1. If a claims office sent EDI transactions on a claim file prior to 12/1/2018 and are now sending subsequent transactions, do they need to send values for data elements that are now mandatory but were not mandatory prior to 12/1/2018?
Yes, please make sure to include all fields that are mandatory effective 12/1/2018 on any transactions sent on 12/1/2018 or later. The data elements that frequently caused rejections during our testing were:
- DN0063 Wage Period Code (FROI);
- DN0159 Employer Contact Business Phone Number (FROI);
- DN0160 Employer Contact Name (FROI);
- DN0165, DN0167, DN0168, DN0170 Employer Mailing Address fields (FROI);
- DN0137 Claim Administrator Claim Representative Business Phone Number (SROI);
- DN0138 Claim Administrator Claim Representative Email Address (SROI); and
- DN0140 Claim Administrator Claim Representative Name (SROI).
2. What types of claims is GA expecting to be reported with Claim Type Code M, I, and W?
There are three (3) types of claims in GA: indemnity (more than 7 days of lost time) which would be reported as I; medical only (less than 7 days of lost time; indemnity benefits are not due; indemnity benefits have not been controverted) which would be reported as M; and controverted claims (claim is controverted in whole or in part) which could be reported as W if there is lost time, but no indemnity benefits are being paid.
3. How is Claim Type Code used in GA?
We are only interested in Clam Type Code at the time of the initial FROI report to tell us whether or not the FROI is reporting a medical only claim.
4. Will a JCN provided for a FROI with Claim Type Code M expire?
No, a FROI 00 with Claim Type Code M will generate a completed WC-1 First Report of Injury (similar to a FROI 04) and no SROI is required to be filed within 21 days.
5. Why is Initial Date of Disability mandatory on the FROI 00?
The Initial Date of Disability is mapped to the WC-1 First Report of Injury Form as “Enter First Date Employee Failed to Work a Full Day.” The WC-1 is required to be filed within 21 days of the employer’s knowledge of disability, injury or death. The FROI 00 should not be filed until an insurer decision has been made on the claim so the Initial Date of Disability should be readily available at that point.
6. If a SSN is sent in DN 0042, will the transaction reject?
Yes, please don’t send any data for DN 0270 Employee ID Type Qualifier, DN0042 Employee Social Security Number or DN0154 Employee ID Assigned by Jurisdiction.
7. How does the insurer/claims office report payment of the waiting week?
It is not necessary to report the waiting week on a payment transaction. Please show the payment of the waiting week on the AN and/or FN as a sweep.
8. How is an attachment filed in EDI?
Attachments cannot be filed in EDI. If an attachment is required for an EDI filing, the claims adjuster may file on ICMS (if access has been granted) or in paper via U.S. mail.
9. Are insurers/claims offices required to report medical only claims in EDI with dates of injury prior to 1/1/2019?
Medical only claims with dates of injury prior to 1/1/2019 may be reported in EDI if an injured employee or attorney representing an injured employee files a claim, WC-14, Notice of Claim/Request for Hearing/Request for Mediation or subsequent indemnity is due.