EDI Forms Solution. Informational Session

Transcription

1 EDI Forms Solution Informational Session April 2016

2 Agenda EDI Forms Solution Overview Important Information and Reminders Next Steps Questions 1

3 EDI Forms Solution Overview

4 EDI Forms Solution Overview On June 24 th, 2016, the EDI Forms Solution enhancement will be implemented into WCAIS. After that date, the following forms can only be filed electronically with the Bureau by providing data though EDI transactions: LIBC-495: Notice of Compensation Payable LIBC-496: Notice of Workers' Compensation Denial LIBC-501: Notice of Temporary Compensation Payable LIBC-502: Notice Stopping Temporary Compensation Due to these changes, WCAIS will not allow the upload of these forms and any of the identified forms mailed to BWC will be returned to the sender. In particular, WCAIS will generate the form, attach a copy of the form to the claim, and forward copies of the form to the Transaction Partner or filing entity. A copy of the system generated form must be sent to the claimant. 3

5 Features and Benefits EDI Forms Solution Streamlines workers compensation claims and forms management processes Links generated forms to claims automatically for increased efficiency Allows users to access and download the generated forms Reduces paper usage for Claim Administrators and BWC staff, as hard copies will no longer be accepted Results in cost savings on postage, mailing, and processing of paper forms 4

6 Processing EDI Transactions EDI Transaction WCAIS LIBC Form Input System of Record Output 5

7 Claim Lifecycle Flow 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 6 NCP = Notice of Compensation Payable; NTCP = Notice of Temporary Compensation Payable; SN = Stopping Notice

8 Automated Claim Association The generated forms will be automatically attached to the respective claim. 7

9 EDI Transactions The below EDI transactions will generate the BWC Claims Forms as part of the WCAIS EDI Forms Solution: 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 8

10 LIBC-496: Notice of Workers Compensation Denial Receipt of the below EDI transactions will generate a Notice of Workers Compensation Denial: Report MTC Description Business Event Trigger FROI 04 Denial SROI 04 Denial SROI PD Partial Denial Full denial sent with initial FROI submission only. Claim Administrator must use SROI 04 to deny if a FROI 00 had already been submitted. Full denial after initial FROI is submitted and before any indemnity payments are due. When the Claim Administrator is denying indemnity benefits in whole, but not medical payments and there is no agreement and the Claim Administrator has not accepted liability for indemnity on the claim. A PY accepting medical and then an IP without liability must be on file in order to file a PD. An LIBC- 502 and LIBC-496 are required. 9

11 10 LIBC-496: Notice of Workers Compensation Denial

12 LIBC-502: Notice Stopping Temporary Compensation Payable Receipt of the below EDI transactions will generate a Notice Stopping Temporary Compensation Payable: Report MTC Description Business Event Trigger SROI 04 Denial Claim Administrator made payments without accepting liability and subsequently denies liability for the injury. An LIBC-502 and LIBC-496 are required. SROI PD Partial Denial When the Claim Administrator is denying indemnity benefits in whole, but not medical payments and there is no agreement and the Claim Administrator has not accepted liability for indemnity on the claim. A PY accepting medical and then an IP without liability must be on file in order to file a PD. An LIBC-502 and LIBC- 496 are required. 11

13 12 LIBC-502: Notice Stopping Temporary Compensation Payable (Cont d)

14 LIBC-501: Notice of Temporary Compensation Payable Receipt of the below EDI transactions will generate a Notice of Temporary Compensation Payable: Report MTC Description Business Event Trigger SROI IP/AP Initial/ Acquired Payment SROI PY Payment Report SROI RB Reinstatement of Benefits If there is no agreement in place, the Claim Administrator is making temporary payments at the time of the initial/acquired payment. Agreement to Compensate Code must be set to 'W'. Please refer to the PA Implementation Guide for details on the 90-day Rule. Immediately upon first payment of medical benefits, when the Claim Administrator reports medical benefits paid on a medical-only claim. If the Claim Administrator does not accept liability for the claim they must populate the Agreement to Compensate Code with a 'W' and comply with the 90-Day Rule described in the PA Implementation Guide. When the Claim Administrator resumes temporary benefits during the 90-day rule period. An IP without liability and then a denial (full or partial) must have been reported on this claim. This transaction resumes temporary benefits for this claim. The Claim Administrator has not accepted liability for this claim (Agreement to Compensate Code = 'W'). 13

15 LIBC-501: Notice of Temporary Compensation Payable (Cont d) Report MTC Description Business Event Trigger SROI RE Reduced Earnings SROI 02 Change When the Claim Administrator reduces benefits during the 90-day rule period. An IP without liability must have been reported on this claim. This transaction reduces benefits for this claim. The Claim Administrator has not accepted liability for this claim (Agreement to Compensate Code = 'W). Immediately when the Claim Administrator has knowledge that the 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 have been reported on this claim. The Claim Administrator has not accepted liability for this claim (Agreement to Compensate Code = 'W'). SROI CA Change in Benefit Amount When the Average Weekly Wage is incorrect and changing it decreases or increases the benefit amount paid and the Claim Administrator has not accepted liability (Agreement to Compensate Code = 'W'). This must be filed in accordance with the 90-Day rule. 14

16 15 LIBC-501: Notice of Temporary Compensation Payable (Cont d)

17 LIBC-495: Notice of Compensation Payable Receipt of the below EDI transactions will generate a Notice of Compensation Payable: Report MTC Description Business Event Trigger SROI IP/AP Initial/ Acquired Payment SROI PY Payment Report If there is no agreement in place, the Claim Administrator is required to indicate whether they are accepting liability at the time of making the initial/acquired payment. Agreement to Compensate Code must be set to 'L'. Please refer to the PA Implementation Guide for details. Immediately upon first payment of medical benefits, when the Claim Administrator reports medical benefits paid on a medical-only claim. If the Claim Administrator accepts liability for the claim they must populate the Agreement to Compensate Code with a 'L'. SROI RB Reinstatement of Benefits An IP without liability and then a denial (Full or partial) must have been reported on this claim. This transaction resumes benefits on this claim. The Claim Administrator is accepting liability for this claim (Agreement to Compensate Code = 'L'). 16

18 LIBC-495: Notice of Compensation Payable (Cont d) Report MTC Description Business Event Trigger SROI 02 Change SROI 02 Change The Claim Administrator sends an Initial Payment without accepting liability for the claim and subsequently accepts liability for the claim. The Claim Administrator is required to 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). The Claim Administrator reports a medical-only claim without accepting liability for the claim and subsequently accepts liability for the claim. The Claim Administrator is required to 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. 17

19 LIBC-495: Notice of Compensation Payable (Cont d) Report MTC Description Business Event Trigger SROI PD Partial Denial When the Claim Administrator is denying indemnity benefits in whole, but not medical payments and there is 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. 18

20 19 LIBC-495: Notice of Compensation Payable (Cont d)

21 Data Element Changes DN # Data Element Name 0134 Calculated Weekly Compensation Amount 0286 Average Wage 0088 Benefit Period Start Date 0192 Benefit Payment Issue Date 0090 Ben Type Claim Weeks 0091 Ben Type Claim Days Mandatory when Claim Type Code is I Indemnity/Wage Loss Claims 20

22 Important Information and Reminders

23 Important Information and Reminders Will PA mandate use of the WCAIS generated forms? Yes, Claim Administrators will be required to use the WCAIS generated LIBC-495/496/501/502 forms beginning June The WCAIS application will also be modified to not allow upload of these forms because the forms would already be generated in WCAIS when the EDI transaction was accepted. Forms mailed to BWC will be returned to sender. Will Claims Administrators be able to download zip files containing their generated forms directly from PA servers? No, zip files will be distributed to Transaction Partners who will be responsible for forwarding the zip files to the respective Claim Administrators. How should Estimated Wages be indicated on forms? o The Estimated Gross Weekly Amount Indicator (DN0172) field should be used to indicate estimated wages on an EDI transaction. 22

24 Important Information and Reminders (Cont d) How do Claim Administrators report bi-weekly payments when the EDI SROI transactions only allow for weekly and monthly periods? As per IAIABC standards, the Wage Period Code does not reflect the frequency of payment being made, but rather the wage calculation period that was used by the Insurer when calculating benefits. Currently, this calculation period is restricted to either weekly or monthly per IAIABC Release 3 EDI Claims Standard. PA requires that the injured worker be paid as per their pre-injury wage schedule. BWC Forms (NCP and NTCP) have been updated to exclude frequency of payment. Note: Claim Administrators must submit EDI transactions via OR the WCAIS EDI Web Portal screens or flat files. Submitting EDI transactions for the same claims using both channels could result in sequencing errors and EDI transaction rejections. 23

25 Important Information and Reminders (Cont d) Will the EDI Forms Solution be able to accommodate the 14-day Resubmission rule? PA will keep track of rejected transactions and will accept resubmitted transactions within the 14-day calendar day period including additional changes. How should Employer Paying Salary in Lieu of Benefits be indicated? o The Employer Paid Salary in Lieu of Compensation Indicator (DN0273) field should be used to indicate these payments on an EDI transaction. 24

26 Next Steps

27 Next Steps Access the EDI Claims Implementation Guide for details on the upcoming changes Testers should follow the test scenarios that has been documented in the EDI Forms Solution Testing Strategy Review the Forms Solution Scenarios Provide feedback to BWC by selecting the Help link in the WCAIS application and then: o o o Select the Submit a Question link Select EDI from the Category drop-down menu Select EDI Generated Forms Solution from the Sub-Category drop-down menu Note: Additional information regarding testing and implementation of the EDI Forms Solution will be distributed soon. 26

28 Questions