March 11 - 13, 2014 - Draft Minutes

IAIABC EDI Claims Committee
Draft Minutes
Atlanta, Georgia
March 11-13, 2014
Attendees:
Name
Tina Queen
Fran Davis
Jim Vogel
Kevin Newlin
Candie Sharrow
Janice Bell
Janna Martin
Brenda Rinehimer
Kevin Guild
Debra Lyerson
Colleen Sniezewski
Linda Yon
Sherri Brown
Jim Eldridge
Robbie Tanner
Lori Raby
Johnnie Perkins
Andre De La Fuente
Patty Burkhart
Jenny Foley
Cindy Hall
Duane Earles
Organization
Mitchell
State of Kentucky
Minnesota Department of Labor &
Industry
Ebix
CNA
Zenith Insurance Company
State of Iowa
Travelers
Virginia
Broadspire Services, Inc.
Broadspire Services, Inc.
State of Florida
State of West Virginia
ISO
ISO
Mitchell
Louisiana Workforce Commission
Louisiana Workforce Commission
West Virginia
AIG
Aon eSolutions
South Carolina WC Commission
E-mail
[email protected]
[email protected]
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1. Introductions: Tina Queen
Guidelines for how the meeting will proceed
2. Agenda Items Overview:
a.
UR/Legacy Catch-up MTC (IRR 749). Clearly define the UR for use in legacy claims reporting when
moving to Release 3 from paper or from a previous EDI Release. Define legacy claims or provide a
mechanism for Jurisdictions to clearly define legacy claims.
b.
Discrepancies in the Implementation Guide for how to report Attorney Fees on PY payment
reports (IRR 739). This is a continuation of discussion from Convention.
c.
Claim Type Code clarification. A suggestion was made to revisit the Claim Type Codes to allow for
a more standard usage of the code.
d.
North Carolina Body Part on SROI
e.
Acquisition Closure MTC (IRR 738). Explore an MTC that will be a sweep used by a new TPA to
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Atlanta, March 11 – 13, 2014
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report an acquired claim that was closed upon receipt. The intent is that a jurisdiction could accept this
MTC in lieu of a Sxx or other MTCs the prior Claim Administrator failed to report.
3. Recap from San Diego on UR and Legacy Claims. The group detailed who is taking a UR MTC and what
the conditions are:
Virginia: FROI and SROI UR; legacy claims for claims with date of injury prior to 10-1-2008. FROI UR
for minors (<1000 in medicals, no permanency, no denial, no lost time). FROI 00 is an option and SROI
you can file every individual MTC or file a catch up UR MTC. If you choose to file the FROI 00, you
must provide the full data set. A SROI UR must be your initial SROI filing on a legacy claim. SROI UR
can be used to catch up a ‘new’ claim if a lot of transactions are missing.
California: SROI UR to catch up sequencing/dollars.
Pennsylvania: FROI 00 must be on file. SROI UR on legacy claims (criteria claims with an open
benefit). A FROI UR may be filed where there was paper filed with the Department. Medical only is
an all paper only process. UR either followed paper or the FROI 00 in Release 1.0. Pennsylvania also
takes the FROI UR for notification only.
New York: FROI and then SROI UR for legacy claims. Legacy for New York is prior to implementation
date or in their database.
Alaska: FROI UR on legacy open claims. All open claims including indemnity and medical where date
claim administrator had knowledge of injury is < event rule criteria from date which includes claims
where a paper report was sent that received a JCN. They only accept an AN or FN MTC after the FROI
UR.
Maine: Accepts a FROI UR when requested due to missing FROI report.
The group also discussed the definition of legacy. States define legacy in many different ways:
a) Pre-EDI - date received, previously reported, previous EDI version
b) Prior to implementation date of EDI/prior release
c) Open/closed according to jurisdiction, not carrier status.
Atlanta Group Discussion:
The primary issue is Can the UR MTC remain a Data Call MTC as well as be used for Legacy Claims? As more and
more jurisdictions have come on board with Release 3.0, there is more usage of the UR MTC and it isn’t clear what
the MTC should be used for as there are varying usages across the board. The UR is like a periodic report; you
don’t get any information to calculate the money. Not to mention the data on old legacy claims isn’t as reliable
as one would think. The editing of the legacy claims is a major issue as there are instances where there isn’t a
match in the state system. Edits have to be built differently for legacy claims than for new claims. Some states do
not allow a SROI to be the initiating transaction. There was discussion over how much data could be requested on
the UR; a smaller subset of Data Elements perhaps. A couple of states already have processes in place that utilize
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the UR MTC for legacy claims or as a catch up (Virginia, California (R1)). The group also discussed the fact that if a
Data Element was not required on paper or a prior EDI release, it could not be asked for in Release 3.0 and
therefore not a required field.
Highlights from the Legacy Processing Rules:
• Newer data may not be captured and/or stored on older claims (for example, NAIC codes)
• New code values
• Definitions can change
• Jurisdiction may have better data than the Claim Administrator
• Legacy data may not include monies and/or calculations
Jurisdiction consideration: Edits applied by a jurisdiction should mimic those in place at the time of the
accident.
Claim Administrator consideration: When a jurisdiction is determining what they will accept, the claim
administrator should let them know that a particular set of data is not available.
FROI UR Requirements
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Legacy/Migration (Paper to Release/Release to Release) for claims (to be defined on the event
table by jurisdiction) to assign or pass back the JCN. The below are event table criteria that
should be considered:
o Claim Status
o Claim Type
o Date Employer Had Knowledge of Injury, Date Claim Admin Had Knowledge of Injury,
Date of Injury, Implementation Date
Reduced data set ie Notification Only claims (VA) If jurisdiction does not use UR, 00 should have
conditions built to require less data.
Reporting in response to a request by the jurisdiction – accident reported by another source (ME)
Data Call
Could be an initiating FROI – may or may not need an 00 after the UR.
Clarify definition of legacy to exclude migration of systems?
Reduced Match Data requirements (jurisdictions accept name spelling differences) JCN vs no JCN
= different requirements
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UR Clarifications Needed:
Definition:
o Intended to be used as a vehicle to match up the claim so a lesser data set is
recommended. Intended to match up and return JCN.
Existing uses are grandfathered (VA, ME) – include in processing rules.
Update legacy processing rules. (i.e. a FROI UR isn’t required on legacy/migration claim if JCN
already exists).
o If UR fails for no match, Claim Administrators attempt to resolve with state; possibly
utilizing 00 or 02 on more complete set of data (assuming it’s a legacy claim that had no
match and was never previously reported).
o Jurisdictions considerations for editing after UR (may need to be relaxed for legacy
claims) – Instructions on ERT specific to UR.
o Legacy benefits shouldn’t be edited against the state database prior to EDI on MTCs after
SROI UR. New benefits can be edited.
JCN Scenarios:
o Claim was previously reported to state (either via paper or prior EDI release version) and
UR may or may not include the JCN when going to the state.
o Claim was not previously reported to the state because it didn’t meet prior reporting
requirements: Should be a FROI other than UR.
Population Restriction Rules for Benefit Segments Events vs. Sweeps:
o Clarify SROI UR is sweep only.
Migration Document:
o Encourage states to define how to deal with no matches, or claims that had never been
reported.
o Options for the jurisdictions to migrate from
FROI only to FROI/SROI (PA, LA, SC, UT)
Paper to FROI/SROI
FROI/SROI to FROI to FROI/SROI (NC)
R2 to R3?
R1 to R3 – current migration document
Minimal data set – Same as AQ plus Date of Death – Accident Premises Code should be excluded.
o Update the ERT to communicate Minimal Data Set
Reduced Match data.
Implementation Date – 1/1/15? On IRR Approval?
UR Re-definition
Business Workgroup: Cindy, Johnnie, Jim E., Candie, Jim V., Lori, Patti, Kevin G. Duane, Fran, Brenda,
Jenny, Colleen, Tina; cc: Linda and if she can attend she will.
Systems workgroup: Sherri, Lori, Andre, Janice, Kevin G., Duane, Tina, Nadia (LA)
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UR Upon Request – Submitted on a legacy or migration claim as defined by the jurisdiction’s Event
Table. Refer also to the Legacy Claims Processing in Section 4. A migration is defined as implementing
the latest EDI release version from a previous release or paper. Refer also to IAIABC website for more
information regarding migrations (http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3370 ).
DP Rule:
FROI: The FROI UR may or may not be the initiating EDI FROI transaction containing a limited data set
(as defined in Section 4 Legacy Claims Processing). The FROI UR is intended to match a claim previously
reported to the state and/or initiate EDI reporting. The FROI UR may or may not be required prior to
submitting the SROI UR if the JCN has already been communicated to the Claim Administrator. Refer to
Legacy Processing Rules in Section 4 and/or Migration Document for more information.
SROI: The SROI UR may or may not be the initiating EDI SROI transaction. The SROI UR is intended to
provide a starting point for the claim in the current release version including but not limited to a
summary of all claim data and benefits paid to date. Jurisdictions who accept a SROI UR should use the
summary as the current picture of the claim. It should not be rejected for reasons other than Match
Data if the data does not match the prior release or paper. Refer to Variable Population Segment Rules
for more information.
Include grandfather clause in IRR but not DP Rule:
States that have implemented uses of the UR for purposes other than legacy or migration reporting prior
to the effective date of this change may continue to use the UR as previously defined. Grandfathered
Jurisdictions may not be able to use the UR in the newly defined manner.
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4. IRR 739 - Discrepancies in the Guide for PYs in regard to Attorney Fees recap from previous
IAIABC Meetings
Notes from Convention 2013: Some jurisdictions currently require everything to be reported
under BTC 500 while others need it reported through the OBTC 340. There is only one payment
segment per payment reason code allowed unless a lump sum payment settlement results in
more than one check being issued. Thus two checks for one benefit segment. The carriers have
to manipulate the payee name for every one that they submit. The group discussed whether
OBT 340 contradicts what the PY payment reports say. To add to this, some jurisdictions do not
accept the OBT 340. The workgroup got together an IRR and put out for review, but there are
still questions surrounding this matter. An attorney fee workgroup was established to try to
resolve these issues. The following individuals will work on this matter: Linda Yon, Kevin Guild,
George Poulin, Candie Sharrow and Collette Turner. They will discuss the payment segment in
the PY reports and flush out for additional clarification. The current IRR will be pulled from the
web until further clarification is made by the work group.
April 2013 Forum notes: Discrepancies in the Guide for PYs in regard to Attorney Fees. Some
jurisdictions currently require everything to be reported under BTC 500 while others need it reported
through the OBTC 340. There is only one payment segment per payment reason code allowed unless a
lump sum payment settlement results in more than one check being issued. Thus two checks for one
benefit segment. Virginia, for example, requires two checks to be issued, but only one transaction is to
be reported. The carriers have to manipulate the payee name for every one that they submit. The
group discussed whether OBT 340 contradicts what the PY payment reports say. To add to this, some
jurisdictions do not accept the OBT 340.
The group feels there are inconsistencies that need to be addressed in this matter, but OBT 340 is ok.
The discrepancy is in Section E relative to lump sum payments/settlements are reported as PY
transaction. ‘Lump sum payment/settlement checks allocated to other benefit type codes such as
attorney fees, penalties, etc. would be reflected in the OBT segment rather than payments segment.’
Jim Vogel drafted language as follows. The group believed there was a typo in the current variable
segment population rules 8e. If so, it should state as the same indemnity type as the lump sum and it
currently says AT the same indemnity type. We later verified the typo was not in the IAIABC Guide.
CHANGES - Variable Segment Population Rules 8e.
All lump sum payments/settlements are reported as a PY transaction: If more than one check is issued
for a lump sum payment/settlement, only the check(s) that relates to indemnity Benefit Type Codes
should be populated in the Payments segment and repeated in the Benefits segment. Employee
attorney fees that are determined to be the responsibility of the employee but are deducted from any
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Atlanta, March 11 – 13, 2014
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lump sum payments/settlements should be coded as the same indemnity type as the lump sum
payment/ settlement. If more than one check is issued for the same Payment Reason Code, the same
Payment Reason Code would be populated in multiple payments segments, but grouped together in the
Benefits segment. Lump sum payment/settlement checks allocated to Other Benefit Type Codes such as
attorney fees (excluding employee attorney fees mentioned above), penalties, etc., would be reflected
in the Other Benefits segment rather than the Payments segment.
Atlanta Discussion/Proposal:
Discussion relative to New York; NY wants the attorney fees on scheduled loss of use (lump sum benefits
OBT 030) or section 32 settlement, coded within the OBT 500. For both of these, New York wants to see
attorney fees broken out in the payment section. However, the fees are from the claimants funds. They
are tracking the timely payment. The Claim administrator can be assessed a penalty if payments are
late. Per conference call with Mary Beth Goodsell relative to penalties and the PY for every penalty
payment: The payment segment is only supposed to be provided on the very first PY. We believe it is
non-standard to expect a payment segment on each PY submitted. Tina Queen will get back with Mary
Beth on this issue.
Virginia says the business scenarios didn’t make it clear on how to do the attorney fees: - see 340 from
the Guide:
VA says the business scenarios didn’t make it clear on how to do the attorney fees. –see OBT 340 from
the guide: 340 Total Claimant’s Legal Expenses – Sum of the claimant’s legal expenses paid for this
claim. Note: This excludes employee attorney fees that are determined to be the responsibility of the
employee but are deducted from any lump sum payments/settlements. Those attorney fees should
be coded as the same indemnity type as the lump sum payment/settlement. If part of a weekly
indemnity check is redistributed to a claimant’s attorney, it should be sent as a weekly Benefit
Redistribution Code “K” (Claimant Attorney Fees) rather than OBT Code 340.
***Bigger issue is do we need to clarify C and is it only one payment segment? Do
we allow more than one payment segment and you can only require one? More
flexibility allowed? Redistribution, etc.
Group Suggestion:
C. More than one Payments Segment for the same Payment Reason Code may be applicable if multiple
payees/checks issued on the same day. Only one Payment Segment per Payment Reason Code is
allowed unless a Lump Sum Payment/Settlement (MTC PY) results in more than one check being issued
to different payees for the same Payment Reason Code. If the maximum 5 Payment Segments are sent
reflecting 5 different payees for the same Payment Reason Code, a jurisdiction cannot return an error
(TE or TR) strictly because the sum total of all Payment Amounts is less than the Benefit Type Amount
Paid in the benefits segment with the same corresponding Benefit Type Code.
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ACTION: CHANGES per Atlanta Group - Variable Segment Population Rules 8e.
All lump sum payments/settlements are reported as a PY transaction: If more than one check is issued
for a lump sum payment/settlement, only the check(s) that relates to indemnity Benefit Type Codes
should be populated in the Payments segment (Payment Reason Code) and repeated in the Benefits
Segment. Employee attorney fees that are determined to be the responsibility of the employee but are
deducted from any lump sum payments/settlements should be coded as the same Benefit Type type as
the lump sum payment/ settlement. If more than one check is issued for the same Payment Reason
Code, the same Payment Reason Code would be populated in multiple payments segments (Payee:
Injured worker; Payee: Attorney), but added grouped together in the Benefits segment. Lump sum
payment/settlement checks allocated to Other Benefit Type Codes such as attorney fees (excluding
employee attorney fees mentioned above), (i.e. Other Benefit Type 340) penalties, etc., would be
reflected in the Other Benefits segment rather than the Payments segment.
PY Payment Report – Identifies lump sum payment/settlement reports (See DN0293
Lump Sum Payment/Settlement Code) OR jurisdiction-required reporting of the
first payment of Other Benefit Type Codes for medical, funeral, penalty, and
attorney fees. This is not to be used for monitoring ongoing payments.
DP Rule: If more than one check is issued for the same indemnity Benefit
Type/Payment Reason Code, all indemnity checks issued should be populated in the
Payments segment. Refer to Variable Segment Population Rules (Payments
Segment) in Section 4.
The Steering Committee/EDI Council directed that Payee (DN0217) was established
for specified transactions only (IP, AP, PY, RB, or any corresponding 02 or CO for
those specified Maintenance Type Codes) and that individual weekly check
information would not be reported in Release 3. This is a free form text field that
cannot be edited by the jurisdiction.
Record: A49; R22
5. North Carolina Body Part –Background:
When North Carolina gets an injury reported, there may be multiple body parts, but you may not
be aware of it on the FROI. On the SROI (on paper on multiple body parts), they are accepting
one body part, but not accepting liability for another body part. SROI multiple body parts are
detailed out i.e. we are accepting liability for a, b, and c but not for e or f. North Carolina is
proposing to utilize the Permanent Impairment Body Part code to capture more than one body
part on a particular claim, even though a permanent impairment may not be present. Janice Bell
suggested that this information is currently being sent to CMS, it is already built in for CMS so
maybe suggest the same format utilizing the ICD9/ICD10? North Carolina is going to be going to
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Medical EDI soon, so does this tell them which ones the carriers are on the hook for based on
body part? All carriers do not have it set up in their system to determine which body parts are
compensable and which ones are denied. For example, if a bill comes into CMS and Janice didn’t
say that they denied a certain body part as compensable, then she could be on the hook for the
injury because she didn’t officially deny this with CMS. The group currently doesn’t know if this
would work for North Carolina or not. You may have/send up to 19 codes to CMS then note
denial or acceptance.
Without going to the Council for a blessing, there is no way without changing the record layout.
We could get a counter, but a variable segment is Mandatory. There is lots of work to do here. It
was suggested to add the ICD10 to the SROI (ICD9 was removed from the SROI in 2004 before R3)
which would take less space in the release. Everything isn’t reportable to CMS therefore, we
would need to have more information on which claims would need additional information on or
what criteria would be needed for body part.
Question/Answer from North Carolina:
1)
Would NCIC consider using ICD-10 codes to identify the body parts instead of narrative?
These codes are broken down further. Carriers report these to CMS today. See link at bottom of
email.
Answer: I am sure they would consider it, but we will have to review it and take it before the
Commissioners. I will try to talk to the Chair about it today.
2) Is 10 occurrences still the goal for number of occurrences?
Answer: I was saying yesterday that 10 seemed like too many. Six? Five?
3) On the paper forms today, if the body parts are not filled in, what happens? Does NCIC return
the forms to be completed?
Answer: The forms are not returned. The defendants risk this being interpreted as accepting
any and every body part claimed to have been injured.
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4) How does NCIC get updates on the forms if applicable? Or is this a onetime reporting?
Answer: Defendants often file amended forms if the body parts become an issue or if they
accept the injury on one form and then another body part is claimed, they might file a denial
form listing that body part.
5) Would this data for example come in on the SROI IP event that is sent after the investigation is
completed and is due within 60 days? There is a reference to this on the SROI Event Table. Or
would it be the MTC's per the Forms to MTC Crosswalk that map to Form 60, 61, 63.
Answer: It would need to be on the IP (60 and 63) and the 04 (61).
6) Would you provide an example of how NCIC uses the data?
Answer: It is required by statute for our Form 60. Without going into too much detail, certain
case law has resulted in a legal presumption for body parts listed on the Form 60 or 63 (IP).
Consequently, defendants in most cases declare accepted and/or denied body parts on the forms
now. If we cannot receive this via EDI, we will have to either cease plans to use the SROIs or
move forward with SROIs but still have to use the paper form of some kind for this purpose.
7) Do you have a few examples of the body part descriptions that you receive on the forms
today?
Answer: Usually they are simple, but they can sometimes get down to the disk level, e.g., L4-L5.
We need left and right and bilateral descriptors, too, which are not in the standard.
Pennsylvania wants the IAIABC to drop the permanent from ‘Permanent Impairment Body Part code’
then no 030 or 040 and detail all body parts involved. They are not interested in joining North
Carolina in this proposed IRR. More Discussion to follow.
6. Claim Type Code
Claim Type Code Discussion- do they relate to Detailed Claim Information (DCI). Not sure.
Examples:
1) Waiting period not met
2) Medical doesn’t meet reporting threshold
3) DOD=DOI
4) PP Indemnity only with no lost time
5) Medical LSS with no lost time
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Cheryl Keyes: Proposed definitions:
N= notification only – medical, if incurred, is less than state threshold; no lost time; no permanency
Medical Only – medical meets or exceeds state threshold, and no lost time beyond remainder of day,
shift or turn or as otherwise defined by jurisdiction.
P – indemnity with no lost time – permanent impairment(s) or death with no lost time beyond
remainder of day, shift, or turn or as otherwise defined by jurisdiction. MMI may or may not be
reached.
Claim Type Code:
M= Medical Only
I – Indemnity/Lost Time
N = Notification Only
B=Became Medical Only
L = Became lost time
Proposal to add one value for indemnity/settlement with no lost time – accounts for Permanent partial
as the first benefit (no lost time), Medical Lump sums, settlement only or settlement with no disability,
DOI = DOD.
Suggestions from Cheryl:
Initial treatment code (DN0039)–look at this just in case – if you define it as first aid, you may have an
issue. Is minor onsite remedy considered first aid?
IAIABC – Glossary:
Indemnity benefits – Benefits paid to the employee, employee’s dependent, or jurisdiction fund, for
wage replacement, permanent partial impairment, vocational rehabilitation maintenance or
dependency benefits.
Disability – Generally, a medical condition that precludes the worker from earning pre-injury wages as
a result of an OD or injury that is subject to jurisdictional Workers’ Compensation coverage.
*Became fields are to figure out timely filings.
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Claim Type Code Proposal:
N = Notification Only – No benefits, medical or indemnity, paid.
M = Medical Only – Only medical benefits paid on this claim where Claim Type Code T does not apply.
T = Medical Only Pursuant to Jurisdictional Threshold – The total amount of medical paid has met the
medical threshold per the Event Table.
I = Lost Time/Indemnity – Lost time within the waiting period or lost time beyond the waiting period
(including employer paid) as defined by the jurisdiction on the Event Table.
P = Indemnity with No Lost Time – When permanent impairment and/or a settlement is the first benefit
paid on the claim and the Initial Date Disability Began (DN0056) is not applicable.
B = Became Medical Only – Previously classified as any other Claim Type Code and now only medical
benefits have been paid on this claim and Claim Type Code T does not apply.
L = Became Lost Time/Indemnity - Previously classified as any other Claim Type Code and now lost time
within the waiting period or lost time beyond the waiting period (including employer paid) as defined by
the jurisdiction on the Event Table has occurred.
DP Rule: Claim Type Code N is applicable to all FROI MTCs and the SROI MTC 04.
Implementation Strategy: to be determined
Suggestions:
Add value for Indemnity/Settlement No Lost Time – Accounts for Permanent Partial as the first benefit
(no lost time), Medical lump sums Settlements only or Settlements with no disability, DOI=DOD
Notification only is for reporting purposes only and no money of any kind has been paid. (first aid only,
incident only, record only)
Became fields are to figure out timely reporting.
There wasn’t time available for the group to discuss Acquisition Closures. This agenda item will be
deferred to the IAIABC Forum in April 2014.
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