Basics of Detailed Claim Information (DCI) Reporting Requirements
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1 Basics of Detailed Claim Information (DCI) Reporting Requirements Presented by: Mitch Cohen and Chris Mercer 1 The whirling gears of progress have put the gear makers out of work. 2 1
2 Objective Provide an overall understanding of Detailed Claim Information reporting, editing, and compliance under the Detailed Claim Information program. 3 Agenda Overview Tools and Resources File Layout Certification Requirements Sampling Requirements Elements and Report Types Editing Reports Compliance Programs 4 2
3 Overview 5 Detailed Claim Information (DCI) Detailed Claim Information is: A method to collect detailed information on Indemnity Claims for legislative pricing and research Indemnity Claims (or Lost-Time Claims): A claim in which compensation is paid to an injured worker for lost wages due to a workrelated injury 6 3
4 DCI Data Usage Detailed Claim Information is used for: Legislative Pricing State Advisory Forums Research Studies Used extensively for a variety of purposes: Comparison of Wages to Benefits Attorney Involvement Lump-Sum Payments 7 Participation Eligibility Part 2 Market Share 1% average over latest 3 years in at least 3 states 5% in latest year in 1 state Carrier State Premium Total State Premium Participation Based on NAIC and Financial Call Data 8 4
5 Participant Reporting Requirements Once a carrier meets the eligibility criteria, it is required to: Report for all applicable DCI states Continue reporting even if below the eligibility threshold Report DCI for all companies aligned within an affiliate group Reporting obligation remains with any carrier/group that was required to report prior to a merger or acquisition. 9 Special Participation Eligibility Carrier participation is mandatory for all workers compensation writers in: Massachusetts Texas 10 5
6 Participation State Map WA OR NV CA ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI IN TN AL KY OH GA WV PA SC VA NC ME VT NH MA NY CT RI NJ DE MD TX LA FL Alaska Hawaii NCCI States Participating Independent Bureaus Mandatory Participation Non-Participating 11 Tools and Resources 12 6
7 ncci.com 13 ncci.com 14 7
8 ncci.com 15 DCI Resources Manuals Detailed Claim Information Reporting Guidebook Including edit matrices Electronic Transmission User s Guide Statistical Plan Communications DCI and DQ Circular/FYI Series Web Articles 16 8
9 DCI Resources Online Tools Detailed Claim Information via DCA Access Online Data Manager Dashboard Webinars Detailed Claim Information Education Data Quality Education 17 File Layout 18 9
10 DCI Record Part 5 Detailed Claim Information Reporting Guidebook Record Type Code = 1 Submitted to NCCI as a flat text file 500 bytes Texas = 600 bytes 19 Submission Control Record Field No. Field Title/Description Class Position Bytes 1 Record Type Code Enter 9. N Carrier Group Code Report the code assigned by NCCI that corresponds to the dominant insurer in a carrier group. 3 Filler Fill positions 7 41 of this record with nines. 4 Record Total Report the total of all Record Type 1 records. Do not count the Submission Control Record in this total. Field is rightjustified and left zero-filled for totals less than eight characters. N N N Reserved for Future Use Only one Submission Control Record must be reported Not included in the Record Total 20 10
11 Electronic Submissions One Submission Control Record DCI Records Flat File File naming conventions: Production = V2DCI.Max 30 characters.txt Certification = V2DCI.Max 30 characters.tst Pre-Edit = V2DCIPR.Max 30 characters.txt 21 DCI Submission Options Online Keying Detailed Claim Information via DCA Access Online Batch Submissions Data Transfer via the Internet (DTVI) Browser Mailbox Secure FTP Data Encryption PGP 22 11
12 Certification Requirements 23 Purpose of Certification Checks Ability for Carrier to Submit FTP connection Access for DTVI and the Detailed Claim Information tool Checks File Naming Convention Is Correct File Formatting Correct Note: Does not test ability to apply sampling methodology nor test data quality 24 12
13 Electronic Certification Testing For general certification requirements, refer to the following manuals: Electronic Transmission User s Guide Data Provider Profile Form Provides user information Provides authorization to DTVI, Detailed Claim Information tool, and Data Manager Dashboard Required for each data reporting group Acceptable file names Detailed Claim Information Reporting Guidebook 25 Electronic Certification Testing Test file should contain at least 25 to 50 transactions Must include the Submission Control Record Original reports only or Original and corresponding Subsequent in same submission If DCI transactions are free of errors, the test submission passes the certification
14 TPA Requirement For each TPA/vendor/outside data provider: Data Provider Profile Form Service Provider Agreement Service Provider Data Tool Access Addendum 27 Recap: True or False? NCCI does certification testing to validate a carrier s ability to apply the DCI sampling methodology DCI is used for legislative pricing and research DCI batch submissions are mailed to NCCI on a 3480 cartridge and must be in EBCDIC format 28 14
15 Sampling Requirements 29 Reported to Insurer (RTI) Date Par3 Triggers first loss valuation Determines valuation level for reporting claims that become Death or Permanent Total Disability May have different definition in your database 30 15
16 Valuation of Claims Initial Valuation Subsequent Valuation Texas 6 months after RTI Due to NCCI by 9th month 18 months after RTI Due to NCCI by 21st month 12 months after the preceding valuation Up to 138 months from RTI Due within 3 months after valuation 31 Valuation Example Reported to Insurer 7/ Value 1/2015 Due by 4/ Value 1/2016 Due by 4/ Value 1/2017 Due by 4/ Value 1/2018 Due by 4/2018 Subsequent valuation level through
17 Claim Selection Process The claim selection process begins 18 months after the RTI date (6 months for Texas) Performed on a monthly basis for each state that the carrier is reporting Sampling occurs only once for each RTI date 33 Claim Selection Process Part 3 Excluded Required Sampled Non-DCI Claims All Death and Permanent Total Disabilities Percentage per State of Open and Closed Claims 34 17
18 Excluded Claims Excluded Non-DCI Claims Not an Applicable DCI State Medical-Only Claims Reinsurance Assumed Claims Claims Payable Under Federal Acts Noncompensable and Fraudulent Claims West Virginia Deliberate Intent (Mandolidis) Coverage 35 Required Claims Required All Death and Permanent Total Disabilities Not sampled Valued based on RTI date Anytime within 138 months of RTI date If reclassified to another benefit type, continue to report 36 18
19 Death or Permanent Total Disability Example: Open claim that was not sampled in original reporting becomes a Permanent Total Disability (PTD) Reported to Insurer 7/ Due by Value 4/2014 1/ Due by Value 4/2015 1/ Due by Value 4/2016 1/ Due by Value 4/2017 1/2017 Subsequent valuation level through 138 Claim #1234 Temporary Claim #1234 Perm Total Dec Sampled Claims Sampled Percentage per State of Open and Closed Claims Based on State Sample Ratio Table Random Sample: Recommend assigning three-digit numbers Each of the 1,000 possible numbers is equally likely (probability = 0.001) Can be assigned/used more than one time 38 19
20 Sampling Ratios Carriers are to report applicable open and closed claim sample ratios for each state. Open claims have a higher percentage ratio than closed claims. State Sample Ratios for DCI Reporting Code Jurisdiction State Open Claims Closed Claims 09 Florida 12% 2% 12 Illinois 8% 1% 20 Massachusetts 14% 1% 24 Missouri 14% 1% 29 New Jersey 14% 1% 31 New York 6% 1% 32 North Carolina 19% 2% 37 Pennsylvania 11% 1% State Sample Ratios for DCI Reporting Code Jurisdiction State Open Claims Closed Claims 54 Alaska 100% 5% 08 District of Columbia 100% 9% 18 Maine 100% 5% 28 New Hampshire 100% 4% 38 Rhode Island 100% 3% 40 South Dakota 100% 8% 42 Texas 100% 66% 44 Vermont 100% 7% 39 Sampling Dos and Don ts Do Verify the sample rates (1% vs. 10%) Only report claims that the random sampling method chooses for you Don t Not Used For: Expect sampling to select claims for each state each month Try to compute the number of claims to send each month and send that number of claims If you sample correctly, the number of claims submitted each month per state will vary
21 Claim Selection Process Recap 1 Select Jurisdiction State and Reported to Insurer Month 2 Exclude non-dci claims 3 Select required claims 4 Assign random numbers 5 Apply sampling ratios 41 Recap: True or False? DCI claims are due to NCCI by the 21st month from the RTI date All Death and Permanent Total Disabilities are required to be included in each month s submission You should try to compute the number of claims to send each month and send that number of claims 42 21
22 Elements and Report Types 43 DCI Report Types Original Subsequent Replacement 44 22
23 Original Reports Original Subsequent Replacement Valued 18 months after Reported to Insurer (RTI) Date All Death and Permanent Total Disability Eligible open and closed claims selected in the random sampling process Texas: Reports valued six months after RTI Date 45 Subsequent Reports Original Subsequent Replacement Provide changes due to development of the claim Valued every 12 months after initial report Must match a claim on NCCI s DCI database (based on key fields) unless: Reporting a Death or Permanent Total claim that has not been previously reported 46 23
24 Subsequent Reports Reclassified Valued at 138th month Closed Report at next loss valuation period Report all data valued as of the subsequent loss valuation No further reporting unless claim reopens or claim values change Subsequent 47 Replacement Reports Original Subsequent Replacement Report R in the Replacement Report Code field Used For: Not Used For: Correcting nonrejected claims at any valuation level Changing key field information Correcting rejected claims Loss valuation updates due to normal development 48 24
25 Replacement Reports Non-key field each valuation level that contains the incorrect value Replaces previously reported value for each valuation replaced Key field most recently reported valuation level Replaces previously reported value for ALL valuation levels Reminder: This is a complete replacement; ALL revised and unchanged data must be reported. 49 Key Field Changes Data Reporting Element Carrier Code Policy Number Policy Effective Date Reported to Insurer Date Claim Number Previous Carrier Code Previous Policy Number Previous Policy Effective Date Previous Reported to Insurer Date Previous Claim Number 50 25
26 Claim Deletion Deleting of claim can only be done through the Detailed Claim Information tool Conditions when to delete claims: Noncompensable or fraudulent claims Note: Deletion of a claim at any valuation will delete all valuations. 51 General Claim Information 55 Unique Elements Key fields must match across valuations and other data types
27 Claimant and Employer Information 53 Claim Expense and Payment Information Lump-Sum Benefits Indemnity Benefits 54 27
28 Multiple Benefits Reported Benefit Type Array: Benefit Type Code Benefit Amount Paid Weekly Benefit Amount Lump-Sum Array: Benefits Covered by Lump- Sum Code Lump-Sum Payment Amount 55 Data Dictionary Part 6 Organized alphabetically Includes data element descriptions, format, allowable content, code tables, relationships, and reporting rules 56 28
29 Texas-Only Elements Employer FEIN Employee SSN Hospital Costs Amount Paid Total Payments to Physicians Date of First Payment 6 Unique Texas Elements Zip Code of Injury Site Medical Extinguishment Indicator Not Applicable Texas-only elements are at the end of the record layout. If you re not reporting for Texas, you don t need to report the additional elements. 57 Recap: True or False If a DCI claim that has already been reported to NCCI becomes noncompensable or fraudulent, it should be deleted from DCA To correct a DCI claim, just submit a subsequent report with the corrected information You can report up to six different benefit type codes for lump-sum payments 58 29
30 Editing 59 Editing Flow NCCI Correct the issue and resubmit 60 30
31 Editing Part 7 Checks the validity, accuracy, and completeness of the data Ensures that the data submitted is consistent with reporting requirements and meets quality standards Identifies errors so that data providers can replace the data and/or take any other corrective action necessary Can receive more than one edit 61 Edit Types Submission Relational Edits Field Logical 62 31
32 Submission Edits DCI File Submitted via DTVI Step 1: Is the file name valid? If yes, go to step 2. If No, send Invalid File Name to sender Step 2: Is the user authorized? If yes, go to step 3 If No, send Unapproved Data to sender Step 3: Does the file have the proper PGP encryption key (if encrypted)? If the file does, go to step 4 If file is incorrect, send Invalid Encryption Key to sender. Step 4: Does the file have the proper record length or contain NULL characters? If the file does, go to step 5 If file is incorrect, send Invalid Data to sender. Step 5: File moves to application for further editing and backup file is created Send Successful Transmission to sender 63 Submission Edits From: Customer_Service@ncci.com [mailto:customer_service@ncci.com] Sent: Thursday, October 16, :35 AM To: Mitch Cohen Subject: Record Type Code Must Be Valid Per Table Dear Mitch Cohen: NCCI would like to inform you that the following file submission was not processed: Mailbox: File Name: v2dci.deptest_ txt Name: Mitch Cohen Account ID: /16/2014 The entire submission was rejected for the following error(s): Record Type Code Must Be Valid Per Table Found invalid record type(s) BLANK Please review the file submission as well as the information in your system to determine the necessary corrective action. Once the file is corrected you may resubmit the file for processing. You are receiving this as a data customer of NCCI. Please do not respond to this systemgenerated . If you have questions or feel that you have received this in error, please contact Customer Service
33 Data Grades Edit Class Error Free Data Grade Description 0 The DCI report is free of errors. (This error class and data grade are applicable and viewable only when using the DCI online tool.) Corrective Action Required None. Default 3 A data element was reported incorrectly and NCCI substituted an assumed correct default value for this data element. Reject 9 A critical data element or condition needed for loading and mapping the data was reported incorrectly and is invalid. The DCI report was rejected, is not captured on the production database, and is not used in NCCI s products and services. None unless default value is incorrect. A resubmission of the report is required. Edit Classes determine how data is processed. Data Grades describe the level of severity. 65 DCI Edit Matrices 66 33
34 DCI Edit Matrices DCI Edit Matrix All Edits in Production DCI Edit Matrix Future Edit Enhancements 67 DCI Production Edit Matrix Record Edit Data Data Field Edit Message Report Edit Applicable Excluded Effective Date Edit Change Type Number Grade Type Type States States Incurred Indemnity Incurred Indemnity Amount Total must equal the sum Original, L All others FL, MI 03/11/11 Amount Total of: Subsequent, Benefit Amt Pd, Replacement Indemnity Lump Sum Amt, Claimant Legal Amt, and any Voc Rehab Amt 10/01/10 when: Claim Status Cd equals 1, Type of Recovery Cd equals 01, and Recovery Reimbursement Amt equals zero Updated Edit Message to remove redundancy between Data Field and Edit Message. Added edit Jurisdiction State Must be valid per table. Code Preinjury/Average Must be greater than 0. Weekly Wage Amount Original, F All 10/01/10 Added edit Subsequent, Replacement Original, F All 04/10/14 Added edit Subsequent, Replacement Weekly Benefit Amount Weekly Benefit Amount Miscellaneous Link Edits Weekly Benefit Amount reported exceeds the Original, L All 10/01/10 Added edit maximum benefit for reported Jurisdiction State Subsequent, Code. Replacement Weekly Benefit Amount reported is less than the Original, L All 10/01/10 Added edit minimum benefit for reported Jurisdiction State Subsequent, Code. Replacement A subsequent report must have a matching claim for Subsequent R All TX 03/31/11 Added TX to Excluded a prior valuation level when Benefit Type Code is not States. equal to 01 or /01/10 Added edit. Note-Matching key fields are: Policy Number Policy Effective Date Carrier Code Claim Number Reported to Insurer Date 68 34
35 Field Edit Edit number looks at the Jurisdiction State Code Must be valid per table Most often the field is: Zero-filled Blank-filled Alpha-filled 69 Edit Discussion 70 35
36 Logical Edits 71 Edit Discussion 0434 series are logical edits that compare the Benefit Type Code, Amount Paid, and Weekly Benefit Amount fields. Must be greater than zero when Benefit Type Code is not equal to a death or employers liability benefits Weekly Benefit Amount reported exceeds the maximum benefit for reported Jurisdiction State Code Weekly Benefit Amount reported is less than the minimum benefit for reported Jurisdiction State Code Weekly Benefit Amount and Benefit Amount Paid were used to calculate a duration that exceeds the period of time for the reported Valuation Level 72 36
37 Logical Edits When reporting the Weekly Benefit Amount: Submit data as of report valuation All elements of the array are edited Benefit Type Code Benefit Amount Paid Benefit Array Weekly Benefit Amount 73 Weekly Benefit Amount Example: 018 = $4,180 Weekly Benefit Amount Valuation Maximum Benefit Paid 74 37
38 Weekly Benefit Amount Example: Carrier reported values 018 = $4,180 $5,000 Weekly Benefit Amount Valuation Maximum Benefit Amount Benefit Paid 75 Weekly Benefit Amount Example: Carrier reported values Edit Number Edit The Weekly Benefit Amount and $50 Benefit Amount 018 Paid were used to calculate a duration that exceeds the period of time for the reported Valuation Level. Valuation = $4,180 $5,000 Maximum Benefit Amount Benefit Paid 76 38
39 Weekly Benefit Amount Edit Number Data Field Edit Message Weekly Benefit Amount R E A S O N S The Weekly Benefit Amount and Benefit Amount Paid were used to calculate a duration that exceeds the period of time for the reported Valuation Level. Benefit Paid Amount is too high ($5,000 vs. $500) Weekly Benefit Amount is too low ($50 vs. $150) Benefit Type may have been reported incorrectly (TP vs. TT) Lump-sum payment placed in the wrong array 77 Relational Edits Also known as Miscellaneous Link Edits, they compare the data in a specific field on the report with another data field: Contained in the same report submission Already stored on NCCI s database Both Prevent the duplication of claims and correctly link subsequent and replacement reports 78 39
40 Relational Edits 9900 series of edits are relational edits that compare the following: Subsequent reports Must have a matching claim for a prior valuation level Must not already reside on the DCI database Must be submitted in proper sequence Key Field Changes must not match a claim on the DCI database based on revised key fields Replacement reports must have a matching claim for the same valuation level within the submission or on DCI database Multiple changes for a DCI report, with the same Valuation Level and Replacement Report codes, are present within the submission file Note: Gaps in sequence are permitted for reopened claims when prior reports are closed or medical only. 79 Recap: True or False? A claim can receive more than one reject edit When a claim receives a reject (Data Grade 9) it is stored on the database The DCI Reporting Guidebook provides the details of each DCI edit Relational edits only look at data already stored on NCCI s database 80 40
41 Reports 81 Reports Part 8 Formats: CSV, PDF, XLS Notification via Submission Results returned to submitter All others to the DCI data reporting contact Also available through the Detailed Claim Information tool Data Reports Web page at ncci.com 82 41
42 Available Reports NCCI-Generated Reports DCI Submission Results Reports DCI Reject Follow-Up Report DCI Expected Subsequents Report DCI Overdue Subsequents Report Report Frequency Upon Receipt of DCI File Monthly Monthly Monthly 83 Submission Results Report Details of claims submitted, including rejects (Data Grade 9) and default errors (Data Grade 3) Generated with each electronic submission Submission Results returned to submitter via
43 Reject Follow-Up Report Details of claims with one or more rejects (Data Grade 9) Remains on the report until corrected or is removed from staging ed to the DCI data reporting contact 85 Expected Subsequents Report Details subsequent valuation claims expected in the next 60 days Generated two months prior to its valuation month (five months prior to due date) ed to the DCI data reporting contact 86 43
44 Overdue Subsequents Report Details subsequent valuation not received three months after valuation month Overdue 1 12 months, summary and detail Overdue 13 or more months, counts only ed to the DCI data reporting contact 87 Customer-Generated Reports Provides a customized version of the information found on NCCI-generated reports Based on user criteria Available upon customer request Provides the most current view Customer-Generated Reports DCI Reject Report DCI Expected Subsequents Report DCI Overdue Subsequents Report DCI Saved Claims Report: Provides a listing of all claims entered and saved within the last 24 hours in the Detailed Claim Information tool but not yet submitted DCI Saved Claims Report 88 44
45 Compliance Programs 89 Compliance Programs Goal Measure data provider expected DCI submissions Provide debits to encourage timely submissions Data Quality Incentive Program (DQIP) Carrier Data Quality Report Program (Report Card) 90 45
46 Compliance States Map WA OR NV CA ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI IN TN AL KY OH GA WV PA SC VA NC ME VT NH MA NY CT RI NJ DE MD TX LA FL DCI Compliance States Non-Participating Alaska Hawaii 91 Data Quality Incentive Program DQIP for DCI evaluates: month DCI valuations Does not evaluate Texas 6-month valuations Applicable compliance states only Based on timeliness 92 46
47 Data Quality Incentive Program Two debit categories: 18 Month Valuations Past Due >18 Month Valuations Past Due Debits apply to the overall data quality incentive factor used to modify the data collection and statistical agent fees Refer to the Data Quality Web page on ncci.com. 93 Data Manager Dashboard 94 47
48 Data Manager Dashboard 95 Carrier Data Quality Report Program NCCI Holdings The Report Card evaluates the overall annual reporting performance
49 Carrier Report Card Each category is graded separately and combined for one overall grade. Volume eligibility: 18 Month Valuations 40 expected >18 Month Validations 20 expected Number of valuations received on time is compared to the number expected for all states combined 97 Recap: True or False NCCI mails out the monthly reports via hard copy Overdue Subsequents Report details subsequent valuations not received three months after valuation month DQIP does not evaluate Texas 18-month valuations Carrier Data Quality Report Program (Report Card) is part of NCCI s compliance program 98 49
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51 Supplemental Information
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53 Presenter Biographies Christopher Mercer manages NCCI s Medical Data and Detailed Claim Information Validation Teams. Chris possesses more than 18 years of experience in the insurance industry, predominantly in the workers compensation field. He has served as a manager in NCCI s Data Resources Division for more than 12 years, which includes time managing the Financial Data Validation and Unit Data Validation Teams. Prior to that, he spent six years working for an insurance carrier, auditing and reporting data to NCCI as well as being responsible for carrier compliance. Mitch Cohen has been with NCCI for 16 years and currently works in the Data Collection Department on the Customer Support Team of Data Resources. He works with data providers to resolve their Unit and DCI data reporting issues. Mitch was with the Customer Service Department prior to joining Data Resources.
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