Forms Solution Functionality Cutover Strategy Important Reminders Questions Resources and Assistance Appendix A: Generated Forms Appendix B: Frequently Asked Questions

3 Overview and Objectives

4 Overview and Objectives 4 Review the EDI Forms Solution functionality (automatic Form generation) Demonstrate EDI transactions that will generate Forms after submission Review the cutover strategy and important information when submitting EDI transactions

5 EDI Forms Solution Functionality

6 Overview of EDI Forms Solution Functionality 6 Below is a high-level depiction of the EDI Forms Solution: First Report of Injury (FROI) Second Report of Injury (SROI) Update/ Change Initial Payments Generates NCP/NTCP Denial Generates Denial + SN Injury Establish Changes Generates NCP/NTCP Wait Execute NCP = Notice of Compensation Payable; NTCP = Notice of Temporary Compensation Payable; SN = Stopping Notice

7 EDI Forms Solution Functionality 7 The main components of the WCAIS EDI Forms Solution functionality include: Automatic Form Generation WCAIS will generate the following four Forms when appropriate EDI transactions are accepted and will send them back to the filer in the Acknowledgement for service upon the Claimant: LIBC-496: Notice of Workers Compensation Denial LIBC-502: Notice Stopping Temporary Compensation Payable LIBC-501: Notice of Temporary Compensation Payable LIBC-495: Notice of Compensation Payable All Trading Partners will not have to submit the above listed Forms to BWC because the Forms will be automatically generated through the receipt of the EDI transactions and accessible on the Actions tab of the Claims Summary in WCAIS (will serve as the official Bureau record) There will no longer be an option to upload these Forms into WCAIS and any of the identified Forms mailed to BWC after Friday, September 16, 2016, will be returned to the sender 14 Day Rule Carriers will have 14 days after the submission of a rejected transaction to resubmit a corrected transaction; BWC will preserve the original filing date

8 EDI Forms Solution Functionality (Cont d) 8 Forms will be generated based on the data submitted below: EDI Transactions That Can Generate Forms Report MTC Description FROI 04 Denial FROI 02 Change SROI 02 Change SROI 04 Denial SROI CA Change in Benefit Amount SROI IP Initial Payment SROI AP Acquired Payment SROI PD Partial Denial SROI PY Payment Report SROI RB Reinstatement of Benefits SROI RE Reduced Earnings Data Fields Impacting Form Generation Award Order Date (DN0299) No Form will be generated when this field is populated Lump Sum Payment/Settlement Code (DN0293) No Form will be generated when this field is populated Agreement To Compensate Code (DN0075) Will determine NTCP vs NCP W Without Liability; Insurer not accepting liability for the Claim NTCP L With Liability; Insurer accepting liability for the Claim NCP Claim Type Code (DN0074) Will determine Medical- Only Forms I Indicates a Indemnity/Wage Loss Claim NCP/NTCP M Indicates a Medical Only Claim Medical Only NCP/NTCP NCP = Notice of Compensation Payable; NTCP = Notice of Temporary Compensation Payable; SN = Stopping Notice

9 EDI Forms Solution Functionality (Cont d) 9 Location and Access to Forms Newly generated Forms will be displayed and available for download on the Actions tab of the Claims Summary for the applicable Claim

10 EDI Forms Solution Functionality (Cont d) 10 Mandatory Fields for Indemnity/Wage Loss Claims Required fields for submission of Indemnity/Wage Loss Claims will be indicated by a red asterisk (*) DN # Data Element Name 0134 Calculated Weekly Compensation Amount 0286 Average Wage 0088 Benefit Period Start Date 0192 Benefit Payment Issue Date 0090 (Only required for specific loss) 0091 (Only required for specific loss) Benefit Type Claim Weeks Benefit Type Claim Days Increased Frequency of Batch Runs EDI batches will run at the following times: 9:00 AM, 1:00 PM, 6:00 PM, and midnight EST

11 EDI Forms Solution Functionality Demos

12 Demo 1 Generate LIBC-496 by Submitting FROI 04 Transaction 12 Purpose: Full denial of liability for injury Form Generated: LIBC-496: Notice of Workers Compensation Denial Pre-Conditions: None

13 Demo 2 Generate LIBC-501 by Submitting IP Transaction 13 Purpose: To accept payments for temporary benefits Form Generated: LIBC-501: Notice of Temporary Compensation Payable Pre-Conditions: FROI Claim Type Indemnity (I) Agreement to Compensate Code should be W

14 Demo 3 Generate LIBC-496 and LIBC-502 by Submitting a SROI 04 Transaction for a Claim in Temporary Status Purpose: Full denial of liability and notification of temporary payment termination Forms Generated: LIBC-496: Notice of Workers Compensation Denial LIBC-502: Notice Stopping Temporary Compensation Pre-Conditions: Claim must be in Temporary Status 14

15 Demo 4 Generate Amended LIBC- 501 by Submitting a PD 15 Purpose: To accept Medical liability and deny Indemnity liability Form Generated: Amended LIBC-501: Notice of Temporary Compensation Payable Pre-Conditions: FROI Claim Type Medical (M) Claim must be in Temporary Status

16 Cutover Strategy

17 Cutover Strategy 17 The key dates/times for the migration to the new EDI Forms Solution functionality include: Thursday, September 15 th, 2016: EDI transactions can be submitted via WCAIS Applicable Forms will still need to be mailed to BWC Friday, September 16 th, 2016: EDI transactions submitted via the EDI Web Portal before 12:00 PM will require the applicable Forms be mailed to BWC WCAIS will be unavailable from 12:00 PM until midnight and therefore, EDI transactions will not be able to be submitted EDI transactions filed after 12:00 AM will automatically generate the four Claim Forms BWC will return Forms related to EDI transactions submitted after Friday, September 16 th Monday, September 19 th, 2016: EDI Forms Solution functionality is live Forms will be generated automatically and accessible to view and download via the Actions tab of the Claim Summary EDI batches will run at the following times: 9:00 AM, 1:00 PM, 6:00 PM, and midnight EST Forms will not be accepted by mail by BWC or uploaded to WCAIS o NOTE: A copy of the Forms must still be mailed to the Claimant.

18 Cutover Strategy Legacy Claims 18 The SROI UR (Upon Request) transaction should be used to update existing Claims* that have erroneous information. The goals is to sync up the Claim to its correct current state and also that no duplicate Forms are generated. NOTE: Submission of a FROI UR will not prevent subsequent EDI SROI transactions from triggering an LIBC Form, nor will it update the Claim to a SROI Claim Status. NOTE: Please refer to the EDI Claims Release 3 Migration Strategy document for information on submission of a UR for all other legacy Claims. *Refer to the EDI Forms Solution Cutover Strategy document on the Department of Labor & Industry s website for more information on the UR.

19 Important Reminders

20 Important Reminders 20 Are required to use the WCAIS generated LIBC-495/496/501/502 Forms following the go-live of the Friday, September 16 th, 2016 release Mandated Use Form Submission Estimated Wages Discontinue uploading EDI Forms to WCAIS or mailing them to BWC after the Friday, September 16 th, 2016 release Option to upload Forms into WCAIS will be removed and Forms received by the BWC will be returned to the sender A copy of the Forms must still be mailed to the Claimant Use the Estimated Gross Weekly Amount Indicator (DN0172) to indicate estimated wages BWC will also publish updated NCP and NTCP Forms that will contain a checkbox to indicate estimated wages Bulk Download Access and download bulk zip files that are generated for Transaction Partners and Direct Filers who submit EDI transactions via batch files directly to BWC Files will be generated and available along with the corresponding Acknowledgment files

21 Questions

22 Resources and Assistance

23 Resources and Assistance 23 Access and review the EDI Forms Solution Q&A Document: Guide--Supporting-Documents.aspx Note: This document was recently updated by Claims staff to address questions that have arisen out of the testing period. It is also included in the Appendix for your reference/use. Access the Customer Service Center (via the Customer Service Center Home link in the drop-down menu in the top right-hand corner of WCAIS) to: Browse the Questions Repository View Process Guides & Simulations Watch Previously Recorded Trainings Access and review the EDI Implementation Guide and other supporting documents at the Department of Labor & Industry s website: Guide--Supporting-Documents.aspx Submit a Question to BWC by selecting the Submit a Question option from the Customer Service Center drop-down menu (top right-hand corner of WCAIS): Select EDI for the Category Select EDI Generated Forms Solution for the Sub-Category

24 Appendix A: Generated Forms

25 LIBC-496: Notice of Workers Compensation Denial 25 Receipt of the below EDI transactions will generate a Notice of Workers Compensation Denial Form (LIBC-496): Report MTC Description Business Event Trigger FROI 04 Denial No liability for Claim and submission of FROI 04 for full denial Note: Use SROI 04 to deny if a FROI 00 was submitted. SROI 04 Denial SROI PD Partial Denial Full denial after initial FROI is submitted and before any indemnity payments are due. Indemnity benefits are denied in whole Medical payments are delivered No agreement Claim Administrator has not accepted liability for indemnity Note: A PY accepting medical payments and an IP without liability must be on file in before PD submission. An LIBC-502 and LIBC-496 are required.

26 LIBC-501: Notice of Temporary Compensation Payable Receipt of the below EDI transactions will generate a Notice of Temporary Compensation Payable Form (LIBC-501): Report MTC Description Business Event Trigger SROI IP/AP Initial/ Acquired Payment No agreement in place Temporary payments at the time of the initial/acquired payment Agreement to Compensate Code must be set to 'W Note: Refer to the PA Implementation Guide for the 90-day Rule details. SROI PY Payment Report Report of medical benefits paid on a medical-only Claim Agreement to Compensate Code must be 'W' to comply with the 90-Day Rule if liability is not accepted SROI RB Reinstatement of Benefits SROI RE Reduced Earnings SROI 02 Change SROI CA Change in Benefit Amount Temporary benefits are resumed during the 90-day rule period An IP without liability and a denial (full or partial) must be on record. The Claim Administrator has not accepted liability for the Claim (Agreement to Compensate Code = 'W') Reduction of benefits during the 90-day rule period An IP without liability must be on record The Claim Administrator has not accepted liability for this Claim (Agreement to Compensate Code = 'W) Information associated with one or more of the data elements marked with a Y or FY in the SROI MTC 02 column of the Element Requirement Table has changed An IP without liability must be on record The Claim Administrator has not accepted liability for this Claim (Agreement to Compensate Code = 'W'). Average Weekly Wage is incorrect The Claim Administrator has not accepted liability (Agreement to Compensate Code = 'W'); This must be filed in accordance with the 90-Day rule 26

27 LIBC-502: Notice Stopping Temporary Compensation Payable 27 Receipt of the below EDI transactions will generate a Notice Stopping Temporary Compensation Payable Form (LIBC-502): : Report MTC Description Business Event Trigger SROI 04 Denial Payments were made without accepting liability A liability denial is submitted for the injury Note: An LIBC-502 and LIBC-496 are required. SROI PD Partial Denial Indemnity benefits are denied in whole Medical payments are delivered No agreement Claim Administrator has not accepted liability for indemnity Note: A PY accepting medical payments and an IP without liability must be on file in before PD submission. An LIBC-502 and LIBC-496 are required.

28 LIBC-495: Notice of Compensation Payable Receipt of the below EDI transactions will generate a Notice of Compensation Payable Form (LIBC-495): Report MTC Description Business Event Trigger SROI IP/AP Initial/ No agreement in place Acquired Accept or deny liability Payment Agreement to Compensate Code must be set to 'L' Note: refer to the PA Implementation Guide for the 90-day Rule details. SROI PY Payment Report Report of medical benefits paid on a medical-only Claim SROI RB Reinstatement of Benefits If liability is accepted the Agreement to Compensate Code is 'L' IP without liability and a denial (Full or partial) must be on record Accepting liability for this Claim (Agreement to Compensate Code = 'L') SROI 02 Change Initial Payment made without accepting liability. Liability is accepted Submit a change transaction to change the Agreement to Compensate Code from 'W' to 'L' (refer to 90-Day Rule reporting requirements in the PA Implementation Guide). SROI 02 Change Medical-only Claim without accepting liability. Liability is accepted Submit a change transaction to change the Agreement to Compensate Code from 'W' to 'L' (refer to 90-Day Rule reporting requirements in the PA Implementation Guide) SROI CA Change in Benefit Amount When the Average Weekly Wage is incorrect and changing, it increases the benefit amount paid SROI PD Partial Denial Denial of indemnity benefits in whole, but not medical payments No agreement and the Claim Administrator has not accepted liability for the Claim An IP without liability must be on file in order to file a PD 28

29 Appendix B: Frequently Asked Questions

30 Frequently Asked Questions 30 Question What is Forms Solution? What are the benefits of Forms Solution? Why aren t all Bureau forms and EDI transactions included in Forms Solution? Answer Forms Solution is the EDI-triggered generation of the following four forms: NCP, NTCP, NCD, & Stopping Notice. Accepted EDI transactions will satisfy your filing requirement by placing the form on the Bureau record in WCAIS and return a copy of the form to the user by batch run to be served upon the claimant. Carriers will save on postage because they will no longer have to submit these forms to BWC by mail. The multiple batch process will make it easier than ever for forms to be filed by their statutory deadlines while affording the filer the entire time allotted for deadlines. Adjusters will no longer have to duplicate their efforts to report the associated claim events by both preparing the form and submitting the EDI transaction. One additional cost-saving benefit is that the forms created from Forms Solution will have a condensed employee address section which is positioned perfectly to sit in the window of a standard business-sized envelope, saving the carrier from printing labels or creating and printing cover letters. The NCP, NTCP, NCD and Stopping Notice are the most often filed forms. Forms Solution will save the time and postage from preparing these forms and mailing them to the Bureau. Additionally, besides the occasional use of the Agreement for Compensation, the four forms included in Forms Solution are generally the first notice forms which are bound by the timeline for 21-Day Compliance. *Please note that Med Only filings are not subject to the 21-day statutory time period for claim acceptance. However, SROI transactions intended to report Med Only activity and create Med Only forms will be generated by Forms Solution as well.

31 Frequently Asked Questions (Cont d) 31 Question Why isn t the Statement of Wages form available through Forms Solution? Is the carrier still required to file/issue a Statement of Wages along with every indemnity NCP and NTCP where the wages are not marked estimated? Will PA mandate use of the WCAIS generated forms? Will WCAIS send the form to the claimant? Will the system ask me what form to generate? Will a form issue from a rejected transaction? How many pages will the forms be? Where will the Bureau copy of the Forms Solution forms get posted on the official Bureau file? Answer Yes, the carrier is still required to file a Statement of Wages form with the Bureau and issue same to the claimant along with all NCPs and NTCPs where the wages are not marked estimated. The SOW forms (LIBC 494A and LIBC 494C) are not available for preparation with Forms Solution (see answer to previous question). You may choose to prepare Statement of Wage forms from the Actions tab of the claim in WCAIS or by preparing and mailing or uploading onto the Bureau record on the Actions tab. Yes, Claim Administrators will be required to use the WCAIS generated LIBC 495, 496, 501, & 502 after 12:00 noon on September 16, The WCAIS application will be modified to not allow upload of these forms because the forms would already have been generated in WCAIS when the EDI transaction was accepted. Forms mailed to BWC will be returned to sender. No, the carrier is still responsible for submitting the forms to the claimant. No, the transaction submitted along with specific associated data fields will determine the form that will generate and which fields are included. No, only accepted transactions will come back with an LIBC form so filers will want to take note of the current Claim Status when preparing to enter a sequential transaction to ensure the proper form return. Each of these two sided one pagers are intended to be printed as duplex so you should verify your printer settings. The form will be attached to the Actions tab of the claim in WCAIS.

32 Frequently Asked Questions (Cont d) 32 Question How often will the batches run? Will you mandate we submit more than one batch a day? Even if there are multiple batches available in WCAIS, if the carrier still chooses to only send once a day, will that be acceptable? If we don t pick up the batches you processed for us earlier in the day, will they fold into the next one? Are we allowed to submit a Web Portal transaction to get the form and then go back to using a Transaction Partner for our other transactions? Will Claims Admin who use a Transaction Partner be able to download the zip files containing their generated forms directly from PA servers? Will the claims representative s signature be required on the NCP, NCD, NTCP, & Stopping Notice? Answer Flat file batches will run four times a day; 9 AM, 1PM, 6PM, and 11:59:59PM. Each filing entity should work with their Transaction Partner to determine the submission schedule that best meets their business needs. Yes, the additional batches will still run if you need them but you may stick with only once a day or whichever combination of batches best fits your business practices. The older files will be there waiting for you until you pick them up. Nothing will be lost. Trading Partners should not switch back and forth between flat-file transmissions and using the WCAIS EDI Web Portal or sequencing & data quality issues will surface which could result in increased costs to correct. No, zip files will be distributed to Transaction Partners who will be responsible for forwarding the zip files to the respective Claim Administrators. Your WCAIS credentials serve as verification of your signature when you submit a transaction, so the signature line was removed from the four forms that are included in Forms Solution: The NCP, NTCP, NCD, & Stopping Notice.

33 Frequently Asked Questions (Cont d) 33 Question Is there a possibility that you will allow attorneys to submit EDI? Is the calculation of the 90 days of a Temporary Notice going to be automated or manual? Will the carrier be able to amend a DOI on an NCP if it is incorrect? What is the character limit for the injury narrative field? What if a carrier files an NCD and then gets a conversion notice? Is there a WCAIS glitch that causes an NCD to turn into an NCP? Why does a TNCP result from our reporting medical bill payment on a denied claim? Why is the system pulling from the FROI for injury data when that is just what the claimant reported and not what is accepted or denied? Answer The carrier is statutorily responsible for administering the claim. The system will calculate the 90 day period based upon the elements provided in the transaction. For Indemnity Claims, the 90 days begins on Date Disability Began; and for Medical Only Claims, the 90 days begins on the Date of Injury. Yes, a corrected Date of Injury will result in a corrected form. There are 500 characters allotted for the Injury Narrative. No, in that case the carrier submitted an EDI transaction after the NCD which changed the claim status to Temporary. Carriers are responsible to ensure that they are filing acceptable transactions. The information on how to file accurately is posted on the website. It is not necessary to report the payment of medical bills to the Bureau and doing so could inadvertently change the claim status or print an unwanted form. Those carriers who wish to create a medical only filing may report the initial payment of medical to establish a medical only claim and generate a medical only form, but should carefully consider the consequences of reporting medical payments beyond the initial establishment of a med only claim. A FROI 02 is expected prior to the SROI transaction to update the injury fields if a change has been determined.

34 Frequently Asked Questions (Cont d) 34 Question How do I report an NCP with specific loss? Answer Benefit Type code 020 must be used along with one Permanent Impairment Body Part in order to populate section 4 of the NCP. You will also need to provide Benefit Type Claim Weeks and Benefit Type Claim Days. The first instance of the Benefit Type Claim Weeks and Benefit Type Claim Days will populate in 4a and the second occurrence, if appropriate, will populate in section 4c.