What is EDI?
EDI release 3 is the computer-to-computer exchange of standard workers’ compensation data between companies and the Commonwealth of Pennsylvania. EDI standards were developed by the International Association of Industrial Accident Boards and Commissions (IAIABC), in conjunction with its members from most U.S. jurisdictions, insurers, self-insureds, TPAs and others. The standards continue to be refined and are used by many jurisdictions as an electronic means to obtain information about work injuries and statuses.
Generally used within the workers’ compensation insurance community to exchange accident, payment, insurance and medical information, EDI permits the transfer of large volumes of information more efficiently and accurately than in paper form.
Who submits EDI transactions?
Insurers or self-insureds submit required data to the Bureau of Workers’ Compensation (bureau) using one of three methods: (1) Trading partners are the insurance clam administrators who use EDI to report claim data to the bureau; (2) Transaction partners are organizations selected by the bureau to accept and forward EDI claim transactions from trading partners to the bureau; and (3) Direct filing is the process of submitting EDI transaction files directly to the bureau without using a transaction partner.
The bureau requires the electronic submission of injury reports as part of its EDI 3 Implementation. A First Report of Injury (FROI) transaction is required to establish a claim in the Workers’ Compensation Automation and Integration System, or WCAIS. The EDI data submitted populates the WCAIS claim to establish things such as: claimant’s name, date of injury, employer, addresses for each, etc. If any of this information needs to be changed at any point, such as a claimant’s name, a new EDI transaction must be smutted.
Forms received by the bureau prior to submission of the initial FROI transaction cannot be uploaded by the bureau into WCAIS, as there is no claim established in the system to which the form can be attached or filed. In this instance, the forms are returned to the insurer, TPA or self-insurer who submits them, with instructions to submit a FROI. This could be one reason that your client has a document, but there is no record of it, or a claim, in WCAIS.
After the FROI is submitted that establishes the claim, subsequent EDI transactions that update the claim status (Subsequent Reports of Injury – SROI), such as denials, payments, etc., become part of the “Claim.”
For all data and information submitted to the department via EDI, if a copy is required by law to be provided to another party, a true and correct copy still must be provided to that party consistent with the Act, regulations and/or any applicable department-issued policy statement or written guidance.
Forms to be filed with BWC
The following forms are required to be submitted to the bureau. Submission of the EDI transactions alone do not satisfy the filing requirements under the PA Workers’ Compensation Act:
1. LIBC-336 Agreement for Compensation for Disability or Permanent Injury
2. LIBC-337 Supplemental Agreement for Compensation for Disability or Permanent Injury
3. LIBC-338 Agreement for Compensation for Death
4. LIBC-339 Supplemental Agreement for Compensation for Death
5. LIBC-340 Agreement to Stop Weekly Workers’ Compensation Payments (Final Receipt)
6. LIBC-380 Third Party Settlement Agreement
Forms to be filed AND sent to the injured worker
In addition to the EDI transaction, the forms listed below must be sent to the injured worker and filed with the bureau. Written notice to the injured worker has not changed due to implementation of EDI Release 3, and is still required.
1. LIBC-494C Statement of Wages (For Injuries Occurring On or After June 24, 1996)
2. LIBC-495 Notice of Compensation Payable
3. LIBC-496 Notice of Workers’ Compensation Denial
4. LIBC-501 Notice of Temporary Compensation Payable
5. LIBC-502 Notice Stopping Temporary compensation (WCAIs has a screen that will collect the LIBC-502 information and create the form that the claim administrator must print and send to the injured worker.)
Forms no longer needed
The following forms are available for download from the Department of Labor & Industry website. These forms will not be filed with the bureau because an EDI transaction satisfies the bureau reporting requirement. However, a copy of the information submitted via the EDI transaction must be sent to the employee/claimant as required by the PA Workers’ Compensation Act.
LIBC-392A FINAL STATEMENT OF ACCOUNT OF COMPENSATION PAID
LIBC-498 COMMUTATION OF COMPENSATION
LIBC-761 NOTICE OF WORKERS’ COMPENSATION BENEFIT OFFSET
LIBC-762 NOTICE OF SUSPENSION FOR FAILURE TO RETURN FORM LIBC-760
LIBC-763 NOTICE OF REINSTATEMENT OF WORKERS’ COMPENSATION BENEFITS
Where do I find Bureau Documents that have been uploaded/submitted?
If the document (NCP, TNCP, etc.) was submitted to the Bureau prior to September 9, 2013 (WCAIS go live), or if it is a Miscellaneous document, e.g. any document not currently found in the list on the Action tab such as a scanned check, payment statement, or form no longer required by the Bureau, click on the “Documents and Correspondences” tab from the Claim Summary, and a link to the document should be there.
If the document was uploaded or submitted to the Bureau after September 9, 2013, you can find it by clicking on the “Actions” tab, and then, the link to the document are you looking for. Bureau documents may be viewable in the dispute if the Judge entered them as exhibits in a dispute. You should then be able to view them from the Exhibits tab.
Recorded EDI webinars covering basic first reports of injury, subsequent reports of injury and Web portal training are available, along with other valuable WCAIS educational resources at www.dli.state.pa.us/wcais.
EDI specific questions can be directed to [email protected] Questions regarding WCAIS and petition, the litigation process or matters in litigation can be directed to [email protected] Questions regarding matters on appeal with the WCAB can be directed to [email protected]
*Copyright 2014 Pennsylvania Bar Institute. Reprinted with permission from PBA Workers’ Compensation Law Section 2014, 30th Annual Fall Section Meeting, PBI Publication 8405. All rights reserved. To order the book, contact customer service at 1-800-932-4637 or pbi.org.
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