Introduction to Detailed Claim Information Reporting. Lesson 2: Data Elements

Transcription

1 Introduction to Detailed Claim Information Reporting Lesson 2: Data Elements 1

2 LESSON 2 OBJECTIVES Learn the four main sections that categorize Detailed Claim Information (DCI) Identify the DCI elements that are required to be reported for all NCCI states/jurisdictions Gain a basic understanding of all the data elements that comprise DCI, how to report them, and how they are viewed online Locate additional information on the data elements, such as more detailed descriptions, specific reporting requirements, and state exceptions 2

3 DCI Components Detailed Claim Information (DCI) consists of 86 data elements reported for a given indemnity claim. These same data elements are reported up to the ninth report level for the reporting of open claims. The data elements provide insight into the comprehensive structure of DCI that is important in analyzing and determining the aggregate costs of workers compensation insurance. The data elements in DCI are categorized into four main sections: Common Information, Claimant and Employer Information, Benefits and Payments, and Claim Administration Details. Some data elements are optional for NCCI states, but required for other states. Refer to NCCI s Call for Detailed Claim Information Instruction Manual for additional information on the data elements, including detailed descriptions, reporting requirements, and state exceptions. Electronic reporting requirements are contained in the Workers Compensation Insurance Organization s (WCIO) Workers Compensation Data Specifications Manual, WCCDCI (Workers Compensation DCI Format) section. 3

4 Common Information Section Overview The Common Information section of DCI contains the key information used to identify the claim and store the related DCI reports (Report Types 1 9) together. The data elements in the Common Information section are used to link related DCI reports, including corrections for the same indemnity claim. It is essential that the Common Information data elements be reported correctly for proper linking. The Common Information section is comprised of the first 10 fields of the 86 data elements. Fields 1 9 are mandatory and are required to be reported for all NCCI states/jurisdictions. The following describes each of these data elements and how they are displayed in DCA Access Online. 4

5 Common Information Data Elements Fields 1 9 are mandatory and are required to be reported for all NCCI states/jurisdictions. Field Number Data Element Data Element Description 1 Carrier Code NCCI-assigned code (5 digits) that identifies the carrier or carrier group submitting the claim (mandatory) 2 Policy Number Alphanumeric code (up to 18 digits) that identifies the policy under which the experience occurred; must match the number on the policy Information Page or as endorsed (mandatory) 3 Policy Effective Date Month, day, and year (6 digits) that the policy became effective; must match the date in Item 2 of the policy Information Page or as endorsed (mandatory) 4 5 Claim Number Alphanumeric code (up to 18 digits) that identifies the specific claim that the report applies to (mandatory) Report Type Code (1 digit) that identifies the report level, Report Types 1 9 (mandatory) 5

6 Common Information Data Elements (continued) Field Number Data Element Data Element Description 6 Transaction Code Code (1 digit) that represents the type of transaction the report is: original ( 1 ), revised ( 2 ), or correction ( 3 ) (mandatory) 7 State of Jurisdiction *Code (2 digits) that represents the state Workers Compensation Act under which the claimant s benefits are being paid; must be a valid DCI state for the carrier submitting the claim as shown in the Carrier Participation Summary (mandatory) The corresponding codes are listed in NCCI s Call for Detailed Claim Information 8 State of Accident *Code (2 digits) that represents the state or foreign location where a claimant was injured or contracted disease (mandatory) 9 Date Reported to Insurer 10 Employee Social Security Number The corresponding codes are listed in NCCI s Call for Detailed Claim Information Month, day, and year (6 digits) that the claim was originally reported to the carrier (mandatory) Number (9 digits) assigned by the Social Security Administration to the claimant (optional for NCCI states, zerofill for electronic submissions if not reported). *The corresponding codes are listed in NCCI s Call for Detailed Claim Information 6

7 Common Information Online View The Common Information section consists of Fields 1 10 and is displayed within DCA Access Online. Click to enlarge 7

8 Claimant and Employer Information Overview The Claimant and Employer Information section of DCI contains basic information on the employer, the claimant, and the circumstances behind the claim. This includes identification numbers, wages and payroll amounts, claimant s personal statistics, claim status information, and dates that initiated the reporting of the claim. The Claimant and Employer Information section is comprised of fields of the 86 data elements. All data elements in this section that apply to the claim are required to be reported for all NCCI states/jurisdictions, unless otherwise indicated. The following describes each of these data elements and how they are displayed in DCA Access Online. 8

9 Claimant and Employer Information Data Elements Field Number Data Element Data Element Description 11 Employer Federal Tax Number 12 Employer SIC Code 13 Employer Payroll 14 Zip Code of Injury Site Number (9 digits), commonly referred to as the Federal Employer Identification Number (FEIN), that is assigned to each employer for federal tax purposes (optional for some states) Code (4 digits) that represents the nature of the employer s business, as contained in the Standard Industrial Classification (SIC) Manual (optional for some states) Code (1 digit) that represents the payroll range that corresponds to the employer s total amount of payroll in the State of Jurisdiction Code Payroll Range 1 $0 2 $1 $100,000 3 $100,001 $1,000,000 4 $1,000,001 $10,000,000 5 Over $10,000,000 Code (the first 5 digits of the 9-digit U.S. Postal Code or foreign country zip code) that identifies the location where the injury occurred 9

10 Claimant and Employer Information Data Elements (continued) Field Number Data Element Data Element Description 15 Employee Name 16 Sex of Injured Worker 17 Marital Status First six letters of the claimant s last name followed by the first initial of the claimant s first name (7 digits, left-justified with no punctuation marks) Code that represents the claimant s sex Code Sex 1 Male 2 Female 3 Unknown Code that represents the injured worker s marital status on the Accident Date Code Marital Status 1 Single, divorced, widowed 2 Married 3 Separated 4 Unknown 18 Date of Birth Month, day, and year (6 digits) that the claimant was born; if only age is known, use the same month and year as in the Accident Date and 01 for the day 10

11 Claimant and Employer Information Data Elements (continued) Field Number Data Element Data Element Description 19 Date of Hire Month, day, and year (6 digits) that the claimant began the most recent employment with the employer 20 Occupation Not applicable for NCCI states Code 21 Employment Status 22 Accident Date Code (1 digit) that represents the claimant s employment status as of the date the claim was first reported to the carrier The corresponding codes are listed in NCCI s Call for Detailed Claim Information Month, day, and year (6 digits) that the claimant was know to be injured, or use the best estimate 11

12 Claimant and Employer Information Data Elements (continued) Field Number Data Element Data Element Description 23 Class Code Classification code (4 digits) where the payroll or other exposure of the injured worker was reported, according to NCCI s Basic Manual for Workers Compensation and Employers Liability Insurance for most jurisdictions 24 Part of Body Code (2 digits) that represents the part of the body that sustained the injury Nature of Injury Cause of Injury The corresponding codes are listed in NCCI s Call for Detailed Claim Information Code (2 digits) that represents the nature of the injury sustained by the claimant The corresponding codes are listed in NCCI s Call for Detailed Claim Information Code (2 digits) that represents the cause of the injury sustained by the claimant The corresponding codes are listed in NCCI s Call for Detailed Claim Information 12

13 Claimant and Employer Information Data Elements (continued) Field Number Data Element Data Element Description 27 Loss Conditions 28 Number of Dependents 29 Preinjury Weekly Wage 30 Method of Determining Preinjury Wage 5 codes (2 digits each) that represent the classification of the accident according to Federal Act (positions 1 2), Type of Loss (positions 3 4), Type of Recovery (positions 5 6), Type of Coverage (positions 7 8), and Type of Settlement (positions 9 10) The corresponding codes are listed in NCCI s Call for Detailed Claim Information Not applicable for NCCI states Average weekly wage (up to 5 digits) of the claimant or deceased worker on the Accident Date Code (2 digits) that represents the method used to determine the preinjury wage for the applicable Injury Type using the minimums/maximums approved by the State of Jurisdiction (Field 7) Code Method 1 Actual 2 Estimated 3 Minimum Weekly Benefit 4 Maximum Weekly Benefit 13

14 Claimant and Employer Information Data Elements (continued) Field Number Data Element Data Element Description 31 Other Weekly Payments 32 Date Reported to Employer Dollar amount (5 digits) of additional contributions or supplements to the preinjury wage made by the employer for economic or fringe benefits (if not applicable, a zero must be reported) Month, day, and year (6 digits) that the claimant reported the injury to his/her supervisor 33 Surgery Code (1 digit) that indicates if the claimant s injury required surgery: Yes ( 1 ) or No ( 2 ) 34 Claim Status Code (1 digit) that represents the current status of the claim at the time of sampling or at the subsequent report (reports 2 9) level; on 1st reports, claim status must be Open ( 0 ) or Closed ( 1 ) 14

15 Claimant and Employer Information Data Elements (continued) Field Number Data Element Data Element Description 35 Date of Closing 36 Date of First Payment 37 Date Disability Began 38 Date of Return to Work Month, day, and year (6 digits) that the claim closed, the same as the judgment date or date an agreement was made as to the final amount paid Month, day, and year (6 digits) that the first indemnity (lost wages) payment was issued Month, day, and year (6 digits) that the claimant originally lost time from work due to the injury or occupational disease Month, day, and year (6 digits) that the claimant originally returned to work following the disability period 15

16 Claimant and Employer Information Online View The Claimant and Employer Information section consists of Fields and is displayed within DCA Access Online. Click to enlarge 16

17 Benefits and Payments Overview The Benefits and Payments section of DCI contains information on the dollar amounts incurred and paid for the benefit of the claimant. This information is categorized by indemnity (lost wages) benefits, vocational rehabilitation benefits, medical benefits, miscellaneous information pertaining to benefits, and other benefits and payments. The Benefits and Payments section is comprised of Data Elements All data elements that apply to the claim are required to be reported for all NCCI states/jurisdictions. The following describes each of these data elements and how they are displayed in DCA Access Online. 17

18 Benefits and Payments Data Elements Field Number Data Element Data Element Description 39 Total Incurred Indemnity Indemnity Benefits Indemnity (lost wages) amount (up to 8 digits) paid to date plus any anticipated future indemnity benefits to be paid, special instructions for special fund reimbursements, third party recoveries, and claims reimbursed by employer-paid deductibles apply: Open claims include indemnity paid to date plus outstanding reserves Closed claims only include the total paid 40 Injury Code *Code (2 digits) that represents the type of benefits the injured worker has received, is currently receiving, and/or expected for the future (Fields 43, 46, 49, and 52 are used for reporting additional benefit types) 41 Benefits Paid to Date *Total indemnity amount (up to 7 digits) paid to date for the corresponding Injury Type; corresponds to the injury reported in Field 40 (Fields 44, 47, 50, and 53 are for reporting benefits paid that correspond to additional benefit types) 42 Weekly Benefit Latest weekly benefit paid to the claimant (up to 6 digits); corresponds to the injury reported in Field 40 (Fields 45, 48, 51, and 54 are for the Weekly Benefit that corresponds to additional benefit types) *The corresponding codes are listed in NCCI s Call for Detailed Claim Information 18

19 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description 43 Injury Code 44 Benefits Paid to Date Indemnity Benefits Type of benefits, reported only if claimant received benefits under more than one benefit type during the life of the claim; see Field 40 for description Benefits paid that correspond to the Injury Code reported in Field 43, reported only if claimant received benefits under more than one benefit type during the life of the claim; see Field 41 for description 45 Weekly Benefit Weekly benefit that corresponds to the Injury Code reported in Field 43; reported only if claimant received benefits under more than one benefit type during the life of the claim; see Field 42 for description 19

20 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Indemnity Benefits 46 Injury Code Type of benefits, reported only if claimant received benefits under more than two benefit types during the life of the claim; see Field 40 for description 47 Benefits Paid to Date Benefits paid that correspond to the Injury Code reported in Field 46; reported only if claimant received benefits under more than two benefit types during the life of the claim; see Field 41 for description 48 Weekly Benefit Weekly benefit that corresponds to the Injury Code reported in Field 46; reported only if claimant received benefits under more than two benefit types during the life of the claim; see Field 42 for description 20

21 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Indemnity Benefits 49 Injury Code Type of benefits reported only if claimant received benefits under more than three benefit types during the life of the claim; see Field 40 for description 50 Benefits Paid to Date Benefits paid that correspond to the Injury Code reported in Field 49; reported only if claimant received benefits under more than three benefit types during the life of the claim; see Field 41 for description 51 Weekly Benefit Weekly benefit that corresponds to the Injury Code reported in Field 49; reported only if claimant received benefits under more than three benefit types during the life of the claim; see Field 42 for description 21

22 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Indemnity Benefits 52 Injury Code Type of benefits, reported only if claimant received benefits under more than four benefit types during the life of the claim; see Field 40 for description 53 Benefits Paid to Date Benefits paid that correspond to the Injury Code reported in Field 52; reported only if claimant received benefits under more than four benefit types during the life of the claim; see Field 41 for description 54 Weekly Benefit Weekly benefit that corresponds to the Injury Code reported in Field 52; reported only if claimant received benefits under more than four benefit types during the life of the claim; see Field 42 for description 22

23 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Total Incurred Vocational Rehabilitation Vocational Rehabilitation Evaluation Expense Paid to Date Vocational Rehabilitation Maintenance Benefit Paid to Date Vocational Rehabilitation Benefits Amount paid to date (up to 8 digits) plus anticipated future amounts to be paid under the provisions of the Workers Compensation Act associated with job retraining, education, job placement, etc. to expedite a claimant s early return to work: Open claims include indemnity paid to date plus outstanding reserves Closed claims only include the total paid Paid-to-date expenses (up to 7 digits) for testing and evaluating the claimant s ability, aptitude, or attitude in determining suitability for vocational rehabilitation or placement Amount paid to date (up to 7 digits) as a maintenance benefit while the claimant is actively participating in a bona fide vocational rehabilitation program; includes Weekly Benefits paid to an injured worker for living expenses 23

24 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Vocational Rehabilitation Education Expense Paid to Date Other Vocational Rehabilitation Expenses Paid to Date Vocational Rehabilitation Benefits Amount paid to date (up to 7 digits) for training costs including tuition, books, tools, transportation, and additional living expenses Report the amount paid to date for any other phases of the vocational rehabilitation program not reported in Field 56, 57, or 58 24

25 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Total Incurred Medical Hospital Costs Paid to Date 62 Total Payments to Physicians 63 Other Medical Paid to Date Medical Benefits Report the total paid to date (up to 8 digits) plus expected future amounts to be paid for physicians, hospitals, drugs, and other related services; net of recoveries (i.e., third party, subrogation, special funds) and gross of deductibles: Open claims include indemnity paid to date plus outstanding reserves Closed claims only include the total paid Amount paid to date (up to 7 digits) of both inpatient and outpatient services (e.g., emergency room services, X-rays and hospital lab tests) that the injured employee received because of the work-related injury; gross of recoveries Amount paid to date (up to 7 digits) to treating physicians, including all clinic and office visits; gross of recoveries Amount paid to date (up to 7 digits) for medical costs not included in hospital costs or total payments to physicians, including non-specific related services, laboratory tests, prescriptions, or medical expert testimony for the benefit of the claimant; gross of recoveries 25

26 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Postinjury Weekly Wage Percentage of Impairment Date of Maximum Medical Improvement Not applicable for NCCI states Miscellaneous Information Percentage amount (3 digits) of anatomic or functional abnormality or loss that results from the injury and exists after the date of maximum medical improvement Month, day, and year (6 digits) after which further recovery from or lasting improvements to an injury or disease can no longer be anticipated based on reasonable medical probability 26

27 Benefits and Payments Data Elements (continued) Field Number Data Element Field Description Funeral Expenses Paid to Date Lump Sum Settlement Amount Employers Liability Paid to Date Other Benefits and Payments Amount paid (up to 6 digits) for the funeral of the deceased employee Amount of compensation paid (up to 6 digits) as a lump sum settlement, including claimant legal expense and expert witness fees; gross of recoveries Not applicable for NCCI states 27

28 Benefits and Payments Online View The Benefits and Payments section consists of Fields and is displayed within DCA Access Online. Click to enlarge 28

29 Claim Administration Details Overview The Claim Administration Details section contains legal information including court costs, attorney fees, and case information deductible information, and managed care administration information. The Claim Administration Details section is comprised of Data Elements All data elements that apply to the claim are required to be reported for all NCCI states/jurisdictions. The following describes each of these data elements and how they are displayed in DCA Access Online. 29

30 Claim Administration Details Data Elements Field Number Data Element Field Description 70 Attorney or Authorized Representative 71 Controverted Case Code (2 digits) that indicates if claimant has an attorney or authorized representative: Yes ( 1 ) or No ( 2 ) Code (2 digits) that indicates whether the claim was ever contested or disputed for compensability and/or disability by the insurer: Yes ( 1 ) or No ( 2 ) 72 Deductible Code (2 digits) that represents the deductible type Product Liability, Automobile Liability, Other Code Deductible Type 00 No Deductible Program 01 Deductible Amount Fully Recovered for Net Reporting Program 02 Deductible Amount Not Fully Recovered for Net Reporting Program 03 Gross Deductible Program Not applicable for NCCI states 30

31 Claim Administration Details Data Elements (continued) Field Number Data Element Field Description 76 Employer Legal Expense Paid to Date 77 Claimant Legal Expense Paid to Date 78 Expert Witness Fees Paid to Date 79 Penalties Paid to Date Amount paid (up to 8 digits) by the employer or benefit payer for the services of an attorney or authorized representative to defend against a proceeding; gross of recoveries Amount specified (up to 7 digits) in the award or paid without an award by the employer for the fee of the claimant s attorney or authorized representative (optional for NCCI states) Amount paid (up to 6 digits) in a legal proceeding for expert testimony or opinion; gross of recoveries Not applicable for NCCI states 31

32 Claim Administration Details Data Elements (continued) Field Number Data Element Field Description 80 Allocated Loss Adjustment Expenses Paid to Date Social Security, Unemployment, Pension Plan, Special Fund, Other 86 Managed Care Organization Indicator (MCO) Total amount paid (up to 7 digits) for expenses directly attributable to a particular claim including attorney fees and court costs Not applicable for NCCI states Code (2 digits) that represents the type of organization that will administer the applicable medical losses of this claim (optional for some states) The corresponding codes are listed in NCCI s Call for Detailed Claim Information 32

33 Claim Administration Details Online View The Claim Administration Details section consists of Fields and is displayed within DCA Access Online. Click to enlarge 33