Is eClaims a mandate?
How will the eClaims mandate be rolled out?
The Board will stagger the implementation beginning in June of 2013 continuing through March of 2014. Initial phases will include national carriers and TPAs followed by groups of New York specific Claim Administrators. The Board has developed an extensive stakeholder communication plan that has supported transparent and continuous two-way communications with all stakeholders impacted by eClaims. The eClaims implementation schedule was developed based on the extensive feedback received by the Claim Administrator community.
Does the eClaims mandate effect medical reporting?
No. The new eClaims filing process will have no impact on Medical Providers or their reporting requirements. Medical Providers will continue to file their reports as they presently do today using the current medical forms. Medical reporting will be evaluated during the Board business process reengineering effort that is currently under way.
Does the eClaims mandate impact the hearing process?
No. The hearing process will remain the same but the format of some supporting documentation may change.
Will the Board continue to assemble and index cases?
Yes. The assembly and indexing process will continue.
Which Board forms currently submitted by Claim Administrators will be replaced by the eClaims filing process?
- C-2: Employer's Report of Work Related Injury/ Illness
- VF-2: Political Subdivision's Report of Injury to Volunteer Firefighter
- VAW-2: Political Subdivision's Report of Injury to Volunteer Ambulance Worker
- C-7: Notice that Right to Compensation is controverted
- C-669: Notice to Chair of Carrier's Action on Claim for Benefits
- C-8/8.6: Notice That Payment of Compensation Has Been Stopped or Modified
Will a C-2 submitted by the employer satisfy the FROI filing requirements?
No. Employers will still be able to file C-2 reports; however, claim administrators will be required to submit a FROI for every reportable claim. A FROI will satisfy the C-2 filing requirement, but a C-2 will not satisfy the FROI filing requirement.
When a carrier submits a FROI to the Board in satisfaction of the employer's obligation to report the injury (WCL §110), does the carrier need to file the C-2F (Employer's First Report of Injury/Illness) with the Board?
No. A timely FROI satisfies the employer's duty to report the injury to the Board.
IMPORTANT: A timely FROI does not replace the requirement of WCL §110(1). The employer and/or carrier should retain the C-2F as required and produce the C-2F to the claimant upon request.
Will the Board still require filing of paper forms such as the C-240, C-11, and Employer’s Reimbursement Request?
Yes. Some paper forms will still be required since the information cannot be filed via a FROI/ SROI transaction.
What should an Uninsured Employer or their counsel file to Controvert a claim since the C-7 form is now obsolete?
No Insurance cases are controverted by nature and should the employer still wish to file a Notice of Controversy they may raise the issues at the first hearing or file a written letter with the Board that will be scanned into the case folder. A paper C-7 should not be filed on these claims.
The local Social Security Administration (SSA) office, Dept. of Labor, or social services agency has asked for a C-8/8.6 form which is now obsolete, how do I inform them that the SROI has replaced the C-8/8.6?
The Board has done outreach with Social Security Administration offices, Dept. of Labor, and local social services organizations throughout the implementation of eClaims. Part of this outreach included a formal letter informing them of the recent changes. If needed, a copy of this letter can be found here Updated SROI Replaced C-8 document.
Who can I contact regarding eClaims?
The Board has established an email address specifically for eClaims. Please send your questions and/or comments to eClaims@wcb.ny.gov.
Who or what is a Trading Partner?
A trading partner is an entity that enters into an agreement with the Workers' Compensation Board (the Board) to exchange data electronically. A trading partner can be an Insurance Company, Third-Party Administrator or Self-Insured Employer.
What is a Trading Partner Profile?
Trading partners will be required to complete a trading partner agreement and profile. The profile requires the trading partner to specify the type of trading partner they are as well as the specification of key organization attributes such as FEIN, address, contact names, etc.
Will there be a charge or fee for completing the Trading Partner Profile documents?
When can I register and complete all the forms to become an eClaims Trading Partner?
The eClaims Trading Partner Registration process is now available.
Will Third-Party Administrators have any reporting requirements?
Yes. TPAs should review section 2 of the eClaims Implementation Guide and register to become an eClaims Trading Partner. Trading Partner Registration must be submitted at least 60 calendar days prior to the Trading Partner testing date, which can be found in the eClaims Test and Implementation Schedule (MS Excel). All registrants should carefully review the overview, requirements, and instructions.
Will a carrier or self-insured be able to submit data for claims using more than one TPA?
Yes. Our Trading Partner Profile will support the submission of data for a single claims administrator and from multiple approved TPAs. Claims administrators will need to communicate these relationship requirements to the Board when completing a Trading Partner Agreement. Trading partners will need to monitor data quality for timely and accurate submission regardless of the number of TPAs they use to administer their claims processes.
eClaims Data Submission
Who should be involved in eClaims on the claim administrator side?
We recommend that you immediately begin to identify the lead business and technical resources within your claims organization that are responsible for regulatory reporting. If you plan to submit flat files, begin project planning immediately with your Information Technology and Project Management units. For all Claim Administrators, begin to evaluate your data quality and the paper based processes that will be impacted by the Board's transition to the eClaims filing process.
Our organization is not familiar with Electronic Data Interchange (EDI); where can we get more information?
The Board is developing training that will explain what EDI is; the training will be available on the Board's website.
How can we ensure that we collect the required information or data for eClaims?
Claim Administrators are strongly encouraged to review the tables in preparation for a full EDI implementation as announced in Subject No. 046-477. These tables should be shared with both business and technical representatives within your organization. We urge claim administrators to pay particular attention to those data elements defined as mandatory or mandatory conditional. We recommend that insurers, along with their Third-Party Administrators, evaluate both their business and technical processes to ensure their ability to collect accurate information for timely transmission to the Board prior to the mandated implementation. NYS Requirement Tables
How can I submit my eClaims filings? Will there be a web data-entry option?
Using a secure file transfer protocol (SFTP), you may submit a flat file. Flat files must adhere to the IAIABC EDI Claims Release 3 format and can be submitted directly to the Board's SFTP server or through a third-party vendor. The Board will also offer a secure data-entry web application intended primarily for small volume filers, but not limited solely to that group.
Will the Board authorize third-party vendors to submit Claims EDI Release 3 filings on behalf of Claim Administrators?
Yes. The Board does not currently authorize vendors to submit claims data electronically. Below is a partial list of known vendors. The Board anticipates that, as part of its eClaims implementation, it will authorize experienced Claims EDI Release 3 vendors to submit claims data to the Board following satisfactory completion of testing with the Board.
The list below includes known vendors offering a Claims EDI Release 3 related product and/or service for submitting claims data electronically. This listing is in alphabetical order and does not represent an endorsement by the Board of any vendor listed, or a recommendation of one vendor over another. The Board does not warrant or represent that this information is current, complete, or accurate. The Board assumes no responsibility for any errors in the information provided, nor assumes any liability for any damages incurred as a consequence, directly or indirectly, of the use and application of this information, and shall be held harmless against all claims, suits, judgments and/or damages resulting from the disclosure of any of this information, including all costs and fees.
NOTE: If you are a vendor with Claims EDI Release 3 experience and would like to have your company added or removed, please contact eClaims@wcb.ny.gov
- Actec Systems, Inc. (www.actec.net)
- Aerie EDI Group (www.aerieedigroup.com)
- Ebix/Peak Performance Solutions, Inc. (www.ebix.com)
- HealthTech, Inc. (www.htedi.com)
- Insurance Services Office (www.iso.com)
- Mitchell Workers’ Compensation Solutions (www.mitchell.com)
- Riskonnect (http://www.Riskonnect.com)
Additional information regarding EDI vendors may be obtained from the IAIABC at: http://www.iaiabc.org
How will a trading partner know if the Board has accepted or rejected an electronic FROI/ SROI filing?
The EDI IAIABC claims standard being adopted by the Board (See Subject Number 046-477) includes an acknowledgment process. Every file and every transaction within a file is acknowledged. Acknowledgments will indicate whether the file or individual transaction has been accepted or rejected. A reason will be provided for rejected transactions.
Will the Board develop reports or a process to assist trading partners in monitoring performance?
The IAIABC Claims Standard provides an acknowledgment process for every transaction submitted in a data file. The acknowledgment process provides enough information for a trading partner to self-monitor the timeliness of its filings and its acceptance and rejection rates. Trading partners will be able to use the Event, Element Requirement, and Edit Matrix tables the Board publishes to interpret the acknowledgment reports. The acknowledgment reports will provide the information needed to determine the success or failure of submissions for both events and data elements. Everyone is encouraged to understand the importance of these tables and the relationship they have to their business process and the collection and reporting of quality information.
Will an XML (Extensible Markup Language) option be available for the submission of EDI Claims Release 3?
XML will be a future consideration; however, in the first phase of implementation it will not be considered.
What is the deadline to submit transactions on a daily basis?
Effective March 10, 2014, the deadline to submit transactions is:
- Monday, Tuesday, Wednesday, and Friday has been extended to be 8 PM EST. Data files uploaded on those nights before 8 PM EST will be processed that night.
- Thursday will continue to be 6 PM EST. Data files uploaded on Thursdays before 6 PM EST will be processed that night.
Acknowledgment files will be available for download the next day before 9 AM EST. The acknowledgment file for any flat file sent on Friday will be available Monday morning (even if Monday is a holiday). Section 3.5 of the eClaims Implementation Guide adobe pdf has been updated to reflect this information.
Is the Board eliminating the use of W numbers?
No. The Board will convert DN0006 (Insurer FEIN) in to the W Number. For most Insurers, the nine digit FEIN will be sent since they only registered one Board assigned W Number for that FEIN. When multiple Board assigned W Numbers are registered for the same FEIN, the Board will inform the submitter to send the Board assigned W Number as the Insurer FEIN value. The Board will return the nine digit FEIN in the acknowledgment record.
What data should be submitted if the field is "AA" (If Applicable/Available Transaction Accepted) or “AR” (If Applicable/Available Transaction Rejected)?
If a Claim Administrator has the information necessary to submit data in the field, the field should be populated with the data. If, however, the Claim Administrator does not have the information to populate this field, it should be left blank and not populated with data that is not accurate. Data Elements listed as “AR” have edits applied and will be rejected if edit is not met. Data Elements listed as “AA” do not have applied edits and will be accepted as entered. For example, Employee Phone Number (DN0051) is listed on the Element Requirement Table as “AR”. This field should only be populated if you can report the claimant's actual phone number, but could be rejected if it does not meet the 0051-111 edit listed on the Population Restriction table which requires the phone number to be between 10 and 15 digits long or the edit listed on the DN Error Message Table with Error Code 028 requiring all digits to be 0-9.
Would you be able to direct me to where I can find the Board FEIN and Postal Code? We need to add it to our program.
The header record of the data file needs to have its Receiver ID (DN0099) be 146013200 122410019 which is Board's FEIN and Postal Code separated by 7 spaces. Additional information can be found in Section 3.3 of the eClaims Implementation Guide.
Our organization is not familiar with the IAIABC. Where can we get more information?
Visit the IAIABC website
Where can we obtain a copy of the IAIABC, Claims Release 3.0 Implementation guide?
Guides must be obtained from the IAIABC. There is a charge for non-EDI members.
Will training be provided?
Yes. The Board provided a series of training programs for Claim Administrators who will be implementing eClaims. The series consists of:
- Course 101: Introduction to NYS eClaims using IAIABC Claims EDI Release 3.0 is designed for all Claim Administrator staff and is an introduction to using EDI for providing the Board with information.
- Course 201 Rev. 9/14/2018 is for business personnel and technical staff
- Course 301 Rev. 6-20-2014 is for technical staff
- Compilation of the training materials for Claim Administrator Claim Adjusters (MS PPT)
Appropriate MTC Filing
Death Benefits: New York legal statute currently requires separate cases for death and accident. How will the eClaims EDI process work with this requirement?
For EDI, each case will require a FROI to precede any SROI filing(s). The FROI for the death case must have some unique values from the FROI on the accident case so that it is not rejected as a duplicate.
The DN's listed below illustrate how NY will distinguish the injury FROI from the death FROI when the date of death does NOT occur on the same date as the injury: DN Data Element Name Injury Claim value Death Claim value 0031 Date of Injury Date injury occurred Date death occurred 0057 Employee Date of Death Date death occurred Date death occurred 0146 Death Result of Injury Code N for No Y for Yes or U for Unknown The DN's listed below illustrate how NY will distinguish the injury FROI from the death FROI when the date of death does occur on the same date as the injury: DN Data Element Name Injury and Death Claim are the same case value 0031 Date of Injury Date injury/death occurred 0057 Employee Date of Death Date injury/death occurred 0146 Death Result of Injury Code Y for Yes or U for Unknown
Note: DN0146 Death Result of Injury Code is required if DN0057 Date of Death is not null. DN0057 Date of Death is required if DN0146 Death Result of Injury Code = Y. This requirement will increase to DN0057 Date of Death is required if DN0146 Death Result of Injury Code is not null effective 2/15/2017 based on eClaims change log ID #256 posted on 8/15/2016
For Claim Administrators that generate flat files, we recognize that reprogramming your computer systems to generate the correct FROI-SROI transactions for the death case may be costly and difficult. Therefore, due to the extremely low volume of death cases, Claim Administrators should consider a manual process using the eClaims FROI-SROI Web App to submit FROI and SROI filings for a death cases (when the death is the result of an accident/illness not occurring on the same day). Paper filings will not be allowed.
Please refer to NYS Business Scenarios (MS Excel) 4-5 and 4-6 for details.
If both a SROI-CA and a SROI-CB apply, should only a SROI-CB be sent or both?
If both the rate and benefit type code are changing, the SROI-CB is the appropriate MTC to file. Please refer to NYS Business Scenarios (MS Excel) 2-5 for details.
Payments are being suspended to the injured worker because he has failed to respond to the requests for job searches – failed to show labor market attachment. We are not under direction on this particular case so it is not a suspension directed by the Board. What SROI would be filed?
The appropriate MTC would be a SROI-SJ. The reason for suspension should be entered in the suspension narrative field.
When should a FROI/SROI-04 versus a FROI/SROI-UR be filed on a Legacy Claim?
If the Claim Administrator has not previously filed a paper C-7 nor any other FROI then the Board would expect a FROI-04 when controverting the claim. If you have already filed a FROI, then a SROI-04 would be expected to controvert the claim. If the Claim Administrator had previously filed a paper C-7 with the Board then a FROI-UR filing is the most appropriate filing.
Can I submit a SROI-02 if I recently sent a SROI that was missing historical (prior) benefits but included the more recent benefits?
The Board recently implemented on 11/13/2014 a relaxation of the SROI-02 requirements to allow the introduction of certain “new” historical benefits on the SROI-02. This is permitted if the newly introduced Benefit Type Codes Benefit Period Through Date does not equal or exceed that of the last accepted SROIs Benefit Period Through Date.
Example 1: I submitted a SROI-UR and included the most recent Benefit Type Code (BTC) of 040 (Permanent Partial Disability - PPD/Unscheduled) for benefits paid 1/1/2010 through 12/12/2014. I accidentally left off the historical BTC 050 (Temporary Total - TTD) paid 1/1/2007 through 12/31/2007 and BTC 070 (Temporary Partial - TPD) paid 1/1/2008 through 12/31/2009. Will my SROI-02 including the TTD and TPD be accepted? Yes. The through date on the TTD and TPD benefits does not exceed the through date of the last accepted Benefit Period Through Date of 12/12/2014 for the PPD benefits.
Example 2: I submitted a SROI-UR and included the TTD and TPD benefits from Example 1 but forgot to include my PPD benefits. Will my SROI-02 including the PPD benefits be accepted? No. The through date on the PPD benefits exceeds that on the last accepted Benefit Period Through Date of 12/31/2009 for the TPD benefits.
The employer (Insured) is paying the claimant wages, however, we (Claim Administrator) are accepting the claim without liability per Section 21-a. Should we file a SROI-EP with Agreement to Compensate Code (DN0075) equal to “W” Without Liability?
Yes. Effective 3/28/2016 New York has implemented the IAIABC Claims EDI standard change to allow Claim Administrators to report the Agreement to Compensate Code (DN0075) on the SROI-EP and SROI-ER.
What MTC should I send if we are paying the claimant under 21-a and we want to suspend payments?
If paying pursuant to 21-a, the Claim Administrator should send a SROI-SJ. For further information regarding 21-a see "Process for Section 21-a and Claims Paid Without Liability" and Subject No. 046-1136.
What should I file if I have filed a suspension and a decision reclassifies a Benefit Type (Modified Prior Awards) as a SROI-CB is not allowed per the sequencing rules when there is a break in continuity of benefits?
The IAIABC Standard does not allow for the filing of the SROI-CB (Change in Benefit Type) after a SROI-Sx (Suspension) has been filed if there is a break in continuity of benefits. If you have filed a suspension and the SROI-CB is not a filing option per the sequencing rules, you can file a SROI-PY (Payment Report). The SROI-PY will allow the reclassification of your Benefit Type and should have Reduced Benefit Amount Code (DN0202) populated with “R” (Reclassification of Benefit). In the alternative, you may also file a SROI-RB (Reinstatement of Benefits) immediately followed by a SROI-SD (Suspension, Directed by Jurisdiction).
How do I accept a case after a FROI-04/SROI-04 has been filed?
Both a FROI-04 and a SROI-04 can be used to deny a claim, for example:
(A) A FROI-04 can be used to deny a claim as your first filing.
(B) To accept a claim after your accepted FROI-04, for cases with a date of accident prior to 1/1/2019, you need to submit a FROI-00 with Claim Type Code other than N (Notification Only). If you try to file a FROI-00 with N after your FROI-04, it will be rejected.
For cases with a date of accident on or after 1/1/2019, you need to submit a FROI-00 with Agreement to Compensate Code of L (With Liability). If you try to file a FROI-00 with W (Without Liability) after your FROI-04, it will be rejected.
(C) A SROI-04 can only be used to deny a claim after a FROI-00/AQ/AU/UR has been accepted.
(D) To accept a claim after your SROI-04, you need to submit a SROI that indicates what event has occurred that shows acceptance or a SROI-02. If sending a SROI-02, for cases with a date of accident prior to 1/1/2019, you will need to send Denial Rescission Date (DN0196). For cases with a date of accident on or after 1/1/2019, the Agreement to Compensate Code shows acceptance of a claim.
How do I report an overpayment?
There is no IAIABC field (free text or otherwise) to note an overpayment you are not actively taking credit for.
- If filing a suspension, you can use the extra characters in the suspension narrative to note your overpayment on the record.
- If not filing a suspension, you can file correspondence on your letterhead via mail, fax or email noting your overpayment for the record. It is recommended you include the why and how much in the letter. If you copied other parties previously, you should continue to do so.
Note: IAIABC Claims EDI Committee IRR812 was approved for a new data element in IAIABC Claims EDI R3.1. DN0433 Overpayment Amount – Current will be available when the Board adopts the new standard with the implementation of the Board’s Business Information System. A date has not yet been set for the implementation of the new system.
If we are using a vendor, will we be able to access the .zip file containing the Transaction Reports from New York State's sFTP server or will we have to have our vendor download that file and receive it from them?
The forms zip file will be placed on our sFTP server for your vendor to pickup. You would obtain the .zip file through your vendor.
Will the transaction report PDFs in the .zip file be populated with the transaction claim information?
Yes. The Board will populate the transaction reports using the transaction data sent by the claim administrator.
Where can I get all of the technical details for how the Board creates the forms .zip file and the transaction report PDFs contained within it?
Please review section 3.6 of the eClaims Implementation Guide.
Can a FROI or SROI PDF document be served via email on the parties?
If either of the parties of interest (POI) have designated email for service, the carrier can serve the PDF via email for that POI. But, for example, if the claimant's attorney allows service by email, and the claimant does not, the PDF must be served by mail on the claimant.
Please see the Periodic Report Event Table for further details.
When is the periodic report due?
The SROI-SA is due 180 days from the date of accident (or when no date of accident or partial date of accident, then due from filing date of first FROI) so this chart shows when SROI-SA are expected. NOTE: For existing cases, the first periodic is due by the end of the 180 days based on the month reported in date of injury.
If the Date of Accident (or First FROI) is in: Then Periodic report is due in the months of: January January and July February February and August March March and September April April and October May May and November June June and December July July and January August August and February September September and March October October and April November November and May December December and June
Note: The above chart shows the month based upon the acceptable practice of considering 180 days to be close enough to 6 months and thus always send 2 SROI-SAs per year. It is also acceptable practice for SROI-SAs to be exactly 180 days apart, which means the month will change over the years and there could be a few years when 3 SROI-SAs are sent in that year (for example, if Date of Accident is 7/4/2014, then the first 3 SROI-SAs would be due on 1/2/2015, 7/1/2015, and 12/28/2015).
For which types of cases is a periodic report required?
The sub-annual report is due if the case is open or closed with continuing indemnity payments. It is not due if the claim has been controverted.
What is the definition of "open"?
If no notice has been issued stating no further action or the claim has been reopened after such a notice has been issued, then the case is considered open. If a notice has been issued stating that no further action is planned at the time, but indemnity benefits are continuing, then the case is considered open.
Are sub-annual reports due for "medical only" claims?
If the case is open at the time that the sub-annual is due, then a report is due. If the case is not open and only medical payments are being made, then the sub-annual report can be filed on a voluntary basis.
After the first SROI-SA filing, are subsequent SROI-SA's a cumulative total to date or only what was paid since the last SROI-SA was filed?
Each SROI-SA is a "cumulative" total of each Benefit Type (BTC) and Other Benefit Type (OBT) paid to date on the claim.
Data Element Reporting
Please see DN Reporting Specifics to NYS Document (MS Excel) for additional details
What date should be entered for the Suspension Effective Date (DN0193)?
The suspension effective date should be the last THROUGH date which the indemnity benefit is due.
What date should be entered for the Award Order Date (DN0299)?
This should be the date that the Notice of Decision was duly filed if decision is from a hearing, Reserved Decision, or Board Panel Decision. This should not be the date of hearing. If decision is from an Administrative Decision or Proposed Decision, the date should be the date the decision became final.
Note: An exception would be in the situation of an ATF deposit. Since Notices of Decision are issued in advance of the due date of the deposit, the date deposit is due should be listed as the Award/Order Date. (i.e., Notice of Decision filed on 10/30/13 directing an ATF deposit due on 12/9/13. In this situation the Award/Order Date should be listed as 12/9/13)
How do I indicate that indemnity payments are being made without acceptance of liability pursuant to §21a?
If indemnity benefits are being made without acceptance of liability, Agreement to Compensate Code (DN0075) should be listed as "W" – Without liability on the first SROI filed with a benefit segment. Please note that Section 21-a no longer applies once Accident, Notice, and Causal Relation (or Occupational Disease, Notice, and Causal Relation) has been established or 365 days have passed since the first Benefit Payment Issue Date reported on the SROI.
Note: §21a does not apply to medical-only cases, it only applies once there is lost time and a SROI is sent showing payment of the lost time has begun.
How is an acceptance of a claim listed on a FROI/SROI?
a) For cases with a date of accident prior to 1/1/2019, Claim Type Code (DN0074) identifies the acceptance of a claim. If this Code is listed as anything other than N=Notification Only, the Claim Administrator has accepted the claim.
b) For cases with a date of accident on or after 1/1/2019, the Agreement to Compensate Code (DN0075) shows acceptance of a claim.
Note: If a Notice of Indexing is issued by the Board, the Claim Administrator must indicate if the claim is accepted by entering the appropriate Claim Type Code/Agreement to Compensate Code or file a FROI-04 or SROI-04 indicating that the claim has been denied. Please see the Event Table (MS Excel) for due dates of the acceptance and denial.
What is the difference between the "through" date (used by IAIABC in Claims EDI) and the "to" date (used by the Board in Decisions)?
The "to" date is the next business day beyond the date in which that last benefit day was payable. The "through" date is through the close of business in which that last benefit day was payable. For example, a Notice of Decision directs payments "to" November 15th when the claimant returned to work, however, the "through" date would be November 14th as you are paying through close of business.
What is the difference between Initial Date Disability Began and First Day of Disability After the Waiting Period?
Initial Date Disability Began is the first day of the waiting period. First Day of Disability After the Waiting Period is the first day after the waiting period requirement has been met. Please note that both of these fields can only be updated on a FROI-02 or SROI-02 if previously reported as an incorrect date.
Note: If there is no waiting period (i.e. VF or VA case) or the waiting period is payable when these dates are first reported, then the First Day of Disability After the Waiting Period is the same date as the Initial Date Disability Began
When would a reimbursement from the Claim Administrator to the Employer be expected when the Employer Paid Wages in Lieu of Compensation?
The Board will issue a decision directing reimbursement to an employer based upon a reimbursement request being submitted by said employer.
How is the reimbursement paid to the Employer from the Claim Administrator to be reported to the Board?
This should be reported on the appropriate SROI. An example of payment of reimbursement after a decision has been issued can be found in NYS Business Scenario 3-3 (MS Excel) and NYS Business Scenario 3-4 (MS Excel). These scenarios are written per the IAIABC Standard of what is to be reported when paying the reimbursement. The Board would also accept the BTC 250 and 270 in lieu of 050 and 070 for the period in which the employer paid.
If a Claim Administrator’s system requires Lump Sum Payment/Settlement Code (DN0293) to be populated with a code on the SROI-PY what should be used if we are not reporting a Section 32 settlement?
For cases other than a Section 32 settlement the Claim Administrator may use “AW” Award or “NS” Non-Specified Lump Sum Payment. This is an optional reporting for all PY’s that do not report a Benefit Type Code of 5xx.
How does a Claim Administrator note they are taking credit against a prior schedule loss of use (SLU)?
If a Claim Administrator is taking credit against a prior SLU they could note the lost time under the appropriate degree of disability and then report Benefit Credit Code (DN0126) as “P” Advance. See NYS Business Scenario 9-6 (MS Excel).
Note: Certain SROI MTC’s will require a Payment Segment in addition to the Benefit Segment. The Payment Segment should be populated with the relevant dates but Amount Paid may be reflected as “0”.
How should Special Funds §14-6 and §15-8 recoveries be reported on a SROI?
Recovery Code (DN0226) of 800 (Special Fund Recovery) should be used to report a §14-6 recovery and 850 (Second Injury Fund) should be used to report a §15-8 recovery.
Note: The reporting of Recoveries for §14-6 and §15-8 are optional.
How should a Claim Administrator who has Section 32 Medical Payments (ie. Medicare Set Aside) payable to the claimant report on the SROI-PY?
The full payment of the Section 32 settlement to the claimant may be reported as Benefit Type Code (BTC) of 500 – Unspecified Lump Sum. If, however, due to internal reporting a Claim Administrator must report these as separate payments they may report the Medicare Set Aside portion as 501 – Medical Lump Sum.
NOTE: You can also still use Other Benefit Type (OBT) 370 – Total Other Medical, however, BTC 501 – Medical Lump Sum would be more appropriate. If the OBT 370 or BTC 501 is used, the Board would expect a Payment Segment for both the indemnity and medical payments to the claimant as they are both monies due directly to the claimant. The underreporting of the Section 32 payment to the claimant could result in a possible penalty that should not have been assessed.
Which SROI should be reported if the Claim Administrator mistakenly submitted the wrong Benefit Type Code?
This would depend on the event and claim circumstances. For example, if a SROI-IP was submitted with TTD benefits and you later discovered they should have been TPD benefits per the medical report, the SROI-CB would be the most appropriate. Reduced Benefit Amount Code (DN0202) should be equal to “R” Reclassification of Benefit. This will allow you to report the new TPD benefits while dropping the TTD benefits from the SROI-CB transaction. See NYS Business Scenario 10-4 (MS Excel).
When is the Work Week Type Code and Work Days Scheduled Code required?
Work Week Type Code is required on FROI-00 and FROI-UR if all of the following occurs:
- Number of Days Worked Per Week (DN0064) is a value other than 5
- Date of Injury (DN0031) is on or after 3/1/14
- Type of Loss Code (DN0290) is either 01 (Traumatic Injury) or is not present
- Claim Type Code (DN0074) is either I or L (Indemnity or Became Lost Time)
Work Days Scheduled Code is required on the FROI-00 and FROI-UR if the Work Week Type Code is F (Fixed) and the Date of Injury is on or after 3/1/14
What are the Values for Work Week Type Code and Work Days Scheduled Code? See NYS Business Scenario 10-1 and 10-2 (MS Excel).
WORK WEEK TYPE CODE Values are:
- S = Standard Work Week (set work days each week are Monday through Friday inclusive)
- F = Fixed Work Week (Set work days each week, but not Monday through Friday inclusive)
- V = Varied Work Week (scheduled work days change from week to week)
WORK DAYS SCHEDULED CODE Values are: S = Scheduled and N = Not Scheduled
FORMAT = DDDDDDD where each D is a calendar day of the week (First position is Sunday, Second position is Monday, Third position is Tuesday, etc)
How do I file a SROI when I am paying intermittent lost time?
If there is intermittent lost time or a non-consecutive period on a claim, you should file the appropriate SROI. The Claims Weeks and Days would be inclusive of the days paid and/or awarded for intermittent lost time. You should send the Non-Consecutive Period Code (DN0212) if the employee returns to work at least once during the waiting period (W = Waiting Period), or the benefit period (B = Benefit Period) being reported does not represent a continuous period of time.
Note: A C-11 should continue to be filed to note the various intermittent lost time periods.
Carrier files FROI-00 with N (Notification Only) and then ANCR/ODNCR is established. Does carrier need to file FROI/SROI for acceptance?
Yes, per regulation 300.22 the carrier should file the proper FROI/SROI to correct the Claim Type Code (DN0074) (to anything other than N=Notification only) for “acceptance” if the date of accident is prior to 1/1/2019. For dates of accident on or after 1/1/2019, the carrier should file the proper FROI/SROI to correct the Agreement to Compensate Code (DN0075) to show acceptance.
How do I file a SROI when I am reporting payment of child support?
You should file the appropriate SROI and use the Adjustments, Credits and Redistributions (ACR) with the Benefit Redistribution Code (DN0130) “H” = Court Ordered Lien.
Note: Must be reported with every SROI when injured worker is not receiving full weekly compensation amount due.
How do I reference a document on a SROI-CB or SROI-CA in compliance with 12 NYCRR 300.23(a) since these transactions do not allow a narrative field in IAIABC Claims EDI R3.0?
The Board has determined that a letter/correspondence must be filed within 3 days of the SROI-CB or SROI-CA indicating therein the document ID number(s) and the date(s) of the supporting documentation (such as an IME-4) along with a summary of the specific findings within that/those document(s) that purportedly supports the reduction in the payment rate. If CA/CB is rejected, then the letter/correspondence should be submitted within 5 days. The letter/correspondence referenced can be either mailed or e-mailed to firstname.lastname@example.org.
Note: The Board notes that the compliance process as set forth in the preceding paragraph should be viewed as a short-term solution pending the anticipated implementation of the Board’s new Business Information System and adoption of IAIABC Claims R3.1.
Web Data Entry
I have noticed while using eCase and Web Data Entry at the same time that my Web Data Entry freezes at times. What causes this and how can I avoid it?
Since both applications utilize the same user name and password, if you log out of eCase and/or are timed out of eCase you will also be logged out of any other Board applications that you are currently logged into within the same browser.
If you open a separate browser for each application (for example, Explorer for eCase and Chrome for Web Data Entry) you will be able to avoid your Web Data Entry application from logging out/freezing if you log out of the eCase application.
Claims EDI R3.1
What is the OnBoard Project?
The OnBoard Project is the final piece of the Business Process Reengineering Program. The new system will offer exciting elements, including improved and expanded access to real-time claim data, new electronic self-service features for interacting with the Board, and a reduction in the amount of overall paper forms to improve system responsiveness to stakeholder needs. The eClaims EDI R3.1 upgrade provides the foundational data pillars for the OnBoard Project. More information is available on the OnBoard Project website.
How and when will the Claims EDI R3.1 upgrade be rolled out?
The Claims EDI R3.1 upgrade will be implemented into Board systems in a two-phased approach:
- The implementation date for phase one is January 24, 2022. Claims EDI R3.1 will be incorporated into the Board’s current systems, and all trading partners will begin using the R3.1 standard.
- Phase two consists of incorporating Claims EDI R3.1 into the OnBoard implementation. This will take place concurrently with the launch of OnBoard in 2023. At this stage, trading partners will have been using Claims EDI R3.1 for some time on the Board’s current systems, but will now change over to use OnBoard. Phase two will include smaller refinements and adjustments of the Claims EDI R3.1 implementation, which will be based on feedback we receive during phase one.
Will the phase one implementation include all trading partners, or will there be a staggered rollout throughout 2021?
All trading partners must transition to Claims EDI R3.1 at the same time on January 24, 2022. There will not be a staggered rollout.
Where can I obtain a copy of the IAIABC Claims EDI R3.1 Implementation Guide?
The Implementation Guide is available on the IAIABC website.
Will I be required to participate in testing before the Claims EDI R3.1 update is implemented?
Due to the additional time required to accurately implement Claims EDI R3.1, testing dates are still pending. All Senders who submit flat-files will be required to complete validation testing. The eClaims team will be reaching out directly to Senders regarding testing. If you are working with an EDI vendor, the eClaims team will be working through your vendor.
Will testing be required for Senders that exclusively submit transactions via eClaims Web Data Entry?
Although not mandatory, testing is highly recommended for our web filers. The Board will provide the upgraded eClaims Web Data Entry application in a TEST web environment. The Board will develop and share test scenarios for all web filers to familiarize Senders with the upgraded web data entry form. We encourage all web filers to take advantage of the TEST web environment to ensure a smooth transition to the upgraded web data entry form.
How do I determine when I have to submit a Change-02 or the change on the subsequent Maintenance Type Code (MTC)? For example, if I submit a SROI-IP with payments continuing, and the claimant subsequently returns to work, would I file an SX with Suspension reason S1 or would I need to submit a Change-02 and an SX?
New York State has worked through the tables to ensure that when a reportable event occurs, the event comes through rather than a Change-02. In this specific example, New York State expects that an SX with Suspension Reason Code S1 would be reported. Change-02s are primarily concerned with changing something that was reported on a previously accepted MTC. Change-02s should not be used for the reporting of new events.
If we are reporting an overpayment on a SROI-02, do we also have to file a Request for Further Action by Carrier/Employer (Form RFA-2) requesting reimbursement?
Yes, a new subdivision (g) of section 300.23 of Title 12 NYCRR is hereby added to read as follows:
In the event that the carrier, self-insured employer or third-party-administrator seeks to recover an alleged overpayment of benefits to the claimant, such carrier, self-insured employer or third-party administrator must file notice to the Board in the format prescribed by the Chair that identifies the amount of such overpayment. Such prescribed notice shall be due as follows:
- When a request for further action is submitted to the Board by the carrier, self-insured employer or third-party administrator, such prescribed notice requesting recovery of an overpayment shall be submitted on the same day as the request for further action.
- When a hearing is scheduled and the carrier, self-insured employer or third-party administrator has requested recovery of an overpayment at the scheduled hearing, the carrier, self-insured employer or third-party administrator must file the prescribed notice identifying the amount of the overpayment no less than ten days before the date of the hearing. The Workers’ Compensation Law Judge will not consider any requests for direct recovery of an overpayment that are not timely made.
- When the Board directs recovery of an overpayment, the carrier, self- insured employer or third-party administrator must file the prescribed notice identifying the amount of the overpayment within ten days of such decision.
If we previously submitted a SROI-02 reporting an overpayment and are required to file Form RFA-2 if we want reimbursement, do we have to file another SROI-02 at the same time that Form RFA-2 is filed?
No, not if the SROI-02 lists the current overpayment amount. If the SROI-02 does not list the current Overpayment Amount, you must file a new SROI-02.
Can we submit Form RFA-2 requesting that the overpayment be addressed without filing a SROI-02 reporting the overpayment?
No, you need to submit Form RFA-2 to ask for the hearing and list the overpayment amount on the SROI-02.
Can more than one update on a Change-02 still be submitted?
Yes, you may continue to submit more than one change on a Change-02 transaction, except for Match Data Elements. As with Claims EDI R3.0, if multiple Match Data Elements are being changed at the same time, in Claims EDI R3.1 you will continue to file one Change-02 transaction per Match Data Element.
How should Claims EDI R3.0 claims be handled after the R3.1 upgrade is implemented? For example, on a claim where a SROI-IP has been accepted prior to the upgrade, and certain Denial Reasons were moved to new Data Element (DN) numbers in Claims EDI R3.1, will the Board automatically re-map these values or will I need to send Change-02s “adding” new values?
The next reportable MTC is due. The severity rankings for all DNs listed on that MTC apply.
How do I accept a case after a FROI-04/SROI-04 has been submitted?
Both a FROI-04 and a SROI-04 can be used to deny a claim. For example:
- A FROI-04 can be used to deny a claim as your first filing. The process to accept a claim after your FROI-04 is accepted depends on the date of injury or illness:
- Prior to January 1, 2019 – you need to submit a FROI-00 with Claim Type Code other than N (Notification Only). If you try to file a FROI-00 with N after your FROI-04, it will be rejected.
- On or after January 1, 2019 – you need to submit a FROI-00 with Agreement to Compensate Code of L (With Liability). If you try to file a FROI-00 with W (Without Liability) after your FROI-04, it will be rejected.
- A SROI-04 can be used to deny a claim but can only be sent after a FROI-00/AQ/AU/UR/04 or another SROI has been accepted. To accept a claim after your SROI-04 has been accepted, you must submit a SROI that indicates the event (IP/AP/EP/CD/ER/RB/PY with benefit segment) that shows acceptance or a SROI-02.
- Prior to January 1, 2019 – you need to send Denial Rescission Date (DN0196).
- On or after January 1, 2019 – the Agreement to Compensate Code shows acceptance of a claim. Agreement to Compensate Code = L (With Liability) indicates acceptance of a claim or Agreement to Compensate Code = W (Without Liability) during the first 365 days of first Benefit Payment Issue Date and/or the Board has made an ANCR finding indicating acceptance pursuant to Section 21a. For details regarding acceptance pursuant to Section 21a, please visit www.wcb.ny.gov/content/ebiz/eclaims/sec21a-claims-paid-without-liability.jsp.
- A FROI-04 can be used to deny a claim as your first filing. The process to accept a claim after your FROI-04 is accepted depends on the date of injury or illness:
How do I update Denial Reason Codes (DN0198) and/or Denial Reason Narratives (DN0197) after a FROI-04/SROI-04 has been submitted?
Since New York does not accept FROI/SROI-02 to update these data elements, a SROI-04 must be filed to update Denial Reason Codes and/or Denial Reason Narratives.
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