DN Change & Reason Date. Table Name

Transcription

1 Florida Division of Workers Compensation Claims Electronic Data Interchange (EDI) R3 Implementation Manual Supplement Rules: 1. Changes to external error message text only are not tracked in this document. 2. Wording changes or clarifications to edits, sequencing or duplicate rules etc., which do not change the meaning, or are not required for FL are not tracked in this document. DN Change & Reason Date le Name Edit Matrix-DN/Error Msg 0086-Benefit Type Amount Paid 0087-Net Weekly Amount 0211 Net Weekly Amount Effective Date 0174 Gross Weekly Amount 0175 Gross Weekly Amount Effective Date 0282 Number of Other Benefits 0282 Number of Other Benefits Below Included in Jan 07 Supplement : Added less than previous exception processing for acquired claims : Added AP to edit to allow Net to Change from previously reported if different on an AP : Added AP to edit to allow Net Eff Date to Change from previously reported if different on an AP : Added AP to edit to allow Gross to Change from previously reported if different on an AP : Added AP to edit to allow Gross Eff Date to Change from previously reported if different on an AP : Added edit that requires an OBT segment of OBT 430 if MTC is SA or FN and AU or AQ has been filed : Added L for new edit that requires an OBT segment of OBT 430 if MTC is SA or FN and AU or AQ has been filed

2 Edit Matrix-DN/Error Msg 0088 Benefit Period Start Date 0088 Benefit Period Start Date : Added new edit If MTC AQ or AU previously reported, BP Start Date must be > BP Thru Date previously reported. Note: This edit was subsequently removed in July : Added L for new edit: If MTC AQ or AU previously reported BP Start Date must be > BP Thru Date previously reported. Note: This edit was subsequently removed in July : Changed L to IA on table. L was a documentation error : Clarified that if invalid do not error. Removed error msg : Changed L to IA on table. L was a documentation error : Clarified that if invalid do not error. Removed error msg : Added IA on table. (documentation error) : Added edit and clarified that if invalid do not error : Added AB to edit. (documentation error) : Added edits for MTC s that must Edit Matrix-DN/Error Msg 0077 Late Reason 0077 Late Reason Edit Matrix-DN/Error Msg 0077 Late Reason 0077 Late Reason Edit Matrix-DN/Error Msg 0077 Late Reason 0077 Late Reason 0288 Number of Benefits 0288 Number of Benefits have at least 1 or 2 Ben Segments. Edit Matrix-Duplicate Line /Initial Payment equivalent filed after FROI 04 Accept FROI instead of Reject, but not load data from FROI Edit Matrix-Value le 0226 Recovery Added Recovery value 845 (Apportionment/Contribution Recovery) to Valid Values for FL in Section 1 &

3 SROI Element Requirement le SROI ERT Conditional Requirements SROI Element Requirement le SROI ERT Conditional Requirements SROI Element Requirement le SROI ERT Conditional Requirements 0005 Jurisdiction Claim Number 0005 Jurisdiction Claim Number Claim Administrator Primary Address 0074 Claim Type 0084 Permanent Impairment Percentage 0084 Permanent Impairment Percentage 0223 Permanent Impairment Minimum Payment Indicator 0223 Permanent Impairment Minimum Payment Indicator Changed requirement from NA to MC for the following MTCs: AP, EP, PY, IP, PD, CD, VE (previously had not considered that these MTCs can come in after the claim has been established) Added conditional requirement for the following MTCs: AP, EP, PY, IP, PD, CD, VE Removed the word Mailing from the Populations Restriction column. This was an oversight that wasn t caught after the IAIABC changed the name of the DN, and DWC defined it as Physical. Changed requirement from M to NA for CD & VE. (See March Supplement below for additional change) Removed SA for condition requiring a PI % when certain benefits are paid, and move SA to condition allowing for the absence of a PI % if PI Minimum Payment Indicator = Y Added FN as the other MTC besides 02 that can reflect a change in the Permanent Impairment Percentage from what was previously reported. For MTC SA, changed requirement from MC to IA. Changed condition to only apply to FN, and clarified that if PI Minimum Payment Indicator was previously sent as Y, a final actual rating must be obtained prior to closing the file, so this indicator must now be sent as N

4 0223 Permanent Impairment Minimum Payment Indicator 0072 Current Return To Work Date 0216 Other Benefit Type Added FN as the other MTC besides 02 that can reflect a change in the Permanent Impairment Minimum Payment Indicator from what was previously reported Changed edit to remove = condition from the edit Modified the edit to allow OBT s 310 and 320 to be sent, if sent in conjunction with OBT s 311 or 321. FROI Element Requirement le 0314 Insured FEIN For MTC 00, changed requirement from M to MC FROI ERT Conditional Requirements 0314 Insured FEIN Added Condition for MTC 00 and modified condition for MTC 04, that DN is required if Date Claim Administrator Had Knowledge of the Injury is on or after the Insurer's R3 production implementation date. FROI ERT Conditional Requirements FROI ERT Conditional Requirements FROI ERT Conditional Requirements 0119 Accident Site Location Narrative 0121 Accident Site City 0122 Accident Site Street Added condition to not require unless "Date Claim Administrator had Knowledge of the Injury is on or after the Insurers R3 Implementation Date" Added condition to only require full address when Date Claim Administrator had Knowledge of the Injury is on or after the Insurers R3 Implementation Date" Added condition to only require full address when Date Claim Administrator had Knowledge of the Injury is on or after the Insurers R3 Implementation Date"

5 FROI ERT Conditional Requirements FROI ERT Conditional Requirements FROI Element Requirement le FROI ERT Conditional Requirements Edit Matrix-DN/Error Msg FROI Element Requirement le Edit Matrix-DN/Error Msg Edit Matrix-DN/Error Msg 0123 Accident Site State 0033 Accident Site Postal 0016 Employer FEIN 0016 Employer FEIN Maintenance Type Claim Admin Claim # Claim Admin Claim # 0016 Employer FEIN Employer FEIN Employer FEIN Added condition to only require full address when Date Claim Administrator had Knowledge of the Injury is on or after the Insurers R3 Implementation Date" Added condition to only require full address when Date Claim Administrator had Knowledge of the Injury is on or after the Insurers R3 Implementation Date" For MTC 00, changed requirement from M to MC Added Condition for MTC 00 and modified condition for MTC 04, that DN is required if Date Claim Administrator Had Knowledge of the Injury is on or after the Insurer's R3 production implementation date. Below Included in Feb 07 Supplement Added edit #4 for MTC Added edit to compare Clm Admin Clm # to ensure match between 148 & R21 also A49 & R22. Added F to table for new edit above, per IAIABC. Changed AQ requirement from IA to M When a claim is being acquired and both Claim Admin and Insurer are changing, need to have additional match data criteria. Added L to table for new edit Added L to table for new edit

6 FROI Element Requirement le FROI ERT Conditional Requirements Edit Matrix-DN/Error Msg Employer FEIN Employer FEIN 0019 Employer Physical Primary Address 0019 Employer Physical Primary Address Employee SSN Employee Date of Death Date of Maximum Medical Improvement Permanent Impairment Percentage Benefit Type Benefit Type Amount Paid Net Weekly Amount 0089 Benefit Period Through Date Employer FEIN Added new edit Employer FEIN - Added new edit. Changed requirement from IA to MC to be consistent with the rest of the Employer Physical Address Added Condition to be consistent with the rest of the Employer Physical Address Expanded edit to ensure SSN is not sent > 9 digits because field length is 15 characters. Also, added minimum SSN edit to ensure Division Assigned # s are no longer reported in SSN field : Added IP, AP, EP, CD, VE, PY, CB, & RB : Added CB and RB to edit : Added CB and RB to edit Removed #4 in edit prohibiting the reporting of BTC 240 and 242, 250, 251, and 270 on same case : Added CA & RB : Added RB to edit Added L for new edit

7 0089 Benefit Period Through Date Edit Matrix-Value le 0097 Dependent/Payee Relationship Edit Matrix-DN/Error Msg Interchange Version ID SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions Edit Matrix-DN/Error Msg Interchange Version ID Calculated Weekly Compensation Amount 0144 Current Date Disability Began 0145 Current Date Last Day Worked Death Result of Injury Indicator Employee ID Assigned By Jurisdiction Employee ID Assigned By Jurisdiction Added new edit for RB Removed Shading from Dependent/Payee Numerical Birth Order 0 because we will not be loading the Birth Order part of the code. Added F to table for edit below, per IAIABC Added edit to compare Interchange Version ID to Transaction Set ID to ensure correct R3 values are sent : Added AP Changed condition for RB to require CDDB if CDLDW Date is present. Previous condition requiring presence of IDDB was redundant (already required for RB). Changed condition for RB to require CDLDW if CDDB Date is present : Added IP, AP, EP, CD, VE, PY, CB, & RB : Added Mandatory field not present edit Added L to table for edit above

8 Employee ID Assigned By Jurisdiction Net Weekly Amount Effective Date Permanent Impairment Minimum Payment Indicator Wage Effective Date Average Wage Number of Benefits Number of ACRs Error Message No Leading/Embedded Spaces : Expanded edit to ensure Employee ID Assigned By Jurisdiction is not sent > 9 digits because field length is 15 characters. Also, added edit to ensure first 4 characters = 0 and all characters are numeric : Added RB to edit to allow Net Eff Date to Change from previously reported if different on an RB : Added CB and RB to edit : Added AP : Added AP : Added RB to edit : Added RB Per addition from IAIABC, added this edit to the following DNs: 0007, 0010, 0012, 0017, 0018, 0019, 0021, 0023, 0033, 0038, 0043, 0044, 0045, 0046, 0048, 0050, 0060, 0119, 0120, 0121, 0122, 0141, 0154, 0188, 0197, 0217, 0233, 0238,

9 Edit Matrix-DN/Error Msg Error Message No Leading/Embedded Spaces Edit Matrix-Duplicate Edit Matrix-Duplicate Event le (FROI, SROI, Periodics) Edit Matrix-Sequencing Line 2.15 AU/AP(or equiv) after AQ same Clm Admin Line 2.15 AU/AP (or equiv) after AU/AP (or equiv) from same Clm Admin Event Rule From Column CB under Bus Event Group 3 Per addition from IAIABC, added L for new edit to DNs: 0007, 0010, 0012, 0017, 0018, 0019, 0021, 0023, 0033, 0038, 0043, 0044, 0045, 0046, 0048, 0050, 0119, 0120, 0121, 0122, 0154, 0188, 0197, 0217, 0233, Added Grayed L s for new edit to DNs: 0026, 0027, 0118, 0135, 0138, 0140, 0152, 0153, 0156, 0160, 0163, 0165, 0167, 0168, Added IA for new edit to DNs: 0060, 0141, Changed this condition from Reject to Accept FROI AU (not loaded to DWC database) and Accept and process SROI. Separated this Reject condition from the one above Changed TBD to Insurer s Mandate Date Added EP to list of MTC s that must precede a CB Below Included in March 07 Supplement Edit Matrix-Match Data Modified to reflect FL s processing Added new conditions to edit Maintenance Type SROI Element Requirement le 0052 Employee Changed condition on MTC 04 from M to SROI Element Requirement le- Conditions Date of Birth 0052 Employee Date of Birth MC. Added condition for MTC 04 to excuse DOB when certain Denial Reason s are present

10 SROI Element Requirement le- Conditions SROI Element Requirement le SROI Element Requirement le SROI Element Requirement le SROI Element Requirement le SROI Element Requirement le SROI Element Requirement le 0068-Initial Return To Work Date 0068-Initial Return To Work Date, 0072-Current Return To Work Date, 0189-RTW Type, 0224-Physical Restrictions Indicator & RTW with Same Employer Indicator 0068-Initial Return To Work Date, 0189-RTW Type, 0224-Physical Restrictions Indicator & RTW with Same Employer Indicator Date of Maximum Medical Improvement 0074 Claim Type 0083 Permanent Impairment Body Part 0084 Permanent Impairment Percentage Added BTC 240 & 270 to condition Changed requirement on these DN s from NA to IA for MTC CA. Changed requirement on these DN s from NA to IA for MTC PY & VE. Changed requirement on MTC EP, S1 and S7 from NA to IA because MMI can be initially reported on an EP, S1 or S7. Changed requirement from NA to IA for CD & VE. If CD or VE filed late due to delayed disability, Claim Type can be sent as L with 8 th day info to explain filing delay. Changed requirement on MTC EP, S1 and S7 from NA to IA because PI can be initially reported on an EP, S1 or S7. Changed requirement on MTC EP, S1 and S7 from NA to IA because PI % can be initially reported on an EP, S1 or S

11 Edit Matrix-DN/Error Msg Edit Matrix-DN/Error Msg Edit Matrix-DN/Error Msg Edit Matrix-DN/Error Msg Edit Matrix-DN/Error Msg Benefit Type Amount Paid Benefit Type Amount Paid Benefit Adjustment End Date Benefit Adjustment End Date Benefit Credit End Date Benefit Credit End Date Benefit Redistribution Start Date Benefit Redistribution Start Date Benefit Redistribution End Date Benefit Redistribution End Date Benefit Redistribution End Date Benefit Redistribution End Date. Added exception to exclude from calculation if Recovery = 880 is present Added edit exceptions for new Reduced Benefit Amount DN and Recovery s values Added L to the table for Error Added edit for Added L to the table for Error Added edit for Added L to the table for Error Added edit for Added L to the table for Error Added edit for Added L to the table for Error Added edit for

12 SROI Element Requirement le SROI Element Requirement le- Conditions Edit Matrix-Value le FROI Element Requirement le Edit Matrix-DN/Error Msg SROI Element Requirement le Edit Matrix-Value le Edit Matrix-DN/Error Msg 0189-RTW Type, 0224-Physical Restrictions Indicator & RTW with Same Employer Indicator 0189-RTW Type, 0224-Physical Restrictions Indicator & RTW with Same Employer Indicator 0198 Full Denial Reason 0200 Claim Administrator Alternate Postal 0201 Anticipated Wage Loss Indicator 0201 Anticipated Wage Loss Indicator 0202 Reduced Benefit Amount 0202 Reduced Benefit Amount 0202 Reduced Benefit Amount Changed requirement on these DN s from NA to MC for MTC CB & EP. Added MTC CB & EP to the existing conditions for when these fields are required. Added values 2F-Accident not major contributing cause of injury, and 3I- Employee not reported to PEO. New codes approved by IAIABC Changed requirement on MTC AQ from NA to M because an AQ is not accompanied by a SROI. Added new DN and edits. New DN approved by the IAIABC. Added new DN and requirements. New DN approved by the IAIABC. Added new DN and Values as approved by the IAIABC. Added new DN and edits 001, 058, 059, 064. New DN approved by the IAIABC. Added new DN and edits 001, 058, 059, 064. New DN approved by the IAIABC

13 SROI Element Requirement le SROI Element Requirement le- Conditions SROI Element Requirement le SROI Element Requirement le 0202 Reduced Benefit Amount 0202 Reduced Benefit Amount 0215 Other Benefit Type Amount Other Benefit Type Amount 0216 Other Benefit Type Payment Reason Edit Matrix-DN/Error Msg Payment Reason SROI Element Requirement le 0223 Permanent Impairment Minimum Payment Indicator SROI Element Requirement le 0225 & 0226 Recovery & Recovery Amount Edit Matrix-Value le Recovery Edit Matrix-DN/Error Msg Recovery Added new DN and requirements. New DN approved by the IAIABC. Added new DN conditions. New DN approved by the IAIABC Changed requirement on MTC AP & IP from NA to IA because Penalties and Interest should be reported on an IP if voluntarily paid by the Claim Administrator. Added new conditions to edit Changed requirement on MTC AP & IP from NA to IA because Penalties and Interest should be reported on an IP if voluntarily paid by the Claim Administrator. Added new edit to DN Added L for new edit Changed requirement on MTC EP, S1 and S7 from NA to IA because PI Min Payment Indicator can be initially reported on an EP, S1 or S7. Changed requirement on MTC AP & PY from NA to IA because there could be a recovery code reported on the PY or AP. Added values 880- Voided Indemnity Benefit Check Recovery; and 890- Voided Other Benefit Check Recovery. New codes approved by IAIABC Added L for new edit

14 Recovery , , Edit Matrix-DN/Error Msg , , Edit Matrix-DN/Error Msg Number of Recoveries Number of Recoveries Number of Benefits SROI Element Requirement le SROI Element Requirement le- Conditions SROI Element Requirement le Edit Matrix-Value le Edit Matrix-DN/Error Msg Edit Matrix- Populations Restrictions 0290 Type of Loss 0290 Type of Loss Lump Sum/Payment Settlement 0068 Initial Return To Work Date 0077 Late Reason 0100 Date Transmission Sent Date Transmission Sent Added new edit to DN Removed edits, since they would never actually be executed. Removed edits, since they would never actually be executed. Added L for new edit Added new edit to DN Added edit exceptions for new Reduced Benefit Amount DN and Recovery s values Changed requirement from M to MC on PY Added condition for PY Added 3 rd edit for new DN Reduced Benefit Amount Added 4 th edit for ensuring proper Payment Reason exists when SF. Below Included in April 07 Supplement For MTC PD changed requirement code from NA to IA because return to work information may be applicable on a PD and we need to capture it. Removed Gray from s L6, LA, and D1-6 because Pop Restrictions edit does not reject for an invalid code, but grayed out codes implied a rejection. Added L to edit 111- Must be valid content Added edit to ensure that Date Transmission Sent can only be equal to or one day prior to the Current Date

15 SROI Element Requirement le 0134 Calculated Weekly Compensation Amount and 0286 Average Wage Changed requirement on MTC AB from NA to M because these DN s should be reported on an AB SROI Element Requirement le SROI Element Requirement le- Conditions SROI Element Requirement le SROI Element Requirement le SROI Element Requirement le- Conditions 0144 Current Date Disability Began 0144 Current Date Disability Began 0189 Return To Work Type 0195 Payment Issue Date 0195 Payment Issue Date Changed condition on CB from NA to MC because this DN can apply to a Change in Benefit Type Added CB to MC condition For MTC PD changed requirement code from NA to IA because return to work information may be applicable on a PD and we need to capture it. Changed requirement for MTC PY from M to MC. Added Condition for MTC PY that Payment segment is not required if Reduced Benefit Amount S is present. SROI Element Requirement le Payee Changed requirement for MTC PY from M to MC. SROI Element Requirement le Payee Added Condition for MTC PY that Payment Conditions segment is not required if Reduced Benefit SROI Element Requirement le SROI Element Requirement le- Conditions SROI Element Requirement le 0218 Payment Amount 0218 Payment Amount 0219 Payment Covers Period Start Date Amount S is present. Changed requirement for MTC PY from M to MC. Added Condition for MTC PY that Payment segment is not required if Reduced Benefit Amount S is present. Changed requirement for MTC PY from M to MC

16 SROI Element Requirement le- Conditions SROI Element Requirement le SROI Element Requirement le- Conditions SROI Element Requirement le SROI Element Requirement le- Conditions SROI Element Requirement le SROI Element Requirement le SROI Element Requirement le SROI Element Requirement le- Conditions Edit Matrix-Duplicate 0219 Payment Covers Period Start Date 0220 Payment Covers Period Through Date 0220 Payment Covers Period Through Date 0222 Payment Reason 0222 Payment Reason 0224 Physical Restrictions Indicator 0228 Return to Work With Same Employer Indicator 0256 Wage Effective Date 0256 Wage Effective Date Maintenance Type Added Condition for MTC PY that Payment segment is not required if Reduced Benefit Amount S is present. Changed requirement for MTC PY from M to MC Added Condition for MTC PY that Payment segment is not required if Reduced Benefit Amount S is present. Changed requirement for MTC PY from M to MC. Added Condition for MTC PY that Payment segment is not required if Reduced Benefit Amount S is present. For MTC PD changed requirement code from NA to IA because return to work information may be applicable on a PD and we need to capture it. For MTC PD changed requirement code from NA to IA because return to work information may be applicable on a PD and we need to capture it. Changed requirement on MTC AB from NA to MC because this DN should be reported on an AB, in accordance with the condition. Added AB to condition Below Included in July 07 Supplement (no May or June Supplement published). Added 50 byte error text column, added/modified rows in Section 2 & 3 and renumbered. Added clarification on #2 that only PY with 0xx Ben Type is an Event Ben that requires MTC at the Ben level

17 Maintenance Type Maintenance Type Maintenance Type Employee Middle Name/Initial Employee Middle Name/Initial Employee Middle Name/Initial Occupation Description Edit Matrix-DN/Error Msg Occupation Description SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions SROI Element Requirement le Initial Return To Work Date 0068-Initial Return To Work Date Current Return to Work Date Current Return to Work Date Amended edit to exclude all recoveries from edit #2 & 3. Modified CB condition in edit #2 and edit # Deleted statement that MTC 00 to uncancel a claim will be accepted without a corresponding SROI. Added caveat to edit if Date Claim Administrator Had Knowledge of the Injury is on or after the Claim Administrator's R3 production implementation date, Added new edit that middle name/initial can not begin with a space. Reworded edit - Employee Middle Name/Initial must be valid if Date Claim Administrator Had Knowledge of the Injury is on or after the Claim Administrator's R3 production implementation date. Changed edit to N/A for FL Changed edit code on DN/Error from IA to a shaded L. Modified edit to clarify it only applies if RTW Type = A Removed BTC 240 from condition requiring presence of IRTW Date. Removed Condition on IP/AP Changed Condition on IP/AP from MC to IA

18 Edit Matrix-DN/Error Msg Edit Matrix-DN/Error Msg Edit Matrix Value le Number of Death Dependent/Payee Relationships Number of Death Dependent/Payee Relationships Permanent Impairment Percentage Permanent Impairment Percentage Benefit Type Benefit Type Amount Paid Benefit Type Amount Paid Net Weekly Amount 0092 Benefit Adjustment Calculated Weekly Compensation Amount Claim Admin Claim Rep Name Removed L because this edit is the same as Removed edit. Same as Change edit from Fatal to EDI Reconciliation Change from L to FL on table Added 4 th edit - If MTC = AB or P7, Benefit Type must be 020 or 021. Amended condition number 3 and PT Reconciliation to cover all recovery codes and not just 830 and 880. Amended condition exception number 4 to cover all recovery codes and not just 880. Added that we will return this edit if Net is more than $.05 less than what is calculated. Added E Employer Provided Pension as a valid value for FL, for use with in line of duty disability offsets : Added RB to edit to allow Calculated Weekly Compensation Amount to Change from previously reported if different on an RB. Changed edit to N/A for FL

19 Edit Matrix-DN/Error Msg SROI Event le SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions SROI Element Requirement le SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions Claim Admin Claim Rep Name 0146 Death Result of Injury Indicator 0146 Death Result of Injury Indicator Gross Weekly Amount Gross Weekly Amount Effective Date Suspension Effective Date 0195 Payment Issue Date Changed edit code on DN/Error from IA to a shaded L Added MC Condition to MTC EP Added EP to Condition for Death Result of Injury : Added RB to edit to allow Gross to Change from previously reported if different on an RB : Added RB to edit to allow Gross Eff Date to Change from previously reported if different on an RB. Added exception for 030 and 530 on Edit # Added Condition #2 for MTC PY to be based on Number of Payments segment counter. Changed requirement on PY from MC to IA. Removed PY from conditions Denial Rescission Date 0196 Denial Rescission Date 0202 Reduced Amended condition to include all Benefit Amount recoveries Reduced Amended edit to include all recoveries in Benefit Amount edit Other Amended exception on edit to include all Benefit Type recovery codes. Amount Payee Added Condition #2 for MTC PY to be based on Number of Payments segment counter

20 SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions SROI Element Requirement le- Conditions Edit Matrix-DN/Error Msg Edit Matrix-DN/Error Msg 0218 Payment Amount 0219 Payment Covers Period Start Date 0220 Payment Covers Period Through Date 0222 Payment Reason Recovery 0238 Witness Name Witness Name Witness Name Witness Name Employee Last Name Suffix Employee Last Name Suffix Employee Last Name Suffix Added Condition #2 for MTC PY to be based on Number of Payments segment counter. Added Condition #2 for MTC PY to be based on Number of Payments segment counter. Added Condition #2 for MTC PY to be based on Number of Payments segment counter. Added Condition #2 for MTC PY to be based on Number of Payments segment counter. Removed edit addressed under Number of Recoveries. Added IA edit code on DN/Error Msg to run edit on validity of name. If invalid, witness will not be loaded. Changed edit to N/A for FL Shaded L - N/A for FL Added edit to check that Witness Name does not contain numeric values. If invalid, witness will not be loaded. Added caveat to edit if Date Claim Administrator Had Knowledge of the Injury is on or after the Claim Administrator's R3 production implementation date, Added new edit that last name suffix can not begin with a space. Reworded edit - Employee Last Name Suffix must be valid if Date Claim Administrator Had Knowledge of the Injury is on or after the Claim Administrator's R3 production implementation date

21 Edit Matrix- Populations Restrictions SROI Element Requirement le SROI Element Requirement le- Conditions Edit Matrix- Populations Restrictions Edit Matrix-Populations Sequencing Edit Matrix- Sequencing Wage Effective Date Number of Payments Average Wage Number of Benefits Number of Benefits Number of Benefits Number of Benefits Number of ACRs 0293-Lump Sum Payment/Settlement 0293-Lump Sum Payment/Settlement Partial Denial : Added RB to edit to allow Wage Effective Date to Change from previously reported if different on an RB. Added edit for MTC PY to require Number of Payments segment counter > 0 when MTC = PY and Reduced Benefit Amount "S" is not present : Added RB to edit to allow Average Wage to Change from previously reported if different on an RB. Added EP & ER to edit Amended edits #4, 5, & 6 to all for all recoveries Modified CB condition in edit #2 & Amended edit to exclude all recoveries from the edit : Added AP Changed condition for MTC PY from M to MC. Not required if Ben Type = 030. Added condition for MTC PY. Not required if Ben Type = 030. Added edit to 064 that only permits PD A or E to be filed on SROI PD that is filed as a DWC-1 equivalent. 3b. MTC AB (2 nd ) Corrected sequence to reflect that a P7 must have been accepted prior to the 2 nd filing of MTC AB. 5a. & 5b. ER and RB Added SROI PD to sequencing edit

22 SROI Event le AP Acquired Payment Added row to identify that an AP must follow an accepted AQ if indemnity benefits will be continuing. This is to ensure proper sequencing. SROI Event le IP Initial Payment Added row to identify that an IP must follow a Lump Sum Payment if indemnity benefits will be continuing. This is to ensure proper sequencing. Event le SROI MTC 02 Removed Benefit Redistribution because there is only one valid value and you can't change it to another value. This was subsequently added back in because Benefit Red can be initially reported via an 02. Event le FROI MTC AQ Added closed claims to requirement to send an MTC AQ. Event le SROI MTC PY Added row for PY for BTC 030 or Advances < $2,000 to distinguish different filing timeframe, and updated row for other Lump Sum Payments. Edit Matrix-Duplicate Processing Section 1 Modified duplicate processing table to allow combo FROI/SROI filings (in some cases) to be submitted when stand alone SROI s should ve been submitted. Re-numbered section 1. Form DFS-F5-DWC-EDI-1, EDI Trading Partner Profile Form DFS-F5-DWC-EDI-4, TP SSL FTP Instructions Below Included in September 07 Supplement (no August Supplement published). Changed word transmitting on Page 2 to handling/adjusting. Changed SSL FTP file naming conventions for Claims acknowledgement and reacknowledgement transactions

23 Maintenance Type Maintenance Type Maintenance Type Maintenance Type Maintenance Type Maintenance Type Edit Matrix-DN Error Msg le Maintenance Type FROI Element Requirement le Employer Physical Primary Address Corrected MTC AB and P7 to only require 1 Event Benefits Segment Amended edit # Added new Benefit Type 230 to edit. Also added 530, 240, 500 and 540 to this edit. Corrected MTC AB and P7 to only require 1 Event Benefits Segment Added MTC AU to edit Added edit if 2 match data elements are changed on the same transaction. Added L for edit if 2 match data elements are changed on the same transaction. Changed requirement from NA to IA to be consistent with the rest of the address e.g. Postal FROI Element Requirement le Employer Physical Secondary Address Changed requirement from NA to IA to be consistent with the rest of the address e.g. Postal Employee Last Name Employee First Name Employee Middle Name/Initial Relaxed edit for exact name match Relaxed edit for exact name match Relaxed edit for exact name match

24 Employee Last Name Suffix Employee Middle Name/Initial Employee Last Name Suffix Employee Middle Name/Initial Employee Date of Death Initial Return to Work Date Date of Maximum Medical Improvement Number of Death Dependent/Payee Relationships Benefit Type Benefit Type Benefit Type Amount Paid Benefit Type Amount Paid Reworded edit to include internal reconciliation error to account for situations when Employee Last Name Suffix is not required but is not sent properly. Reworded edit to include internal reconciliation error to account for situations when Middle Name is not required but is not sent properly. Reworded edit to include internal reconciliation error to account for situations when Employee Last Name Suffix is not required but is not sent properly. Reworded edit to include internal reconciliation error to account for situations when Middle Name is not required but is not sent properly. Added new Benefit Type 210 to edit Added new Benefit Type s 210 to edit Added AU to edit # Added new Benefit Type 210 to edit Added new Benefit Type 230 to edit Added new Benefit Type s 210 & 230 to edit. Added new Benefit Type s 210 and 510 to edit. Moved edit #2 from Date of Death ( ) to Benefit Type Amount Paid

25 Edit Matrix-DN/Error Message Edit Matrix-DN Error Msg le Edit Matrix-Value Edit Matrix-DN/Error Message Edit Matrix-DN/Error Message Benefit Type Amount Paid Benefit Period Start Date Benefit Period Start Date Benefit Period Through Date 0092-Benefit Type Benefit Adjustment Weekly Amount Benefit Adjustment Weekly Amount Benefit Adjustment Weekly Amount Death Dependent/Payee Relationship Benefit Credit Weekly Amount Benefit Credit Weekly Amount Benefit Credit Weekly Amount Added FL to Invalid Data Relationship for Benefit Type Amount Paid. Removed edit because Acquiring claim administrators may have to pay back benefits. Removed L for edit Added new Benefit Type 230 to edit Added codes 210-Employer Paid Death Benefits and code 230-Employer Paid Permanent Partial/Scheduled. Reworded edit to only execute if an Event Benefits Segment is being reported Added new edit to only allow Benefit Adjustments to change when corresponding Benefits change. Added L Added new Benefit Type 210 to edit Reworded edit to only execute if an Event Benefits Segment is being reported Added new edit to only allow Benefit Credits to change when corresponding Benefits change. Added L

26 Edit Matrix-DN/Error Message FROI Element Requirement le Edit Matrix-DN/Error Message Edit Matrix-Value le Edit Matrix-DN Error Msg le Benefit Redistribution Weekly Amount Benefit Redistribution Weekly Amount Benefit Redistribution Weekly Amount Death Result of Injury Employer Physical Country Claim Administrator FEIN Claim Administrator FEIN Suspension Effective Date Net Weekly Amount Effective Date Other Benefit Type Amount 0222 Payment Reason Payment Reason Reworded edit to look at previously filed Gross Weekly Amount rather than deriving Gross Weekly Amount. Added new edit to only allow Benefit Redistribution to change when corresponding Benefits change or on MTC 02. Added L Added new Benefit Type 210 to edit Changed requirement from NA to IA to be consistent with the rest of the address e.g. Postal Added new edit to validate Claim Administrator relationship to Insurer per Trading Partner forms Added L Added new Benefit Type 230 to edit Added < to edit because Net Eff Date can be less than Adj Start date if first check has an adjustment. Moved edit #2 from Date of Death ( ) to Other Benefit Type Amount Added BTC 210 and 230 as valid values Removed L for edit

27 Edit Matrix- FL Calculation (Proprietary) Benefit Segment Requirement le Payment Reason Permanent Impairment Minimum Payment Indicator Employee Last Name Suffix Employer Paid Salary In Lieu of Compensation Indicator Number of Benefits Number of Benefits Lump Sum Payment/Settlement Edit Matrix- FL Min_Max 210, 230, 250, 251, & 242 Benefit Type s Benefit Segment Requirement le Removed edit that you can not send multiple Payment segments with the same Payment Reason. This can happen if sending out 2 checks (different Payees) for a settlement, coded to the same Payment type. Amended edit to add BTC 500 (previously looking for SF, but Lump Sum Payment Settlement is X on FN Relaxed edit for exact name match Added new Benefit Type s 210 & 230 to edit Added PY to edit Added new Benefit Type 210 to edit Also added 510, 520 and 521 to this edit. Amended edit # IB Benefits Added Benefit Type s 250, 550, 251 and 551 to calculation Employer Paid Added new Benefit Type as discussed Fatal Benefit Type with IAIABC R3 Issues committee Employer Paid Permanent Partial Scheduled (IB) Benefit Type Added these Benefit Type s to Min and Max edits. Added new Benefit Type as discussed with IAIABC R3 Issues committee

28 Benefit Segment Requirement le 242, 250, 251, Employer Paid Benefit Type s Benefit Segment Requirement le Lump Sum Payment/Settlement Benefit Types Edit Matrix-Sequencing Edit Matrix- Population Restrictions Edit Matrix- Population Restrictions Edit Matrix- Population Restrictions Edit Matrix- DN Error Message Element Requirement le/sroi Element Requirements Element Requirement le/sroi Conditions Business Event Group 6 - CB Changed requirement on Benefit Type Amount Paid from NA to M. Added row to clarify different reporting requirements for 500 & 501 from other 5xx Benefit Types. (subsequently removed ) Added the caveat to condition #2 for Red Ben Amt -R. Below Included in January 08 Supplement MTC Removed Calculated Weekly Compensation Amount from condition #53 (because CR can be changed via MTC 02) MTC Added exception to edits #2 and 3 to not require if Date Claim Admin Had Knowledge of Injury is prior to R3 Implementation Date MTC Date Added edit to ensure proper sequencing of filings MTC Date Added edit to ensure proper sequencing of filings Insurer Amended edit to not run edit for first R3 FEIN filing Claim Amended edit to not run edit for first R3 Administrator Postal filing Claim Administrator Claim Number Employee Date of Birth 0063 Wage Period 0063 Wage Period Amended edit to not run edit for first R3 filing Amended edit to not run edit for first R filing. Changed condition from NA to MC for MTC PD. Added PD condition

29 Element Requirement le/sroi Conditions Element Requirement le/sroi Conditions Element Requirement le/benefits Conditions Edit Matrix-DN/Error Message le Edit Matrix- Population Restrictions Element Requirement le/benefits Conditions Edit Matrix- Population Restrictions 0070 Date of Maximum Medical Improvement Permanent Impairment Percentage 0084 Permanent Impairment Percentage Benefit Type Amount Paid Net Weekly Amount Benefit Period Start Date Benefit Period Start Date Death Result of Injury 0174 Gross Weekly Amount Claim Administrator FEIN Benefit Payment Issue Date Denial Rescission Date Claim Administrator Alternate Postal Added 230, 530 and 540 to edit requirement. Amended edit to accept initial reporting of a PI % on a stand alone PY Added 230 to edit requirement Amended edit to not run if Lump Sum Payment AD is present. Changed condition to be consistent with Net Weekly Amount Effective Date Added L for new edit Added edit to ensure 2 Ben segments would not contain the same Benefit Period Start Date, except under conditions listed. Modified edit to exclude CD, VE, PD, FROI 04 and SROI Changed condition to be consistent with Gross Weekly Amount Effective Date Amended edit to not run edit for first R filing. Added PY to edit Modified wording on condition #1 to allow for a rescission of a partial denial Removed edit

30 Edit Matrix-DN Error Msg le Element Requirement le/sroi Conditions Element Requirement le/sroi Conditions SROI Conditional Requirements Edit Matrix- Population Restrictions Element Requirement le/sroi Conditions Element Requirement le/sroi Element Requirements Element Requirement le/sroi Conditions Edit Matrix- Population Restrictions Element Requirement le/sroi Conditions Claim Administrator Alternate Postal 0202 Reduced Benefit Amount Reduced Benefit Amount 0212 Non- Consecutive Period 0212 Non- Consecutive Period Number of Recoveries 0286 Average Wage 0286 Average Wage 0286 Average Wage Number of Benefits Number of Benefits 0299 Award/Order Date Insured FEIN Removed L for edit Modified condition for FN to excuse need for code when case was established as 00/CD, 00/VE or 00/PD and no Ben or Other Ben types reported. Modified edit for FN to excuse S code when case was established as 00/CD, 00/VE or 00/PD and no Ben or Other Ben types reported. Amended calculation edit on #2 for determining when a NCP is due Removed condition #2 for CA, CB, S1-S Modified edit to exclude Removed BTC 250 from the exceptions to when Average Wage is required. Changed condition from NA to MC for MTC PD. Added PD condition Corrected wording on error msg #4 and changed condition #4 to allow for no Ben segments if CD or VE on file. Amended edit to clarify that this edit will not be run on the first R3 EDI transaction. Added BTC 030 exception to condition Amended edit to not apply to Self Insured Funds

31 Edit Matrix-Sequencing Element Requirement le/benefits Segment Requirements Element Requirement le FROI Conditions Business Event Group 2 PD Lump Sum Payment/Settlement s and Maintenance Type Maintenance Type Maintenance Type MTC Maintenance Type Added 04 to condition MTC requirement changed from NA to F to ensure that proper editing can be applied when MTC is sent. (MTC is not required; however, if it is sent it MUST be the same as the MTC at the transaction level). Below Included in May 08 Supplement No Feb, March or April Supplement published. Removed condition #3 because the IAIABC determined that all SROI 04s or PDs should be Sweep Ben Segments. Added edit #54 to prohibit certain SROI MTC s from being sent immediately after an 04 denial. Amended edit to include PD Changed #53 and added # Removed 04 and PD because the IAIABC determined that all SROI 04s or PDs should be Sweep Ben Segments MTC Date Amended edit that all MTC Dates should be no more than 7 days prior to Date Sent. Added condition to not run edit if within 30 after the R3 Implementation Date. 0033, 0119, 0121, 0122, 0123 Accident Site Address Information Amended edit to not require these fields if Date Claim Administrator Had Knowledge of the Injury was prior to the R3 Implementation date

32 Element Requirement le FROI and FROI Conditions Element Requirement le SROI Conditions Element Requirement le SROI Conditions 0033, 0119, 0122, Accident Site Address Information Employee Mailing State 0057 Employee Date of Death & 0097 Dependent/Payee Relationship Employee Date of Death Initial Return To Work Date of MMI 0083 Permanent Impairment Body Part Permanent Impairment Percentage Permanent Impairment Percentage Benefit Type Amount Paid Benefit Type Amount Paid Amended edit to load data if sent but not required if Date Claim Administrator Had Knowledge of the Injury was prior to the R3 Implementation date. Changed requirement from M to MC for MTC 00, 04 and AU. Added condition that only requires EE State if EE Country = US, Canada, Mexico or spaces. Added requirements for BTC Added = to the condition Added S1 to edit to allow for a different Initial RTW Date on an S1. Amended edit to ensure consistency with PI% edit Modified condition to not require if PI 0% is sent. Amended edit to accept initial reporting of a PI % on a stand alone IP, EP or AP. (PY added in previous supplement) Amended edit to allow FN to initially report PI % if PI Min Pymnt Indicator previously on file = Y. Added edit for MTC SA or FN if PY sent and no prior IP, AP, EP on file and Ben Amt Paid has increased. Changed edit for MTC 02 to be a Reconciliation Error, rather than TR

33 Benefit Type Amount Paid Benefit Type Amount Paid Benefit Type Amount Paid Benefit Type Claim Weeks Benefit Adjustment Weekly Amount Dependent/Payee Relationship Test/Production Edit Matrix- DN/Error Message Test/Production Element Requirement le SROI Conditions Benefit Credit Amount Benefit Credit Amount Benefit Credit Weekly Amount Benefit Redistribution Weekly Amount Concurrent Employer Name 0196 Denial Rescission Date Add qualification to exception #1 to for 5xx Added 02 to edit Amended edit to not run if BTC 5xx is present. Added 2 weeks leeway to the calculation Amended edit not to run if Date Claim Administrator Had Knowledge of the Injury is prior to the R3 Implementation date. Amended edit to allow this code to be submitted via 02 on legacy claims Added edit to ensure Test/Production on FTP file name or Advantis Message Class matches the one sent in the Header Added L for edit above Added #2. Credit Amt must not be > 20% of Gross Wkly Amt Changed Overpayment Credit error over 20% to a FL Reconciliation error (TA-FL). Amended edit not to run if Date Claim Administrator Had Knowledge of the Injury is prior to the R3 Implementation date. Amended edit not to run if Date Claim Administrator Had Knowledge of the Injury is prior to the R3 Implementation date. New edit to screen out and not load values that are not actual names Separated condition on MTC PD

34 Element Requirement le SROI Element Requirements Element Requirement le SROI Requirements/Conditions Denial Rescission Date Denial Rescission Date Denial Reason Narrative 0226 Recovery 0225 Recovery Amount Suspension Narrative Number of Other Benefits Number of Benefits Number of Benefits Number of Benefits 0293 Lump Sum Payment/Settlement Lump Sum Payment/Settlement Added condition to not run edit unless the Date Claim Administrator Had Knowledge of the Injury is on or after the Insurer's R3 production implementation date. Added another condition requiring a previous denial must be on file if a Denial Rescission Date is sent. Amended edit to not run if paper DWC-12 denial is the only is only denial on file. Changed requirement from NA to IA for MTC IP and EP Amended edit to not run if paper Suspension is the only is only suspension on file. Added condition to not run edit if it is the first R3 transaction. Added condition to not run edit if it is the first R3 transaction. Added #7 edit to ensure a 2xx segment is sent if Employer Paid benefits previously reported on paper or EDI. Modified edits to ensure initial R3 transaction reflects the history of what was previously paid. Changed requirement from MC to M and removed Condition from SROI Conditions. Added note to edit that spaces can be a valid value for Lump Sum Payment/Settlement, if BTC 030 is the Event being reported on the MTC PY