ࡱ> $     n p r Pa_L'` 'lbjbjDD ,}&&iLpw))) ) 000t2<<<`Xl*t2*~в,[5 }}}}}}}$ԁh<}0>@[>>}))K}h`h`h`>P)0}h`>}h`h`B.0IJ 0DU<jChQf}0*~K20<i 2H h`* 4c i i i }}`di i i *~>>>>t2t2t2dCud t2t2t2ut2t2t2))))))  Workers Compensation Information System (WCIS) California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Version 3.0 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE)  California Department of Industrial Relations John Duncan, Director Division of Workers Compensation Carrie Nevans, Acting Administrative Director January, 2010 Dear Claims Administrators: Welcome to Electronic Data Interchange (EDI). The California Division of Workers Compensation (DWC) is pleased to introduce its revised system for receiving workers compensation claims data via EDI. This data will be integrated with related industry data to make up our Workers Compensation Information System, which is becoming a rich resource for analyzing the performance of Californias workers compensation system. This revised manual, the California EDI Implementation Guide For First and Subsequent Reports of Injury, is intended to be a primary resource for the organizations that comprise the Divisions trading partners claims administrators for California workers compensation claims. Most reporting organizations already have substantial experience with EDI, and transmit data to workers compensation agencies in many states. For them, this Implementation Guide can serve as a reference for California-specific protocols. While we have adhered to national EDI standards, Californias implementation does have minor differences from other states protocols. The Implementation Guide also includes background information for organizations new to EDI. If your organization is just getting started, the Overview of EDI and the Managers Guide are for you. You will also find numerous valuable resource materials. This Implementation Guide will remain under development for some time. As both the Division and our EDI trading partners gain experience with Californias EDI system, updates to the Guide will be posted on our Web site at http://HYPERLINK "http://www.dir.ca.gov/dwc/wcis.htm"www.dir.ca.gov/dwc/wcis.htm. I hope that, if you are new to reporting via EDI, your start-up of reporting in California will be as smooth and as painless as possible, both for the Division and for our EDI trading partners. DWC is dedicated to full, open communication as a cornerstone of a successful start-up process, and this Implementation Guide is a key element of that communication. Sincerely, CARRIE NEVANS Acting Administrative Director Table of Contents  TOC \h \z \t "Heading 1,1,Head 2 Char,2,Head 2.2,2,Head 2.3,2,Head 2.4,2,Head 2.6,2,Head 2.7,2,Heading 1.2,1,Heading 2.2,2,Head 2.92,2,Head 3.1,3,Head 3.2,3,Head2.94,2"  HYPERLINK \l "_Toc272335481" Welcome to Electronic Data Interchange (EDI).  PAGEREF _Toc272335481 \h i  HYPERLINK \l "_Toc272335482" Section A: EDI in California An Overview  PAGEREF _Toc272335482 \h 1  HYPERLINK \l "_Toc272335483" EDI Electronic Data Interchange  PAGEREF _Toc272335483 \h 1  HYPERLINK \l "_Toc272335484" Benefits of EDI within Workers Compensation  PAGEREF _Toc272335484 \h 1  HYPERLINK \l "_Toc272335485" Californias WCIS the Workers Compensation Information System  PAGEREF _Toc272335485 \h 2  HYPERLINK \l "_Toc272335486" History  PAGEREF _Toc272335486 \h 2  HYPERLINK \l "_Toc272335487" WCIS Data Collection  PAGEREF _Toc272335487 \h 2  HYPERLINK \l "_Toc272335488" California EDI Requirements  PAGEREF _Toc272335488 \h 3  HYPERLINK \l "_Toc272335489" Sending Data to the WCIS  PAGEREF _Toc272335489 \h 3  HYPERLINK \l "_Toc272335490" The Five Step Process of EDI--From Testing to Production  PAGEREF _Toc272335490 \h 5  HYPERLINK \l "_Toc272335491" Step 1: EDI Trading Partner Profile  PAGEREF _Toc272335491 \h 5  HYPERLINK \l "_Toc272335492" Step 2: Testing  PAGEREF _Toc272335492 \h 5  HYPERLINK \l "_Toc272335493" Step 3: Pilot  PAGEREF _Toc272335493 \h 5  HYPERLINK \l "_Toc272335494" Step 4: Parallel (optional)  PAGEREF _Toc272335494 \h 5  HYPERLINK \l "_Toc272335495" Step 5: Production  PAGEREF _Toc272335495 \h 5  HYPERLINK \l "_Toc272335496" Section B: Where to Get Help Contacting WCIS and Other Information Resources  PAGEREF _Toc272335496 \h 6  HYPERLINK \l "_Toc272335497" California Division of Workers Compensation  PAGEREF _Toc272335497 \h 6  HYPERLINK \l "_Toc272335498" Our Web Site  PAGEREF _Toc272335498 \h 6  HYPERLINK \l "_Toc272335499" Your WCIS Contact Person  PAGEREF _Toc272335499 \h 6  HYPERLINK \l "_Toc272335500" WCIS eNews  PAGEREF _Toc272335500 \h 7  HYPERLINK \l "_Toc272335501" EDI Service Providers  PAGEREF _Toc272335501 \h 7  HYPERLINK \l "_Toc272335502" IAIABC  PAGEREF _Toc272335502 \h 8  HYPERLINK \l "_Toc272335503" Section C: Implementing EDI A Managers Guide  PAGEREF _Toc272335503 \h 9  HYPERLINK \l "_Toc272335504" 1. Get to know the basic requirements.  PAGEREF _Toc272335504 \h 9  HYPERLINK \l "_Toc272335505" 2. Assign responsibilities for implementing EDI.  PAGEREF _Toc272335505 \h 9  HYPERLINK \l "_Toc272335506" 3. Decide whether to contract with an EDI service provider.  PAGEREF _Toc272335506 \h 9  HYPERLINK \l "_Toc272335507" 4. If your organization will not use an EDI service provider, choose a file format and transmission mode for your data.  PAGEREF _Toc272335507 \h 10  HYPERLINK \l "_Toc272335508" 5. Make sure your computer systems contain all the required data.  PAGEREF _Toc272335508 \h 10  HYPERLINK \l "_Toc272335509" 6. Determine who will handle error messages sent by WCIS.  PAGEREF _Toc272335509 \h 10  HYPERLINK \l "_Toc272335510" 7. Decide whether your organization could benefit by adding data edits.  PAGEREF _Toc272335510 \h 11  HYPERLINK \l "_Toc272335511" 8. Install any software and communications services you will need.  PAGEREF _Toc272335511 \h 11  HYPERLINK \l "_Toc272335512" 9. Test your system internally.  PAGEREF _Toc272335512 \h 12  HYPERLINK \l "_Toc272335513" 10. Move through the Test, Pilot and Parallel stages to reach the Production stage of EDI transmission.  PAGEREF _Toc272335513 \h 12  HYPERLINK \l "_Toc272335514" 11. Evaluate the efficiency of your EDI system and consider future refinements.  PAGEREF _Toc272335514 \h 12  HYPERLINK \l "_Toc272335515" Section D: Authorizing Statutes Labor Code sections 138.6 and 138.7  PAGEREF _Toc272335515 \h 13  HYPERLINK \l "_Toc272335516" Labor Code section 138.6 Development of workers compensation information system  PAGEREF _Toc272335516 \h 13  HYPERLINK \l "_Toc272335517" Labor Code section 138.7 Individually identifiable information; restricted access.  PAGEREF _Toc272335517 \h 13  HYPERLINK \l "_Toc272335518" Section E: Legal Authorities  PAGEREF _Toc272335518 \h 16  HYPERLINK \l "_Toc272335519" Pertinent WCIS Regulations  PAGEREF _Toc272335519 \h 16  HYPERLINK \l "_Toc272335520" Additional Regulations Related to Filing Employers First Reports of Injury  PAGEREF _Toc272335520 \h 16  HYPERLINK \l "_Toc272335521" Letter from DIR regarding electronic filing  PAGEREF _Toc272335521 \h 16  HYPERLINK \l "_Toc272335522" Section F: Trading Partner Profile  PAGEREF _Toc272335522 \h 18  HYPERLINK \l "_Toc272335523" Who Should Complete the Trading Partner Profile?  PAGEREF _Toc272335523 \h 18  HYPERLINK \l "_Toc272335524" ELECTRONIC DATA INTERCHANGE TRADING PARTNER PROFILE  PAGEREF _Toc272335524 \h 19  HYPERLINK \l "_Toc272335525" INSTRUCTIONS FOR COMPLETING TRADING PARTNER PROFILE  PAGEREF _Toc272335525 \h 23  HYPERLINK \l "_Toc272335526" Section G: Test, Pilot, Parallel and Production Phases of EDI  PAGEREF _Toc272335526 \h 29  HYPERLINK \l "_Toc272335527" Step 1. Complete an EDI Trading Partner Profile  PAGEREF _Toc272335527 \h 29  HYPERLINK \l "_Toc272335528" Step 2. Complete the Test Phase  PAGEREF _Toc272335528 \h 31  HYPERLINK \l "_Toc272335529" Purpose  PAGEREF _Toc272335529 \h 31  HYPERLINK \l "_Toc272335530" Order of Testing  PAGEREF _Toc272335530 \h 31  HYPERLINK \l "_Toc272335531" Test Criteria  PAGEREF _Toc272335531 \h 32  HYPERLINK \l "_Toc272335532" Test Procedure  PAGEREF _Toc272335532 \h 32  HYPERLINK \l "_Toc272335533" Step 3. Complete the Pilot Phase  PAGEREF _Toc272335533 \h 35  HYPERLINK \l "_Toc272335534" Overview  PAGEREF _Toc272335534 \h 35  HYPERLINK \l "_Toc272335535" Purpose  PAGEREF _Toc272335535 \h 35  HYPERLINK \l "_Toc272335536" Data Quality Criteria  PAGEREF _Toc272335536 \h 36  HYPERLINK \l "_Toc272335537" Maintenance Type Codes Piloted  PAGEREF _Toc272335537 \h 37  HYPERLINK \l "_Toc272335538" Step 4. Parallel Procedure (Optional)  PAGEREF _Toc272335538 \h 38  HYPERLINK \l "_Toc272335539" Moving from Parallel to Production Status  PAGEREF _Toc272335539 \h 41  HYPERLINK \l "_Toc272335540" Step 5. Production  PAGEREF _Toc272335540 \h 41  HYPERLINK \l "_Toc272335541" Paper Reports  PAGEREF _Toc272335541 \h 41  HYPERLINK \l "_Toc272335542" Data Quality Requirements  PAGEREF _Toc272335542 \h 42  HYPERLINK \l "_Toc272335543" Data Quality Reports  PAGEREF _Toc272335543 \h 42  HYPERLINK \l "_Toc272335544" Trading Partner Profile  PAGEREF _Toc272335544 \h 42  HYPERLINK \l "_Toc272335545" WCIS PARALLEL BATCH IDENTIFICATION FORM  PAGEREF _Toc272335545 \h 43  HYPERLINK \l "_Toc272335546" Section H: File Formats and Supported Transactions  PAGEREF _Toc272335546 \h 44  HYPERLINK \l "_Toc272335547" Supported Transactions  PAGEREF _Toc272335547 \h 44  HYPERLINK \l "_Toc272335548" Understanding ANSI and Flat Files  PAGEREF _Toc272335548 \h 44  HYPERLINK \l "_Toc272335549" Section I: The FTP Transmission Modes  PAGEREF _Toc272335549 \h 45  HYPERLINK \l "_Toc272335550" File Transfer Protocol (FTP)  PAGEREF _Toc272335550 \h 45  HYPERLINK \l "_Toc272335551" Data Transmission with File Transfer Protocol  PAGEREF _Toc272335551 \h 45  HYPERLINK \l "_Toc272335552" Transmission Pathways  PAGEREF _Toc272335552 \h 48  HYPERLINK \l "_Toc272335553" Section J: Events that Trigger Required EDI Reports  PAGEREF _Toc272335553 \h 49  HYPERLINK \l "_Toc272335554" First Report of Injury  PAGEREF _Toc272335554 \h 49  HYPERLINK \l "_Toc272335555" Subsequent Report of Injury  PAGEREF _Toc272335555 \h 50  HYPERLINK \l "_Toc272335556" Annual Summary  PAGEREF _Toc272335556 \h 51  HYPERLINK \l "_Toc272335557" Section K: Required Data Elements  PAGEREF _Toc272335557 \h 52  HYPERLINK \l "_Toc272335558" WCIS Data Requirement Codes  PAGEREF _Toc272335558 \h 53  HYPERLINK \l "_Toc272335559" Data Requirements for First Reports of Injury  PAGEREF _Toc272335559 \h 54  HYPERLINK \l "_Toc272335560" FROI Conditional Rules and Implementation Notes  PAGEREF _Toc272335560 \h 57  HYPERLINK \l "_Toc272335561" Data Requirements for Subsequent Report of Injury  PAGEREF _Toc272335561 \h 59  HYPERLINK \l "_Toc272335562" SROI Conditional Rules and Implementation Notes  PAGEREF _Toc272335562 \h 63  HYPERLINK \l "_Toc272335563" Section L: California-Specific Data Edits and Sorted Data Element Lists  PAGEREF _Toc272335563 \h 67  HYPERLINK \l "_Toc272335564" All Transactions  PAGEREF _Toc272335564 \h 67  HYPERLINK \l "_Toc272335565" First Reports (FROIs)  PAGEREF _Toc272335565 \h 67  HYPERLINK \l "_Toc272335566" Subsequent Reports (SROIs)  PAGEREF _Toc272335566 \h 68  HYPERLINK \l "_Toc272335567" FROI Data Elements, Sorted by Data Element Number (DN)  PAGEREF _Toc272335567 \h 69  HYPERLINK \l "_Toc272335568" FROI Data Elements, Sorted Alphabetically  PAGEREF _Toc272335568 \h 71  HYPERLINK \l "_Toc272335569" SROI Data Elements, Sorted By Data Element Number (DN)  PAGEREF _Toc272335569 \h 73  HYPERLINK \l "_Toc272335570" SROI Data Elements, Sorted Alphabetically  PAGEREF _Toc272335570 \h 74  HYPERLINK \l "_Toc272335571" Section M: System Specifications  PAGEREF _Toc272335571 \h 76  HYPERLINK \l "_Toc272335572" Agency Claim Number/Jurisdiction Claim Number (JCN)  PAGEREF _Toc272335572 \h 76  HYPERLINK \l "_Toc272335573" Changed or Corrected Data  PAGEREF _Toc272335573 \h 76  HYPERLINK \l "_Toc272335574" Transaction Processing and Sequencing  PAGEREF _Toc272335574 \h 77  HYPERLINK \l "_Toc272335575" General Rules  PAGEREF _Toc272335575 \h 77  HYPERLINK \l "_Toc272335576" First Reports  PAGEREF _Toc272335576 \h 78  HYPERLINK \l "_Toc272335577" First Report Transaction Sequencing Requirements Summary  PAGEREF _Toc272335577 \h 79  HYPERLINK \l "_Toc272335578" Subsequent Reports  PAGEREF _Toc272335578 \h 79  HYPERLINK \l "_Toc272335579" Transaction Sequencing Requirements for Subsequent Reports  PAGEREF _Toc272335579 \h 82  HYPERLINK \l "_Toc272335580" Sequencing Rules  PAGEREF _Toc272335580 \h 82  HYPERLINK \l "_Toc272335581" Related Business Rules  PAGEREF _Toc272335581 \h 82  HYPERLINK \l "_Toc272335582" WCIS Matching Rules and Processes  PAGEREF _Toc272335582 \h 83  HYPERLINK \l "_Toc272335583" Acquired Claims  PAGEREF _Toc272335583 \h 84  HYPERLINK \l "_Toc272335584" Section N: Code Lists  PAGEREF _Toc272335584 \h 85  HYPERLINK \l "_Toc272335585" Nature of Injury Codes (DN35)  PAGEREF _Toc272335585 \h 85  HYPERLINK \l "_Toc272335586" Part of Body Codes: FROI (DN36) and SROI (DN83)  PAGEREF _Toc272335586 \h 87  HYPERLINK \l "_Toc272335587" Cause of Injury Codes (DN37)  PAGEREF _Toc272335587 \h 90  HYPERLINK \l "_Toc272335588" Late Reason Codes (DN77)  PAGEREF _Toc272335588 \h 92  HYPERLINK \l "_Toc272335589" Class Codes (DN59)  PAGEREF _Toc272335589 \h 93  HYPERLINK \l "_Toc272335590" Payment/Adjustment and Paid to Date (DN85 and DN95) Benefit Type Codes  PAGEREF _Toc272335590 \h 94  HYPERLINK \l "_Toc272335591" Industry Codes (DN25)  PAGEREF _Toc272335591 \h 95  HYPERLINK \l "_Toc272335592" Section O: EDI Terminology  PAGEREF _Toc272335592 \h 96  HYPERLINK \l "_Toc272335593" Abbreviations and Acronyms  PAGEREF _Toc272335593 \h 96  HYPERLINK \l "_Toc272335594" EDI Glossary  PAGEREF _Toc272335594 \h 97  HYPERLINK \l "_Toc272335595" Appendix A: Revised WCIS System Updates  PAGEREF _Toc272335595 \h 101  HYPERLINK \l "_Toc272335596" Clarification of Issues:  PAGEREF _Toc272335596 \h 101  HYPERLINK \l "_Toc272335597" Differences Between Version 2.1 and Version 3.0 of WCIS  PAGEREF _Toc272335597 \h 102  HYPERLINK \l "_Toc272335598" Differences Between Version 2.0 and Version 2.1 of WCIS:  PAGEREF _Toc272335598 \h 104  HYPERLINK \l "_Toc272335599" Appendix B: Revision History Summary of Principal Changes from Previous Versions  PAGEREF _Toc272335599 \h 106  HYPERLINK \l "_Toc272335600" Version 3.0  PAGEREF _Toc272335600 \h 106  HYPERLINK \l "_Toc272335601" Version 2.1  PAGEREF _Toc272335601 \h 107  HYPERLINK \l "_Toc272335602" Version 2.0  PAGEREF _Toc272335602 \h 109  HYPERLINK \l "_Toc272335603" Version 1.2  PAGEREF _Toc272335603 \h 111  HYPERLINK \l "_Toc272335604" Version 1.1  PAGEREF _Toc272335604 \h 112  HYPERLINK \l "_Toc272335605" Version 1.02  PAGEREF _Toc272335605 \h 112  HYPERLINK \l "_Toc272335606" Version 1.01  PAGEREF _Toc272335606 \h 113  HYPERLINK \l "_Toc272335607" Version 1.00  PAGEREF _Toc272335607 \h 113  Section A: EDI in California An Overview EDI Electronic Data Interchange Electronic Data Interchange (EDI) is the computer-to-computer exchange of data or information in a standardized format. In workers compensation, EDI refers to the electronic transmission of claims information from claims administrators (insurers, self-insured employers, and third party administrators) to a State Workers Compensation Agency. Data are transmitted in a format standardized by the International Association of Industrial Accident Boards and Commissions (IAIABC). The IAIABC is a professional association of workers compensation specialists from the public and private sectors and has spearheaded the introduction of EDI in workers compensation. All collected data elements are reviewed for valid and standardized business definitions and formats. Benefits of EDI within Workers Compensation Allows state agencies to respond to policy makers questions regarding their state programs Electronic data interchange allows states to evaluate the effectiveness and efficiency of their workers compensation system by providing comprehensive and readily accessible information on all claims. This information can then be made available to state policy makers considering any changes to the system. Avoids costs in paper handling Electronic data interchange reduces costs in the processing of paper documents for the claims administrator and the jurisdiction: mail processing costs, duplicated data entry costs, shipping, filing and storage costs. Increases data quality Electronic data interchange has built-in data quality checking procedures that are triggered when data are received by the state agency. Many claims administrators choose to replicate these data-checking procedures to reduce the cost of data correction. Simplifies reporting requirements for multi-state insurers Electronic data interchange helps claims administrators cut costs by having a single system for internal data management and reporting. Californias WCIS the Workers Compensation Information System History The California Legislature enacted sweeping reforms to Californias workers compensation system in 1993. The reform legislation was preceded by a vigorous debate among representatives of injured workers, their employers, insurance companies, and medical providers. All parties agreed that changes were due, but they could not reach agreement on the nature of the problems to be corrected nor on the likely impact of alternative reform proposals. One barrier to well-informed debate was the absence of comprehensive, impartial information about the performance of Californias workers compensation system. Foreseeing the strengths and weaknesses of the system, the Legislature directed the Division of Workers Compensation (DWC) to put together comprehensive information about workers compensation in California. The result is the WCIS-- the Workers Compensation Information System. The WCIS has been in development since 1995, and its design has been shaped by a broad-based advisory committee. The WCIS has four main objectives: help DWC manage the workers compensation system efficiently and effectively, facilitate the evaluation of the benefit delivery system, assist in measuring benefit adequacy, provide statistical data for further research. WCIS Data Collection The core of the system is standardized data on every California workers compensation claim. Much of this data has historically been collected in paper form: employers and physicians first reports of injury and benefit notices. Beginning in 2000, standardized data was transmitted to the WCIS by EDI. These EDI transmissions are the main subject of this Guide. EDI reporting allows DWC to understand and improve the California workers compensation system. California EDI Requirements Californias WCIS regulations define EDI reporting requirements for claims administrators. A claims administrator is an insurer, a self-insured employer, or a third-party administrator. In brief, claims administrators are required to submit the following: First Reports: First Reports of Injury (FROIs) must be submitted by EDI to WCIS in the Division of Workers Compensation (DWC) no later than 10 business days after claim administrator knowledge of the claim. Subsequent Reports: Subsequent Reports of Injury (SROIs) are submitted within 15 business days whenever benefit payments to an employee are started, changed, suspended, restarted, stopped, delayed or denied or when a claim is closed, reopened or upon notification of employee representation. Medical Bill/Payment Records: Medical bill payment reporting regulations require medical services with a date of service on or after September 22, 2006 and a date of injury on or after March 1, 2000 to be transmitted to the DWC within 90 calendar days of the medical bill payment or the date of the final determination that payment for billed medical services would be denied. These medical services are required to be reported to the WCIS by all claims administrators handling 150 or more total claims per year. Annual Summary of Benefits: An Annual Summary of Benefits must be submitted for every claim with any benefit activity (including medical) during the preceding year. Section ELegal Authorities includes the full WCIS regulations along with a more detailed summary. Sending Data to the WCIS Workers compensation claims are handled by diverse organizations: large multi-state insurance companies, smaller specialty insurance carriers, self-insured employers, and third-party administrators handling claims on behalf of insured and self-insured employers. These organizations have different information systems and capabilities. The WCIS has been designed to be as flexible as possible in the support of a variety of EDI systems. The allowed methods of transmitting data from claim administrators to WCIS are: File Transfer Protocol (FTP) over SSL (Secure Sockets Layer), also known as FTPS, or FTPS with PGP (Pretty Good Privacy) encryption. The electronic communications options are described more fully in Section HFile Formats and Supported Transactions and Section ITransmission Modes. The WCIS is also flexible in supporting two different file formats, known as American National Standards Institute (ANSI) X12 and flat-file formats. Claim administrators can avoid the details of EDI by selecting among several firms that sell EDI-related software products, consulting, and related services.  The Five Step Process of EDI--From Testing to Production Full production EDI reporting status is a five step process. Each step of the process is described in more detail in Section GTest, Pilot, Parallel and Production Phases of EDI. These steps should be repeated each time the claims administrator is ready to move into a new transaction type, i.e., the First Reports and Subsequent Reports. Step 1: EDI Trading Partner Profile The claims administrator first provides an EDI Trading Partner Profile to the Division at least 30 (thirty) days before its first submission of EDI data. The Trading Partner Profile form is provided in Section FTrading Partner Profile. The Trading Partner Profile is used to prepare WCIS for your data transmission: what file format to expect, where to send an acknowledgment, when you plan to transmit reports, and similar information. Step 2: Testing The claims administrator runs a preliminary test by transmitting a test file to ensure that the WCIS system can read and interpret the data. The claims administrator has passed the test when minimum technical requirements are met: WCIS recognizes the sender, the file format is correct, and the claims administrator can receive electronic acknowledgments from WCIS. Step 3: Pilot After a test file is successfully transmitted, real claims data is transmitted in the Pilot stage. During the Pilot step, data submissions are analyzed for completeness, validity, and accuracy. The data should meet minimum data quality requirements in order to complete the Pilot stage. Step 4: Parallel (optional) The claims administrator submits reports both electronically and in hard copy during the Parallel phase. The WCIS uses these parallel reports to conduct a comparison study. Step 5: Production During Production, data transmissions will be monitored for completeness, validity, and accuracy. Each Trading Partner will be routinely sent reports describing their data quality. Those in Production status for EDI First Reports will no longer be required to send paper copies of the Employers Report (Form 5020) to Department of Industrial Relations Division of Labor Statistics and Research (DLSR). Section B: Where to Get Help Contacting WCIS and Other Information Resources Starting up a new EDI system isnt simple. It requires detailed technical information, as well as close cooperation between the organizations that send data, the trading partners and the organization that receives data, the California Division of Workers Compensation (DWC). The following is a list of resources available for information and assistance. California Division of Workers Compensation Our Web Site Visit our web site at http://HYPERLINK "http://www.dir.ca.gov/dwc/WCIS.htm"www.dir.ca.gov/dwc/WCIS.htm to: ( Download the latest version of the California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI), ( Get answers to Frequently Asked Questions, ( Review archived WCIS eNews letters. Your WCIS Contact Person Each WCIS Trading Partner will be assigned a WCIS contact person at DWC. This person will help answer your questions about EDI reporting in California, work with you during the Test-Pilot-Parallel-Production process, and be an ongoing source of support during production. Your WCIS liaison can be reached by phone, e-mail, or mail. When initially contacting us, be sure to provide your company name so that you may be directed to the appropriate WCIS staff. By phone: (510)286-6753 Trading Partner Letters C, G-H, M, P-R (510)286-6763 Trading Partner Letters B, D-F, N-O, W-Y (510)286-6772 Trading Partner Letters A, I-L, S-V, Z By fax: (510)286-6862 By e-mail: wcis@dir.ca.gov By mail: WCIS EDI Unit Attn: Name of WCIS Contact (if known) Department of Industrial Relations 1515 Clay St, Ste 1902 Oakland, CA 94612 If you find errors or omissions in the California EDI Implementation Guide (FROI/SROI), please inform your WCIS contact person. WCIS eNews WCIS eNews is an e-mail newsletter sent out periodically to inform WCIS Trading Partners of announcements and technical implementations. The WCIS eNews will be archived on the WCIS web site. Interested parties who are not already receiving WCIS eNews can register at the WCIS website to be added to the WCIS eNews mailing list. EDI Service Providers Several companies can assist you in your efforts to report data via EDI. A range of products and services are available, including: ( software that works with your organizations computer systems to automatically transmit data, ( systems consulting, to help get your computer systems EDI-ready, ( data transcription services which accept paper forms, keypunch data, and transmit the data via EDI. A list of companies known to DWC that provide these services can be found at http://www.dir.ca.gov/DWC/EDIvend.HTM. Claims administrators seeking assistance in implementing EDI may wish to consult one or more of the EDI service providers listed on the DWC website. Many of these firms offer a full range of EDI-related services: consultation, technical support, value added network (VAN) services, and/or software products. These products and services can make it possible for claims administrators to successfully transmit claims data via EDI and avoid the technical details of EDI. Another alternative to developing a complete EDI system is to contract for the services of a data collection agent. For a fee, a data collection agent will receive paper forms by fax or mail, enter the data, and transmit it by EDI to state agencies or other electronic commerce trading partners. The California Division of Workers Compensation does not have a process for granting approvals to any EDI service providers. Listings of providers, which are found on the Divisions website, are simply of providers known to the Division. The lists will be updated as additional resources become known. Appearance on the EDI service provider lists does not in any way constitute an endorsement of the companies listed or a guarantee of the services they provide. Other companies not listed may be equally capable of providing EDI-related services. Note to suppliers of EDI-related services: Please contact HYPERLINK "mailto:wcis@hq.dir.ca.gov"wcis@dir.ca.gov if you wish to have your organization added or removed from DWCs list, or to update your contact information. IAIABC The International Association of Industrial Accident Boards and Commissions (IAIABC) is the organization that sets the national standards for the transmission of workers compensation claims data via EDI. The IAIABC publishes these standards in their EDI Implementation Guide. For more information about the IAIABC and how to purchase the IAIABC EDI Implementation Guide, visit the IAIABC web site at http://HYPERLINK "http://www.iaiabc.org"www.iaiabc.org. Section C: Implementing EDI A Managers Guide 1. Get to know the basic requirements. Starting up a new EDI system can be a complex endeavor. Make sure you understand all that is required before investing resources. Otherwise, you may end up with a collection of piecemeal fixes rather than a comprehensive solution. This guide and the IAIABC guide contain much of the information needed to implement EDI in California. As more information becomes available it will be posted on our Web site at http://HYPERLINK "http://www.dir.ca.gov/dwc/WCIS.htm"www.dir.ca.gov/dwc/WCIS.htm. 2. Assign responsibilities for implementing EDI. Some organizations put an Information Systems (IS) manager in charge, while others designate a claims manager. Implementing EDI will affect your information system, flow of claims information and your business process. The most effective approach may be to have Claims and Information Systems departments collaborate on the project. Regardless of who is assigned primary responsibility, make sure that both Claims and IS departments maintain continual oversight as your solution is designed and implemented. 3. Decide whether to contract with an EDI service provider. Formatting electronic records and transmitting them by EDI generally requires some specialized automated routines. Programming a complete EDI system also requires in-depth knowledge of EDI standards and protocols. Some organizations choose to develop these routines in-house, especially if they have an IS department that is familiar with EDI and is efficient in bringing new technology online. Other organizations choose to contract with vendors for dedicated EDI software or services. Typically, an EDI vendors products interface with your organizations data to produce EDI transactions in the required formats. The benefit is that no one in your organization has to learn all the intricacies of EDI. The service provider takes care of file formats, record layouts, and many other details that may seem foreign to your organization. Some EDI vendors can also provide full-service consulting, helping you update your entire data management process for electronic commerce. A list of known EDI vendors can be found on the DWC website: HYPERLINK "http://www.dir.ca.gov/dwc/EDIvend.HTM"http://www.dir.ca.gov/dwc/EDIvend.HTM. 4. If your organization will not use an EDI service provider, choose a file format and transmission mode for your data. Contracting with an EDI service provider would relieve your organization of the detailed mechanics of EDI, such as file formats and transmission modes. If you decide to develop your own system, you will have some important decisions to make that will determine the scope and difficulty of the programming work. Probably the most important decision is whether your data will be packaged as flat files or as ANSI X12 files. More information on these choices is provided in Section HFile Formats and Supported Transactions. In general, Release 1 flat files are relatively easy to get up and running quickly. ANSI X12 may be a wise investment in long-run flexibility and compatibility. Information about file formats can be found in the IAIABC EDI Implementation Guide, at http://HYPERLINK "http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3339"www.iaiabc.org. This guide is essential if you will be programming your own EDI system. You will also need to choose a transmission mode that WCIS supports. See Section IThe FTP Transmission Modes - for further information. 5. Make sure your computer systems contain all the required data. Youll have a hard time submitting data by EDI if the data are not readily accessible on your systems. Give your Information Systems department a copy of Section KRequired Data Elements. If all are available and readily accessible, then you are in great shape. If not, your Claims and IS departments will need to develop and implement a plan for capturing, storing, and accessing the necessary data. 6. Determine who will handle error messages sent by WCIS. Your organization will receive error messages from WCIS if you transmit data that cannot be interpreted or do not meet the regulatory requirements to provide complete, valid and accurate data. Some glitches are inevitable. Youll need a system for forwarding any error messages to people who can respond as necessary. Establish a procedure for responding to error messages before you begin transmitting data by EDI. Otherwise, your organization may find itself unprepared for the inevitable. Typically, errors related to technical problems may be aggravating when a system is new, but they quickly become rare. Error messages related to data quality and completeness are harder to correct, and you can expect them to present an ongoing workload that must be managed. 7. Decide whether your organization could benefit by adding data edits. Data you transmit to the WCIS will be subjected to edit rules to assure that the data are valid and consistent with data previously reported for a particular claim. For example, one edit rule would reject an injury date of February 31. Another rule would reject a benefit notice if a First Report had not been previously filed. These edit rules are detailed in Section K Required Data Elements, Section LCalifornia-Specific Data Edits, and Section MSystem Specifications. Data that violate these edit rules will cause transmissions to be rejected or will be returned with error messages. Correcting erroneous data often requires going to the original source, perhaps the applicant or the policyholder. In some organizations, the data passes through many hands before it is transmitted to WCIS. For example, the injury type and cause may be initially reported by the applicant, then go through the employer, a claims reporting center, a data entry clerk, a claims adjuster, and an Information Systems department. Any error messages would typically be passed through the same hands in the opposite direction. An alternative is to install in your system, as close as possible to the original source of data, data edits that match the WCIS edit rules. As an example, consider a claims reporting center in which claims data are entered directly into a computer system, and the system has data edits in place. Most data errors could be caught and corrected while the employer was still on the phone. This eliminates the expense of passing bad data from hand to hand and back again. 8. Install any software and communications services you will need. Once your system is planned, you will need to purchase and/or develop any software and services for your system Most systems will need at least the following: software (or other means) to identify events that trigger required reports, software (or other means) to gather required data elements from your databases, software (or other means) to format the data into an approved EDI file format, a File Transfer Protocol (FTP) process that sends EDI files, an FTP process to receive acknowledgments and error messages from WCIS. Some organizations, especially those that handle few California claims, may wish to contract for EDI services rather than handle EDI in-house. EDI service providers offer all the services listed above--see the DWC website, HYPERLINK "http://www.dir.ca.gov/dwc/EDIvend.HTM"http://www.dir.ca.gov/dwc/EDIvend.HTM. 9. Test your system internally. Not every system works perfectly the first time. Make sure your system gets thoroughly tested before you begin reporting data to WCIS. Catching any bugs internally will spare you the blizzard of error messages that a faulty system can cause. Include in your internal tests some complex test cases as well as simple ones. For example, challenge your system with claims that feature multiple episodes of disability and partial return to work. Fix any identified problems before you try transmitting EDI data to WCIS. 10. Move through the Test, Pilot and Parallel stages to reach the Production stage of EDI transmission. Complete an EDI Trading Partner Profile and insurer/claim administrator ID list--see Section FTrading Partner Profile. The Profile and ID list are used to prepare WCIS for your data transmission: what file format to expect; where to send your acknowledgments; when you plan to transmit reports; and similar information. Once you have completed a successful test and verified that your transmissions match our technical specifications, you will be ready to enter the Pilot stage. During the optional Parallel stage, a sample of your EDI transmissions will be compared with the paper reports, and will also be tested against the WCIS data validation rules. Upon your successful completion of the Parallel step, DWC will issue you a written determination that you have demonstrated capability to transmit complete, valid, and accurate data. You will then be authorized to move into the Production stage, routinely transmitting your data via EDI. 11. Evaluate the efficiency of your EDI system and consider future refinements. Many organizations find that implementing EDI brings unexpected benefits. For example, EDI may provide an opportunity to address long-standing data quality problems. Arrange a review session after your system has been running for a few months. Users will be able to suggest opportunities for future refinements. Managers from departments not directly affected may also be interested in participating because EDI may eventually affect many business processes in other departments. Please let us know if you have any comments on this Managers Guide. We cant anticipate every challenge you may face in implementing EDI data reporting. Please e-mail any comments or suggestions you may have to HYPERLINK "mailto:wcis@dir.ca.gov"wcis@dir.ca.gov. Section D: Authorizing Statutes Labor Code sections 138.6 and 138.7 Labor Code section 138.6 Development of workers compensation information system (a) The administrative director, in consultation with the Insurance Commissioner and the Workers' Compensation Insurance Rating Bureau, shall develop a cost-efficient workers' compensation information system, which shall be administered by the division. The administrative director shall adopt regulations specifying the data elements to be collected by electronic data interchange. (b) The information system shall do the following: (1) Assist the department to manage the workers' compensation system in an effective and efficient manner. (2) Facilitate the evaluation of the efficiency and effectiveness of the benefit delivery system. (3) Assist in measuring how adequately the system indemnifies injured workers and their dependents. (4) Provide statistical data for research into specific aspects of the workers' compensation program. (c) The data collected electronically shall be compatible with the Electronic Data Interchange System of the International Association of Industrial Accident Boards and Commissions. The administrative director may adopt regulations authorizing the use of other nationally recognized data transmission formats in addition to those set forth in the Electronic Data Interchange System for the transmission of data required pursuant to this section. The administrative director shall accept data transmissions in any authorized format. If the administrative director determines that any authorized data transmission format is not in general use by claims administrators, conflicts with the requirements of state or federal law, or is obsolete, the administrative director may adopt regulations eliminating that data transmission format from those authorized pursuant to this subdivision. Labor Code section 138.7 Individually identifiable information; restricted access. (a) Except as expressly permitted in subdivision (b), a person or public or private entity not a party to a claim for workers' compensation benefits may not obtain individually identifiable information obtained or maintained by the division on that claim. For purposes of this section, "individually identifiable information" means any data concerning an injury or claim that is linked to a uniquely identifiable employee, employer, claims administrator, or any other person or entity. (b)(1) The administrative director, or a statistical agent designated by the administrative director, may use individually identifiable information for purposes of creating and maintaining the workers' compensation information system as specified in Section 138.6. (2) The State Department of Health Services may use individually identifiable information for purposes of establishing and maintaining a program on occupational health and occupational disease prevention as specified in Section 105175 of the Health and Safety Code. (3)(A) Individually identifiable information may be used by the Division of Workers' Compensation, the Division of Occupational Safety and Health, and the Division of Labor Statistics and Research as necessary to carry out their duties. The administrative director shall adopt regulations governing the access to the information described in this subdivision by these divisions. Any regulations adopted pursuant to this subdivision shall set forth the specific uses for which this information may be obtained. (B) Individually identifiable information maintained in the workers' compensation information system and the Division of Workers' Compensation may be used by researchers employed by or under contract to the Commission on Health and Safety and Workers' Compensation as necessary to carry out the commission's research. The administrative director shall adopt regulations governing the access to the information described in this subdivision by commission researchers. These regulations shall set forth the specific uses for which this information may be obtained and include provisions guaranteeing the confidentiality of individually identifiable information. Individually identifiable information obtained under this subdivision shall not be disclosed to commission members. No individually identifiable information obtained by researchers under contract to the commission pursuant to this subparagraph may be disclosed to any other person or entity, public or private, for a use other than that research project for which the information was obtained. Within a reasonable period of time after the research for which the information was obtained has been completed, the data collected shall be modified in a manner so that the subjects cannot be identified, directly or through identifiers linked to the subjects. (4) The administrative director shall adopt regulations allowing reasonable access to individually identifiable information by other persons or public or private entities for the purpose of bona fide statistical research. This research shall not divulge individually identifiable information concerning a particular employee, employer, claims administrator, or any other person or entity. The regulations adopted pursuant to this paragraph shall include provisions guaranteeing the confidentiality of individually identifiable information. Within a reasonable period of time after the research for which the information was obtained has been completed, the data collected shall be modified in a manner so that the subjects cannot be identified, directly or through identifiers linked to the subjects. (5) This section shall not operate to exempt from disclosure any information that is considered to be a public record pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code) contained in an individual's file once an application for adjudication has been filed pursuant to Section 5501.5. However, individually identifiable information shall not be provided to any person or public or private entity who is not a party to the claim unless that person identifies himself or herself or that public or private entity identifies itself and states the reason for making the request. The administrative director may require the person or public or private entity making the request to produce information to verify that the name and address of the requester is valid and correct. If the purpose of the request is related to pre-employment screening, the administrative director shall notify the person about whom the information is requested that the information was provided and shall include the following in 12-point type: "IT MAY BE A VIOLATION OF FEDERAL AND STATE LAW TO DISCRIMINATE AGAINST A JOB APPLICANT BECAUSE THE APPLICANT HAS FILED A CLAIM FOR WORKERS' COMPENSATION BENEFITS." Any residence address is confidential and shall not be disclosed to any person or public or private entity except to a party to the claim, a law enforcement agency, an office of a district attorney, any person for a journalistic purpose, or other governmental agency. Nothing in this paragraph shall be construed to prohibit the use of individually identifiable information for purposes of identifying bona fide lien claimants. (c) Except as provided in subdivision (b), individually identifiable information obtained by the division is privileged and is not subject to subpoena in a civil proceeding unless, after reasonable notice to the division and a hearing, a court determines that the public interest and the intent of this section will not be jeopardized by disclosure of the information. This section shall not operate to restrict access to information by any law enforcement agency or district attorney's office or to limit admissibility of that information in a criminal proceeding. (d) It shall be unlawful for any person who has received individually identifiable information from the division pursuant to this section to provide that information to any person who is not entitled to it under this section. Section E: Legal Authorities Pertinent WCIS Regulations The regulations pertinent to WCIS are stated in Title 8, California Code of Regulations, sections 9701-9704. They are available at HYPERLINK "http://www.dir.ca.gov/t8/ch4_5sb1a1_1.html"http://www.dir.ca.gov/t8/ch4_5sb1a1_1.html. Additional Regulations Related to Filing Employers First Reports of Injury The regulations related to filing First Reports of Injury are stated in Title 8, California Code of Regulations, sections 14001 and 14005. They are available at HYPERLINK "http://www.dir.ca.gov/t8/ch7sb1a1.html"http://www.dir.ca.gov/t8/ch7sb1a1.html. Letter from DIR regarding electronic filing (Note: The filing requirement for first reports of injury has been changed from five days to 10 days.) February 7, 2000 To: California Workers Compensation Insurers and Self-Insured Employers Re: Electronic Filing of the Employers Report of Occupational Injury or Illness (Form 5020) Labor Code 6409.1 and Title 8, California Code of Regulations (C.C.R.) Section 14001 require that both workers compensation insurers and self-insured employers file with the Division of Labor Statistics and Research (DLSR) a complete report of every occupational injury or illness that results in lost time beyond the date of injury or which requires medical treatment beyond first aid. The report must be filed within five days after obtaining knowledge of the injury or illness. Labor Code 6409.1 (a); 8 C.C.R. 14001 (d) & (e). 8 C.C.R. 14001 (c) provides that the mandatory filing shall be made by a photocopy of the Form 5020, the Employers Report of Occupational Injury or Illness, or by use of computer input media, prescribed by the Division and compatible with the Divisions computer equipment. Please be advised that DLSR hereby prescribes the Workers Compensation Information System (WCIS. See Labor Code 138.6 and 8 C.C.R. 9700-9704) as the computer input media referenced in 8 C.C.R. 14001 (c). The obligation of an insurer or a self-insured employer to submit a complete report of occupational injury or illness pursuant to Labor Code 6409.1 and 8 C.C.R. 14001 is satisfied provided that the insurer or self-insured employer submits data to the WCIS as required under 8 C.C.R. 9702 (b) and demonstrates capability to submit complete, valid, and accurate data under 8 C.C.R. 9702 (h)(1). Assuming such data is electronically transmitted to the WCIS in an acceptable manner, claims administrators need not submit paper copies of the Form 5020 to DLSR. Please note that specific information, or data elements (DN), required under 8 C.C.R. 9702 (b) is not included on the Form 5020. For example, the Form 5020 does not include the employers or insurers Federal Employer Identification Number (FEIN) (DN6 and DN16). Pursuant to 8 C.C.R. 14005 (b) and (c), which allow insurers and self-insured employers to reproduce a revised Form 5020 to include additional questions, DLSR will approve the inclusion of questions asking for information necessary to comply with 8 C.C.R. 9702 (b). Thank you for your anticipated cooperation in this matter. Extensive information about the Workers Compensation Information System, including a technical description of the prescribed computer input media, can be found on the Departments Web site at HYPERLINK "http://www.dir.ca.gov/dwc/wcis.htm"http://www.dir.ca.gov/dwc/wcis.htm. Any inquiries should be made to the Division of Workers Compensation, Research Unit by e-mail at wcis@dir.ca.gov. Sincerely, Daniel M. Curtin Chief Deputy Director Department of Industrial Relations Section F: Trading Partner Profile Who Should Complete the Trading Partner Profile? A separate Trading Partner Profile form should be completed for each Sender ID that will be used in EDI transmissions sent to WCIS. The Sender ID, which is composed of the trading partner's Master FEIN and physical address postal code (see profile form instructions), must be reported in the header record of every transmission. The Sender ID is used by WCIS to identify communication parameters as specified on the Trading Partner Profile form. For many organizations, the claim administrator FEIN (Federal Employer Identification Number) provided on each transaction will always be the same as the Senders Master FEIN. For EDI transactions, WCIS substitutes the Third Party Administrator FEIN (DN8), when applicable, for the claim administrator FEIN. If there is no Third Party Administrator, WCIS substitutes the Insurer FEIN (DN6) for the claims administrator FEIN and assumes that the insurer is administering the claim. Other organizations may have multiple claim administrator FEINs for their various operating units. If the transactions for these various claim administrator FEINs will all share the same transmission specifications, their data can be sent under the same Sender ID and be represented by a single Trading Partner Profile form. For example, the information systems department of a single parent organization might wish to send transactions for two subsidiaries batched together within transmissions. In such a case, the parent organization could complete one Trading Partner Profile--providing the Master FEIN for the parent company in the Sender ID--and could then transmit transactions from both subsidiaries, identified by the appropriate claim administrator FEIN on each transaction. The WCIS uses the insurer and claim administrator FEIN to process individual transactions. Transactions for unknown insurers and claim administrators will be rejected with the error code 039-No match on database. For this reason, it is vital for each WCIS Trading Partner Profile to be accompanied by a list of all insurer and claim administrator FEINs whose data will be reported under a given Sender ID. This list can be downloaded in Microsoft Excel format from the WCIS website at HYPERLINK "http://www.dir.ca.gov/DWC/WCIS.htm"http://www.dir.ca.gov/DWC/WCIS.htm. If this ID list is not provided, WCIS will assume that the only claim administrator FEIN reportable by that trading partner will be the Master FEIN from the trading partners Sender ID. The 9 digit postal code for the physical adjusting locations of each listed claim administrator must also be provided. These postal codes will be validated against incoming data and transactions with non-matching Claim Administrator Postal Codes (DN14) will be rejected with error code 032-Must be valid on zip code table. To prevent rejections, an updated ID list must be sent to your trading partner liaison each time there is a change.  FROI/SROI ELECTRONIC DATA INTERCHANGE TRADING PARTNER PROFILE The EDI Trading Partner Profile is available online at: HYPERLINK "http://www.dir.ca.gov/DWC/WCIS.htm"http://www.dir.ca.gov/DWC/WCIS.htm. PART A. Trading Partner Background Information: Date: ____________________________________ Sender Name: ________________________________________________ Senders Master FEIN: _________________________________________ Physical Address: _____________________________________________ City: ________________________________________ State: ______ Postal Code (Zip+4): _____________________ (Senders postal code) Mailing Address: ______________________________________________ City: ________________________________________ State: ______ Postal Code: _____________________ Trading Partner Type (check any that apply): __ Self-Administered Insurer __ Self-Administered, Self-Insured (employer) __ Third Party Administrator of Insurer __ Third Party Administrator of Self-Insured (employer) __ Other (Please specify):____________________ PART B. Trading Partner Contact Information: Business Contact: Technical Contact: Name: _________________________ Name: __________________________ Title: __________________________ Title: ___________________________ Phone: _________________________ Phone: __________________________ FAX: ___________________________ FAX: ___________________________ E-mail Address: __________________ E-mail Address: __________________ PART C. Trading Partner Transmission Specifications: If submitting more than one profile, please specify: PROFILE NUMBER (1, 2, etc.): __________ DESCRIPTION: ______________________________________ Part C1: TRANSACTION SETS FOR THIS PROFILE: Transaction TypeFile Format (circle one per row):Expected Transmission Days of Week (circle any that apply):Production Response PeriodFlat File Release #ANSI X12 Version #First Reports of Injury 11 - Version 3041 Daily Mon Tues Weds Thurs Fri Sat Sun3 business daysSubsequent Reports of Injury 11 Version 3041Daily Mon Tues Weds Thurs Fri Sat Sun3 business days PART C2: FTP ACCOUNT INFORMATION: User Name (8 characters max., alpha-numeric only)Password (8 characters min.)Transmission Mode (check one) _____ SSL _____ SSL+PGPSource Network IP Address (only public IP addresses) File Naming ConventionFile Name Prefix (4 characters max.)Unique Identifier (check one)_____ Sequence _____ Date/Time _____ Date/Sequence _____ Other ___________________ PART D. Receiver Information (to be completed by DWC): Name: California Division of Workers Compensation FEIN: 943160882 Physical Address: 1515 Clay Street, Suite 1800 City: Oakland State: CA Postal Code: 94612-1489 Mailing Address: P.O. Box 420603 City: San Francisco State: CA Postal Code: 94142-0603 Business Contact: Technical Contact: Name: (Varies by trading partner) Name: (Varies by trading partner) Title: (Varies by trading partner) Title: (Varies by trading partner) Phone: (xxx) xxx-xxxx Phone: (xxx) xxx-xxxx FAX: (510) 286-6862 FAX: (510) 286-6862 E-mail Address: wcis@dir.ca.gov E-mail Address: wcis@dir.ca.gov RECEIVERS NETWORK IP ADDRESS FOR CONNECTING VIA FILE TRANSFER PROTOCOL (FTP): (Please contact DWC for this information) RECEIVERS FLAT FILE RECORD DELIMITER: CR RECEIVERS ANSI X12 TRANSMISSION SPECIFICATIONS: Segment Terminator: ~ ISA Information: TEST PROD Data Elements Separator: * Sender/Receiver Qualifier: ZZ ZZ Sub-Element Separator: > Sender/Receiver ID: (Use Master FEINs PART E. California EDI Trading Partner Insurer/Claim Administrator ID List: This Sender ID list is available online at: HYPERLINK "http://www.dir.ca.gov/DWC/WCIS.htm"http://www.dir.ca.gov/DWC/WCIS.htm. Date Prepared: _________________ Sender Company Name: ______________________________ _______ Sender E-mail Address: ____________________________________________ Sender Master FEIN: ______________________________________________ Sender Physical Postal Code (Zip+4): _________________________________ Trading Partner Type: _______________(refer to Trading Partner Types below*) This list will be used to reconcile profile identification records. If, after filing this form with the Division, any entries are added or removed from the listing, the trading partner shall submit a revised California EDI Trading Partner Insurer/ Claim Administrator ID List. List all insurer/claim administrator FEINs and claim administrator postal codes that will be reported by the Sender. For each claim administrator, all physical adjusting locations must be listed separately. Anytime there is a change, Trading Partners must submit a revised ID List. #Insurer/Claim Administrator/Self-Insurer Legal NameFEIN #Trading Partner Type*Postal Code (Zip+4)**1Sender must be added to the list.234567891011121314151617181920Please add additional lines and pages as needed. *Trading Partner Types 1 = Self-Administered Insurer 2 = Self-Administered, Self-Insured (employer) 3 = Third Party Administrator of Insurer  4 = Third Party Administrator of Self-Insured (employe 5 = Other (Please specify): _______________________ **Nine-digit postal codes required for Claim Administrator Types 1-4. The FEIN and nine-digit postal code must match the DN6 or DN8 and DN14, respectively, submitted in your transmissions. WORKERS COMPENSATION INFORMATION SYSTEM Electronic Data Interchange Trading Partner Profile INSTRUCTIONS FOR COMPLETING TRADING PARTNER PROFILE Each claims administrator will complete parts A, B, C and E, providing information as it pertains to them. Part D contains receiver information and will be completed by the Division of Workers Compensation (DWC). PART A. TRADING PARTNER BACKGROUND INFORMATION: Sender NAME: The name of your business entity corresponding with the Master FEIN. Senders Master FEIN: The Federal Employers Identification Number of your business entity. This FEIN, along with the 9-position zip code (Zip+4) in the trading partner address field, will be used to identify a unique trading partner. Physical Address: The street address of the physical location of your business entity. It will represent where materials may be received regarding this trading partner agreement if using a delivery service other than the U.S. Postal Service. City: The city of the physical address of your business entity. State: The 2-character standard state abbreviation of the state of the physical address of your business entity. Postal Code: The 9-position zip code of the physical address of your business entity. This field, along with the Trading Partner FEIN, will be used to uniquely identify a trading partner. Mailing Address: The mailing address used to receive deliveries via the U. S. Postal Service for your business entity. This should be the mailing address that would be used to receive materials pertaining to this trading partner agreement. If this address is the same as the physical address, indicate Same as above. Claims Administrator Type: Indicate any functions that describe the claims administrator. If other, please specify. PART B. TRADING PARTNER CONTACT INFORMATION: This section provides the ability to identify individuals within your business entity who can be used as contacts. Room has been provided for two contacts: business and technical. The BUSINESS CONTACT should be the individual most familiar with the overall extract and transmission process within your business entity. He/she may be the project manager, business systems analyst, etc. This individual should be able to track down the answers to any issues that may arise from your trading partner that the technical contact cannot address. The TECHNICAL CONTACT is the individual that should be contacted if issues regarding the actual transmission process arise. This individual may be a telecommunications specialist, computer operator, etc. BUSINESS/TECHNICAL The name of the contact. CONTACT: Name BUSINESS/TECHNICAL The title of the contact or the role that contact CONTACT: Title performs. BUSINESS/TECHNICAL The telephone number at which that contact can be CONTACT: Phone reached. BUSINESS/TECHNICAL If FAX facilities are available, the telephone number of CONTACT: FAX the FAX machine to use for the contact. BUSINESS/TECHNICAL If the contact can be reached via electronic mail, an CONTACT: E-mail e-mail address that may be used to send messages to this contact should be provided in this section. PART C. TRANSMISSION SPECIFICATIONS: This section is used to communicate all allowable options for EDI transmissions between the trading partner and DWC. PROFILE ID: A number assigned to uniquely identify a given profile. PROFILE ID DESCRIPTION: A free-form field used to uniquely identify a given profile between trading partners. This field becomes critical when more than one profile exists between a given pair of trading partners. It is used for reference purposes. PART C1: TRANSACTION SETS FOR THIS PROFILE: This section identifies all the transaction sets/report types described within the profile along with any options that DWC provides to the claims administrator for each transaction set. TRANSACTION TYPE: Indicates the types of EDI transmissions accepted by DWC. FILE FORMAT: DWC will specify below any FLAT FILE RELEASE #(s) and ANSI X12 VERSION #(s) which can be accepted for a given transaction set by DWC. The claim administrator should select ONE mode of transmission (flat file release # or ANSI X12 version #) from the alternatives specified. NOTE: WCIS will transmit acknowledgments using the acknowledgment format that corresponds to the format of the original transaction. EXPECTED TRANSMISSION DAYS OF WEEK: Indicate expected transmission timing for each transaction type by circling the applicable day or days. Transmission days of week information will help DWC to forecast WCIS usage during the week. Note that DWC reserves the right to impose restrictions on a trading partners transmission timing in order to control system utilization. PRODUCTION RESPONSE PERIOD: DWC will indicate here the normal period of elapsed time within which a sending trading partner may expect to receive an acknowledgment for a given transaction type. PART C2: FTP ACCOUNT INFORMATION: SENDER NAME: The name of your business entity corresponding with the Master FEIN. USER NAME: Specify a user name, which will be used to identify the authorized claim administrator for access to the WCIS-hosted FTP server. User names should be 8 characters maximum in length (alpha-numeric only) with a suffix added to the user name according to your mode of transmission. The suffix for SSL users will be @WCISSSL and for PGP users, it will be @WCISPGP. If you do not provide a username and/or password, they will be generated by the DWC WCIS and sent to you. PASSWORD: Specify a password, which will be used by the WCIS in combination with the user name to prevent data file submission by unauthorized parties. Passwords should be at least 8 characters in length, and may contain letters or numbers (but no spaces or other symbols). If you do not provide a username and/or password, they will be generated by the DWC WCIS and sent to you. TRANSMISSION MODES: Select one of the following transmission modes: FTP over SSL or FTP over SSL using PGP encryption and authentication. SOURCE NETWORK IP ADDRESS: This Internet Protocol (IP) address will be used for allowing access to the WCIS FTP server through our firewall to establish the FTP connections between the claims administrator and DWC. FILE NAMING CONVENTION: Each sender shall use a unique file naming convention for their incoming files based on the file name prefix and a unique identifier, such as date/time or date/sequence. PART D. RECEIVER INFORMATION (to be completed by DWC): This section contains DWCs trading partner information. Name: The business name of California Division of Workers Compensation (DWC). FEIN: The Federal Employers Identification Number of DWC. This FEIN, combined with the 9-position zip code (Zip+4), uniquely identifies DWC as a trading partner. Physical Address: The street address of DWC. The 9-position zip code of this street address, combined with the FEIN, uniquely identifies DWC as a trading partner. Mailing Address: The address DWC uses to receive deliveries via the U.S. Postal Service. Contact Information: This section identifies individuals at DWC who can be contacted with issues pertaining to this trading partner. The TECHNICAL CONTACT is the individual that should be contacted for issues regarding the actual transmission process. The BUSINESS CONTACT can address non-technical issues regarding the WCIS. RECEIVERS NETWORK IP ADDRESS FOR CONNECTING VIA FILE TRANSFER PROTOCOL (FTP): DWC will provide the appropriate network IP (Internet Protocol) address. RECEIVERS FLAT FILE RECORD DELIMITER: This character is to be used by claims administrators to indicate the end of each physical record when submitting flat file transactions formatted according to the IAIABC proprietary standards. RECEIVERS ANSI X12 TRANSMISSION SPECIFICATIONS: SEGMENT TERMINATOR: The character to be used as a segment terminator is specified here. DATA ELEMENT SEPARATOR: The character to be used as a data element separator is specified here. SUB-ELEMENT SEPARATOR: The character to be used as a sub-element separator is specified here. SENDER/RECEIVER QUALIFIER: This will be the claims administrators ANSI ID Code Qualifier as specified in an ISA segment. Separate Qualifiers are provided to exchange Production and Test data, if different identifiers are needed. SENDER/RECEIVER ID: If the claims administrator can accept ANSI transmissions, this will be the ID Code that corresponds with the ANSI Sender/Receiver Qualifier (ANSI ID Code Qualifier) as specified in an ISA segment. Separate Sender/Receiver IDs are provided to exchange Production and Test data, if different identifiers are needed. PART E. ELECTRONIC PARTNERING INSURER/CLAIM ADMINISTRATOR ID LIST This ID List includes all insurers and claim administrators whose data will be reported under a given Sender ID. The ID List includes insurer and claim administrator names, FEINs, claim administrator postal codes and trading partner types. For each claim administrator, all physical adjusting locations must be listed separately. Anytime there is a change, Trading Partners must submit a revised ID List. Section G: Test, Pilot, Parallel and Production Phases of EDI Test, Pilot, Parallel and Production Phases of EDI This section is a step-by-step guide to become a successful EDI Trading Partner in the California workers compensation system. Attaining EDI capability can be viewed as a five step process: 1) begin with completing a Trading Partner Profile, 2) send a test transmission to make sure your system and the WCIS system can communicate with each other, 3) complete a Pilot phase, to check for complete, valid, and accurate data, 4) (optional) complete a Parallel phase, where your EDI transmissions are compared to their corresponding paper reports and 5) attain and maintain full production capability. The steps outlined below are meant to help you through this process by providing you with information on what to expect in terms of electronic acknowledgments, what could go wrong along the way, and how to fix problems as they arise. Your WCIS contact person is available to work with you during this process to make sure that the transition to attaining Production status in California workers compensation EDI is as successful as possible. Step 1. Complete an EDI Trading Partner Profile Completing a Trading Partner Profile form is the first step in reporting workers compensation EDI data to WCIS. As stated in the WCIS regulations (Section 9702(j)), the form should be submitted to the Division at least 30 days before the first transmission of EDI data--at least 30 days before the Trading Partner sends the first test transmission (see Step 2). See Section F of this guide for details on who should complete a Trading Partner Profile form. 1. Get a copy of the Trading Partner Profile form Form DWC WCIS TP01 (Revised DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE), entitled Electronic Data Interchange Trading Partner Profile, is available from the following sources: ( Section FTrading Partner Profile. ( California Division of Workers Compensation web site at HYPERLINK "http://www.dir.ca.gov/DWC/wcis.htm"http://www.dir.ca.gov/DWC/wcis.htm ( Call or e-mail your WCIS liaison--see Section BWhere to Get Help. When contacting us, please provide your name, company, and the e-mail or mailing address you would like the form sent to, and we will mail you a copy. 2. Complete the form The form contains instructions about how to complete it. If you need additional help completing the form, contact your WCIS liaison. The Trading Partner Profile form asks you to provide the following information: ( Your business name, FEIN, 9-digit postal code, address, and type of business (insurer, employer, TPA, etc.) ( Name, phone, fax, and e-mail of business contact person ( Name, phone, fax, and e-mail of technical contact person ( Transmission mode ( Transmission specifications for each transaction type (flat file or ANSI X12) ( Transmission schedule (how often, what days) Complete a list of all company names, FEINs and nine-digit postal codes of adjusting locations (DN14) for claim administrators whose data will be reported under the Sender ID of the Trading Partner profile (see Section F, Part E for more information). The WCIS uses the claim administrator FEIN to process individual transactions. Since transactions for unknown claim administrators will be rejected by WCIS, it is imperative that this information be provided along with the Trading Partner Profile form. 3. Return the completed forms to the Division E-mail the Trading Partner Profile form and, if applicable, the sender ID list of claim administrator names, FEINs and postal codes reported under that Profile to the attention of your WCIS contact person or to wcis@dir.ca.gov. 4. Wait for approval of your Trading Partner Profile ( Your WCIS contact person will review your Trading Partner Profile and Sender ID list for completeness and accuracy. If there are any questions, you will be notified. ( Upon approval of your application, you will be notified. You are now ready to move into the Test phase and may begin sending test files (see Step 2) to assess the capability of your system to send transmissions to WCIS. Step 2. Complete the Test Phase Purpose The purpose of the Test phase is to make sure that your transmissions meet certain technical specifications. WCIS needs to be able to recognize and process your transmissions, and your system needs to be able to recognize and process transmissions from WCIS. The following are checked during the test: ( the transmission mode for both report and acknowledgment files is functional and acceptable for both receiver and sender ( the sender ID is valid and recognized by the receiver and vice versa ( the file format (ANSI X12 or flat file) matches the file format specified in the Trading Partner Profile of the sender and is structurally valid ( the batch format of files sent by the Trading Partner is correct, (i.e., each batch contains an appropriate header record, one or more transaction records, and a trailer record, and the number of records sent matches the number indicated in the trailer) Order of Testing The Test (Step 2), Pilot (Step 3), and Parallel (Step 4) phases are done separately for each transaction type supported by WCIS: ( First Report of Injury (FROI) ( Subsequent Report of Injury (SROI) You should be in Production with First Reports before testing and piloting Subsequent Reports. This is because the WCIS system will not be able to recognize your Subsequent Report transmissions unless it has already received the corresponding First Report. Test Criteria In order for your system and the WCIS system to communicate successfully, the following conditions must be met: ( No errors in header or trailer records ( Correct ANSI structure (if using ANSI) ( TP can receive electronic acknowledgment (AK1/824) reports Test Procedure Trading Partners should follow the steps given in Data Transmission with File Transfer Protocol in Section I The FTP Transmission Mode before sending a test file. 1. Prepare a test file Trading Partners send data to WCIS in batches. A batch consists of 3 parts: ( a header record which identifies the sender, receiver, test/production status, time and date sent, etc. ( one or more transactions (First Reports or Subsequent Reports) ( a trailer record which identifies the number of transactions in the batch We suggest that the test file consist of one batch of 5 production-quality reports of unique claims, real or simulated. Each test file must have the Test/Production indicator (DN104) located in the Header record set to T. For First Reports: Submit Original first reports (Maintenance Type Code 00) For Subsequent Reports: Submit Initial Payment reports (MTC IP) Note: If you would like to send additional MTCs while testing, please let your WCIS contact person know so that the WCIS system can be set up to receive them. Annual Reports (MTC AN), are a type of subsequent report and need not be tested. If a Trading Partner successfully tests SROIs with MTC IP, then it automatically passes the Test phase for SROIs with MTC AN. 2. Send the test file Send the test file to WCIS. The test data you send, if successful, will be posted to our test database. They will not be posted to the WCIS production database. This means that any live California claims sent as test data will have to be resent to WCIS, after passing the test stage, in order to be posted to the WCIS production database. 3. Wait for electronic acknowledgment from WCIS Trading Partners must be able to receive and process an electronic acknowledgment--AK1 (flat file) or 824 (ANSI)--from WCIS. When a test file has been processed, an electronic acknowledgment will be transmitted to the Trading Partner. The acknowledgment will report whether the transmission was successful, and, if not successful, any errors that occurred, as outlined in the following table. Note that if the test file is missing the header, or if the sender ID in the header is not recognized by WCIS, no acknowledgment will be sent. Also, the acknowledgment sent during the test phase will be header-level only; it will not contain information about the individual claims that you sent. Structural Edits Error Code, if applicableEditResultPresence of HD1 (Header record)Transmission rejected; no ACK sent042Presence of TR1 (Trailer record)ACK rejecting transmission002Transaction Set ID at record level invalidACK rejecting transmission 997 Error CodesANSI structure validation Segment Count does not match Transaction Set Trailer Missing Transaction Set not Supported Transaction Set Control # in Header/Trailer dont match Missing or Invalid Transaction Set ID Missing or Invalid Transaction Set Control #997 functional acknowledgment 042Header record must be 87 bytes longACK rejecting transmission Data Edits Error CodeMessageData Elements to ValidateResult001Trading Partner Table Mandatory field not presentSender ID Receiver ID Date Transmission Sent Time Transmission Sent Test/Production Indicator Interchange Version IDTransmission rejected; no ACK sent (Sender ID) ACK rejecting transmission (remaining elements)028Must be Numeric (0-9)Detail Record Count ACK rejecting transmission029Must be a valid Date (CCYYMMDD)Date Transmission SentACK rejecting transmission 031Must be a valid Time (HHMMSS)Time Transmission SentACK rejecting transmission 039No match on databaseSender Id Transmission rejected; no ACK sent041Must be <= Current DateDate Transmission SentACK rejecting transmission056Detail Record Cnt NE number recs receivedDetail Record CountACK rejecting transmission057Duplicate TransmissionTransaction Set ID ACK rejecting transmission058Code/ID InvalidTest/Production Indicator Interchange Version ID Receiver ID ACK rejecting transmission058Code/ID InvalidRelease Number = 1ACK rejecting transmission Trading Partners should receive an electronic acknowledgment within 48 hours of sending the test transmission. If you do not receive an acknowledgment within 48 hours, contact your WCIS contact person. Trading Partners using ANSI X12 file format will receive a 997, or functional acknowledgment, in addition to the 824. 4. Process the acknowledgment and correct any errors If you receive an acknowledgment error (Application Acknowledgment Code (DN111) = TR or transaction rejected), you will need to check the batchs file format, and make corrections before re-transmitting the file to WCIS. If the acknowledgment has a TA code (transaction accepted), skip to step 6. 5. Retransmit corrected file to WCIS Send the corrected file to WCIS. If your test fails again, repeat steps (2) through (5) until your test file is accepted by WCIS (no TR code). You may send as many test files as you need to. Let your WCIS liaison know if you have any questions or problems along the way. 6. Notify the Division when you are ready to move on to the Pilot Phase When WCIS accepts your test transmission without technical errors, this means that your system and the WCIS system are able to successfully communicate with each other and your files are in a format readable by WCIS. Let your WCIS liaison know when you have successfully transmitted a test file. This person will verify the success of your test by accessing the WCIS system. If you have passed, your Trading Partner Profile on the WCIS system will be updated to prepare WCIS for your pilot data. Your WCIS liaison will notify you when the WCIS system is ready to accept your pilot data. You may then begin transmitting pilot data as described in Step 3 below. Step 3. Complete the Pilot Phase Overview During the Pilot phase, the Trading Partner sends live California workers compensation injury reports--First Reports of Injury and/or Subsequent Reports of Injury--to WCIS to be analyzed for data validity and completeness. The Test/Production Indicator (DN104) should be set to P at this point. Purpose Testing for data quality during the Pilot, Parallel and Production phases will help Trading Partners comply with Section 9702, Electronic Data Reporting of the WCIS Regulations (8 CCR 9702(a)): Each claims administrator shall, at a minimum, provide complete, valid, and accurate data for the data elements set forth in this section. ( complete data In order to evaluate the effectiveness and efficiency of the California workers compensation system (one of the purposes of WCIS set forth in the 1993 authorizing statute), claims administrators must submit all required data elements on workers compensation claims for the required reporting periods. ( valid data Valid means that the data are what they are purported to be. For example, data in the date of injury field must be date of injury and not some other date (or something else entirely). Data must consist of allowable values, e.g., date of injury cannot be September 31, 2005, a non-existent date. At a more subtle level, each Trading Partner must have the same understanding of the meaning of each data element and submit data with that meaning only. Review the definitions for each required data element in the Data Dictionary of the IAIABC EDI Implementation Guide (HYPERLINK "http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3339"http://www.iaiabc.org) to be sure that your use of the data element matches that assigned by the IAIABC. If your meaning or use of a data element differs, you will need to make changes to conform to the IAIABC standards. ( accurate data Accurate means free from errors. There is little value in collecting and utilizing data unless there is assurance that the data are accurate. WCIS currently follows the IAIABC Edit Matrix error messages in the February 15, 2002 revised edition of the IAIABC EDI Implementation Guide. The Pilot phase is used to ensure that the above requirements are met before a Trading Partner is allowed to routinely submit electronic data to WCIS in the place of hard copy reports--in other words, before the Trading Partner is moved to Parallel status. Data Quality Criteria Reports are first transmitted to WCIS via EDI, and they are tested for completeness and validity using automatic built-in data edits on the WCIS system. DWC suggests that you transmit at least 30 live claims to WCIS. These claims should meet or exceed the following two data quality criteria: ( No more than 5% of transmitted reports are rejected (Application Acknowledgment Code = TR or transaction rejected). This is the same as saying that at least 95% of transmitted reports are free of any errors in mandatory/fatal or conditional/fatal data elements, AND ( Of the accepted reports (( 95% of transmitted reports), no more than 10% contain errors (Application Acknowledgment Code = TE or accepted with errors). This is the same as saying that at least 90% of the accepted reports are free of any errors in mandatory/serious or conditional/serious data elements. Note: Trading Partners whose claim volume is too low to reasonably send 30 claims may send fewer claims. Your WCIS contact will be able to advise you on how many claims to send. First Reports: If data do not meet the above data quality criteria on the initial submission because of missing data, the Trading Partner has up to 60 days from the initial submission to fill in missing data in order to meet these criteria (see section 9702(b) of the WCIS regulations). Any corrections made will be reflected in the remainder of the pilot process. The data reporting requirements for each data element are listed in Section K Required Data Elements. Transactions that are rejected (TR) must be corrected and resent with the original MTC code of the rejected transaction. Transactions that are accepted with error (TE) must be corrected and resent with the CO (Correction) MTC code. Test/Production Indicator The Test/Production indicator (DN104) located in the Header record is set to P during the Pilot stage. Data are posted to the California WCIS live database. Maintenance Type Codes Piloted The following are the maintenance type codes piloted in California at this time: FROI 00 (Original) SROI IP (Initial Payment) During the Pilot process, Trading Partners may also need to submit reports with MTC CO (Correction) in order to correct data reported in error or to fill in missing data. Trading Partners may also submit reports with MTC 02 (Change) to update any previously reported data elements that were accepted without error. After a report type has been successfully piloted, all other maintenance type codes for that report type become reportable. For example, once a Trading Partner has successfully piloted Original First Reports, the AU, 01, 04, 02, and CO maintenance type codes for first reports are reportable. Depending on overall Trading Partner performance, California may later choose to incorporate additional maintenance type codes into the piloting requirements. Step 4. Parallel Procedure (Optional) 1. Request Parallel analysis After you have fulfilled the completeness and validity data quality requirements of EDI, the next step is to submit the paper reports of the corresponding EDI reports to be cross-checked for accuracy. Notify your WCIS contact person when you are ready for a Parallel analysis. This person will verify that the EDI completeness and validity requirements are fulfilled before you proceed. Unresolved mismatches between the paper and EDI reports should not exceed 5% of all reportable data elements across all cross-checked reports. In addition, there may be no data mapping errors (e.g., employer telephone number always sent in place of the employee telephone number, or part of body = foot always sent when part of body = hand). A cross-walk of data elements contained on California First Report Forms 5020 and 5021 and on the EDI First Report of Injury is provided at the end of this section. For data elements that appear on all three reports, a match on the EDI First Report with at least one of the corresponding values from the paper reports is required. For example, if the employer address field is filled in on Form 5020 but not on Form 5021, the address on Form 5020 should match the corresponding EDI data elements for employer address. If different employer addresses are provided on Forms 5020 and 5021, one of these addresses should match the corresponding EDI data elements for employer address. Additionally, the following data elements are used in the Parallel analysis: DNData Element44Employee First Name43Employee Last Name45Employee Middle Name/Initial46Employee Street Address Line 148Employee City49Employee State50Employee Postal Code51Employee Phone Number42Social Security Number52Employee Date of Birth53Gender Code61Date of Hire59Class Code58Employment Status Code60Occupation18Employer Name19Employer Street Address Line 121Employer City22Employer State23Employer Postal Code62Wage63Wage Period31Date of Injury65Date Last Day Worked56Date Disability Began35Nature of Injury Code36Part of Body Injured Code37Cause of Injury Code38Accident Description/Cause33Postal Code of Injury Site68Date of Return to Work 57Employee Date of Death40Date Reported to Employer 2. Prepare paper copies of reports First Reports: Make one copy of completed Form 5020, Rev. 6, Employers Report of Occupational Injury or Illness for each Original First Report that you submitted in the EDI portion of the pilot. If you wish, you may also make one copy of Form 5021, Rev. 4, Doctors First Report of Occupational Injury or Illness. This gives you more opportunities for a successful match if information on Form 5020 fails to match the EDI First Report. Fill out a WCIS Parallel Batch Identification Form (at the end of this section). The purpose of this form is to allow DWC to link your EDI reports to your paper reports. Subsequent Reports (IP): Make one copy of the benefit notice sent to the employee notifying him/her of the start of benefit payments for each Subsequent Report that you submitted in the EDI portion of the Pilot. Fill out a WCIS Parallel Batch Identification Form (at the end of this section). This form allows DWC to link your EDI reports to your paper reports. 3. Send paper reports to DWC Send the paper forms to your WCIS liaison. Please include a completed WCIS Parallel Batch Identification Form to facilitate identification of your claims. Mail the entire packet to: WCIS Parallel Phase Attn: Your WCIS Contact Department of Industrial Relations 1515 Clay St, Suite 1800 Oakland, CA 94612 4. Wait for Parallel Analysis Report Your WCIS contact will compare your paper and EDI reports for consistency and prepare a Parallel Analysis Report, which will be sent to you. The report will describe any discrepancies noted between data sent on paper and data sent electronically, as well as any other suspected data issues/errors not detected by the routine EDI program edits. You may be asked to explain any discrepancies. Depending on the extent of the discrepancies, this may require a phone consultation, a meeting, a brief note, or a more formal written justification. Moving from Parallel to Production Status When the data quality criteria of the Pilot and the optional Parallel phase have been met for a given transaction, the Trading Partner will be approved for Production status for that transaction. You will receive written authorization from the Division to submit Production status data to WCIS for the transaction type successfully tested and piloted. Once Production status for a transaction type has been granted, you will no longer be required to send the corresponding paper report to the Division of Labor Statistics and Research (DLSR). Step 5. Production Congratulations! You are now officially in Production for EDI reporting of workers compensation claims data with the State of California Division of Workers Compensation. During Production, the following conditions apply: Paper Reports The EDI First Report fulfills the requirement to submit paper copies of the Employers Report (Form 5020) to the California Division of Labor Statistics and Research (DLSR), pursuant to Labor Code 6409.1 and 8 C.C.R. 14001 (see letter from DLSR in Section EWCIS Regulations). However, the submission of paper copies of the Doctors First Report of Occupational Injury or Illness (Form 5021) to DLSR is still required at this time (LC 6409 and 8 C.C.R. 14001-14002). In the future, submission of the ICD-9 CM Diagnosis Code, on the first Medical Bill/Payment Report, may substitute for the requirement to submit the paper Doctors First Report (Form 5021) to DLSR. Trading Partners in Production status for Subsequent reports satisfy the obligation to submit paper copies of benefit notices to the Administrative Director pursuant to Labor Code 138.4 (see 9702 (h)(1) of the WCIS regulations). Data Quality Requirements Data sent to WCIS will continue to be monitored for completeness and validity. The following are guidelines for data quality that Trading Partners should strive to meet or exceed: At least 95% of transmitted reports should be free of any errors in mandatory/fatal and conditional/fatal data elements, At least 90% of accepted reports should be free of any errors in mandatory/serious and conditional/serious data elements. Note: As in the Pilot phase, these requirements need not be met upon the first submission of data to WCIS. Trading Partners have up to 60 days after the first submission of First Report data to submit data elements that were omitted on the first transmission because they were not known to the claims administrator (see Section 9702(b). Electronic Data Reporting of the WCIS Regulations). Notwithstanding this requirement, the claims administrator is required to transmit data in response to a data error message generated by WCIS, or when the claims administrator becomes aware of the need to update data elements previously transmitted or omitted, no later than the next submission of data for the affected claim (see Section 9702(f) of the WCIS Regulations). DWC anticipates that, in the future, its claims auditors will collect data from claims administrators. These data will be checked for data accuracy against EDI data that were already submitted to WCIS (see LC 129; 8 CCR 10105). Data Quality Reports WCIS automatically monitors the quality of data received from Trading Partners during the Pilot and Production phases. The system tracks all outstanding errors and produces automated data quality reports. The Division provides data quality reports to each Trading Partner upon request. Trading Partner Profile Trading Partner Profiles must be kept up-to-date. The Division must be notified of any changes to the Trading Partner Profile, since these may affect whether WCIS recognizes your transmissions. WCIS PARALLEL BATCH IDENTIFICATION FORM TO: ___________________________ WCIS Contact FROM: TRADING PARTNER (the following information must be as it appears on your Trading Partner Profile) NAME ______________________________________________ ADDRESS ______________________________________________ ______________________________________________ ______________________________________________ FEIN ________________________ ZIP CODE ___________________ DATE(S) ELECTRONIC TRANSMISSION(S) WERE SENT _______________ TOTAL NUMBER OF EDI CLAIMS SENT ___________________ DATE PAPER REPORTS MAILED _________________________ NUMBER OF PAPER REPORTS MAILED ___________________ PREPARED BY __________________________________________________ PHONE _________________________________ COMPLETE THIS FORM AND RETURN WITH COPIES OF PAPER 5020 (and 5021 REPORTS, if desired) OR NOTICES OF INITIAL BENEFIT PAYMENTS TO: WCIS Parallel Phase Attn: WCIS Contact Department of Industrial Relations 1515 Clay St, Suite 1800 Oakland, CA 94612 Section H: File Formats and Supported Transactions Supported Transactions The WCIS accepts transactions in the IAIABC Release 1 format. Since the IAIABC no longer supports the Release 2 format, WCIS does not accept Release 2 transactions. Understanding ANSI and Flat Files The IAIABC has approved two file formats for the electronic submission of Release 1 transactions: ANSI X12 formats based on the American National Standards Institute (ANSI) X12 EDI standard and proprietary IAIABC flat file formats. First ReportsANSI X12 Release 1 (Version 3041) IAIABC Flat File Release 1 Subsequent ReportsANSI X12 Release 1 (Version 3041) IAIABC Flat File Release 1  ANSI X12 is the primary EDI standard for electronic commerce in a wide variety of applications. Data elements are strung together continuously, with special data element identifiers and separator characters delineating individual data elements and records. ANSI X12 is extremely flexible but also somewhat complex, so most X12 users purchase translation software that handles the X12 formatting. Because X12 protocols are used for many types of business communications, X12 translation software is commercially available. Some claim administrators may already be using X12 translation software for purchasing, financial transactions, or other business purposes. The IAIABCs proprietary flat file formats were designed specifically for transferring workers compensation data via EDI. Data elements are placed in assigned character positions within each record. Different records are presented on separate lines of the file. Flat files have the disadvantage of being inflexible and not easily modified. The Release 1 version of the flat files is fairly straightforward to implement without translation software. Section I: The FTP Transmission Modes File Transfer Protocol (FTP) Trading partners will send all data files to an FTPS (FTP over SSL, RFC4217) server hosted by the WCIS. Acknowledgments will be retrieved from the same server. Use of FTPS to encrypt the network connection is required. In addition, trading partners may optionally use PGP (Pretty Good Privacy, RFC4880) to encrypt the files before transmission. A history of the PGP program and frequently asked questions is available at HYPERLINK "http://www/pgpi.org"http://www/pgpi.org. Data Transmission with File Transfer Protocol Certain processes and procedures must be coordinated to ensure the efficient transmission of data and acknowledgment files via FTP. Step 1. Trading Partner Profile Complete the Trading Partner Profile form in section F trading partner profile. The FTP IP address will be provided to trading partners by their trading partner contact person. After the Trading Partner Profile form is completed, follow the steps below. Step 2. FTP server account and password The WCIS FTP server requires a user account and password for access. The account and password is entered in Part C2 on the trading partner profile form. After establishing connectivity, the trading partner may change the password. Password changes and resets must be coordinated with the trading partner contact. Step 3. FTP communication ports The WCIS FTP server requires the following communications ports to be opened for transmissions: 20, 21, 989, and 1024-1224. The ports 1024 and above are used as data channels. The high-numbered ports are assigned sequentially by the server per session. Step 4. FTP over SSL (FTPS) The WCIS FTP server requires explicit security for negotiating communication security for data transfer for SSL. Explicit security supports the AUTH SLL security command. The WCIS FTP server software (i.e. WS_FTP Server) only supports the explicit security. The WCIS FTP server uses passive mode for transferring data. The server waits for the data connection from the trading partners FTP client software to initiate the data transfer process. The WCIS server uses a private root certificate for SSL encryption. When a trading partner establishes connectivity with the WCIS FTP server, its private certificate is exchanged. Some FTP client software (e.g. WS_FTP, Cute FTP, Smart FTP, and Core FTP) acknowledge the private certificate while others do not. If the certificate is not recognized, the trading partner will need to obtain the WCIS FTP servers root certificate from their trading partner contact person and import it into their system. Trading partner source IP address Access to the WCIS FTP server will be restricted to source IP addresses that are entered on the trading partner profile form. Trading partners may provide up to two source IP addresses. The source IP addresses must be public addresses. Although some network systems use private addresses for internal networks (e.g.; 10.0.0.0, 172.16.0.1 and 192.168.1.1), WCIS will require the public IP address that the private addresses translate to. Step 5. Testing FTP connectivity The WCIS trading partner contact and the trading partner will coordinate testing FTP connectivity. Trading partners will be asked to send a plain text file for testing. The file should not contain data, but a simple test message. The file should be named test.txt and placed in the trading partners root directory of the WCIS FTP server. Sending data through FTP Trading partners will send data files to the WCIS FTP server by placing them in a directory named Inbound. The contents of the directory are not visible by the trading partner. File names must be unique and follow file naming conventions prescribed below. An error will occur when a file with the same name as an existing file is uploaded to the Inbound directory of the WCIS FTP server. Receiving acknowledgment files through FTP WCIS will place functional (997), for ANSI formatted data, and detailed acknowledgment files (824 or AK1) on the WCIS FTP server in the trading partners 997 and 824 folders. Trading partners may delete acknowledgment files after they have retrieved the files. WCIS will periodically review contents of the trading partners directory and may delete unauthorized user folders and files older than 14 days old. File naming conventions The file naming conventions will be based on a unique 4 letter file name prefix and one or more unique identifiers, such as date and sequence number. The specific file naming conventions will be specified by each trading partner in Part C2 of the trading partner agreement and must be approved by the DWC. Sending data using PGP encryption Trading partners who choose to send PGP encrypted data to the WCIS FTP server should follow steps 1-5 and exchange PGP keys with the WCIS before sending data. The PGP program is encryption software available from PGP Corporation (HYPERLINK "http://www.pgp.com"http://www.pgp.com) and the International PGP home page (HYPERLINK "http://www.pgpi.org"http://www.pgpi.org). PGP is also available from previous versions of security programs offered by Network Associates (HYPERLINK "http://www.mcafee.com/us"http://www.nai.com), which had previously acquired the license to distribute PGP. If the Trading Partner does not already have a PGP key, it will need to generate its own unique set of PGP keys. The PGP program will create a set of public and private keys based on information you enter into the program. The PGP public keys are required for encryption to provide data security. Data sent to WCIS is encrypted by WCISs public key and files are signed by the Trading Partners private key. The exchange of public keys ensures that the recipient is the only one that is able to read the file and that the sender is the only one that could have sent the data. Please do not share private keys and passwords with anyone else as this would allow others to create files that would appear to have come from you. Transmission Pathways  EMBED Visio.Drawing.11  Section J: Events that Trigger Required EDI Reports Release 1 First Report of Injury For claims with date of injury March 1, 2000 or later. MTCEventTime Report is Due00A new Employers Report OR A new Doctors First Report of Injury OR An Application for Adjudication OR Information that an injury requires medical treatment by a physician.Within10 business days (report all data known to the claims administrator)01A previously sent First Report was sent in error.Within 10 business days of event02Previously sent First Report was incomplete.Within 60 days of original first report submission 02Data in previous First Report have changed.By next date a submission is due for the claimAUClaim acquired from another claims administrator.Within 10 business days of event COCorrection of previously reported data, in response to a TE (transaction accepted with error) acknowledgment.By next date a submission is due for the claim 04Denial of Claim and no benefits were paid.Within 10 business days of eventMTC is the Maintenance Type Code and is included in all EDI transactions to identify the type of transaction that is being reported. Definitions and technical specifications for each MTC can be found in the IAIABC EDI Implementation Guide at HYPERLINK "http://www.iaiabc.org"http://www.iaiabc.org. Release 1 Subsequent Report of Injury For claims with date of injury July 1, 2000 or later. MTCEventTime Report is DueIPInitial payment of an indemnity benefit.Within 15 business days of eventAPFirst payment of benefits on a claim acquired from another claim administrator.Within 15 business days of eventFSEmployer is paying the injured workers salary.Within 15 business days of eventCDInjured worker died because of a covered injury.Within 15 business days of event04Claim is denied and benefits were paid, including medical.Within 15 business days of event4PA specific benefit has been denied.Within 15 business days of event02A previous benefit report has changed or Employee representation has changed. (Do not include changes in weekly benefit rates/ benefit type).By next date a submission is due for the claim CAThe weekly benefit rate has changed.Within 15 business days of eventCBCurrent benefit type is ending and a new benefit type is beginning or a concurrent benefit type is beginning.Within 15 business days of eventREThe injured worker may return to work with reduced earnings.Within 15 business days of eventP1/S1*Employee returned to work, payments stopped.Within 15 business days of eventP2/S2*There is a medical noncompliance, payments stopped.Within 15 business days of eventP3/S3*There is an administrative noncompliance, payments stopped.Within 15 business days of eventP4/S4*Employee died, payments stopped.Within 15 business days of eventP5/S5*Employee is incarcerated, payments stopped.Within 15 business days of eventS6Employees whereabouts unknown, payments stopped.Within 15 business days of eventP7/S7*Benefits exhausted, payments stopped.Within 15 business days of eventS8Jurisdiction changed, payments stopped.Within 15 business days of eventP9/S9*A settlement is pending, payments stopped.Within 15 business days of eventPJ/SJ*An appeal or review is pending, payments stopped.Within 15 business days of eventRBBenefits are being reinstated after a suspension.Within 15 business days of eventPY^An advance or settlement has been paid.Within 15 business days of eventCOCorrection of previously reported data, in response to a TE (transaction accepted with error).By next date a submission is due for the claim FN#Claim is closed.Within 15 business days of event MTC is the Maintenance Type Code and is included in all EDI transactions to identify the type of transaction that is being reported. Definitions and technical specifications for each MTC can be found in the IAIABC EDI Implementation Guide at HYPERLINK "http://www.iaiabc.org"http://www.iaiabc.org. *If one or more benefit payments continue after the suspension of a concurrent benefit payment, use the MTC Px indicate a partial suspension. If all benefit payments are being suspended, use the MTC Sx. #The WCIS will support substitution of a FN (final) for a final AN (annual), provided that the claim is closed without further benefit activity. ^If the advance or settlement is the first indemnity payment, send the Initial Payment (IP) instead. Examples of an advance are a permanent disability advance or a temporary disability advance for a Qualified Medical Evaluation (QME) appointment. Advances should be reported using the appropriate Payment/Adjustment Codes (DN85). Examples of settlements are Compromise and Release (C&R), commutation and stipulated settlements. Settlements should be sent with the 5xx compromised Payment/Adjustment Codes (DN85). Please refer to Section M-System Specifications for more details. Release 1 Annual Summary For claims with date of injury July 1, 2000 or later. MTCEventTime Report is DueAN#Cumulative totals of payments in any benefit category through the previous calendar year for each claim that had a payment in the same year. The exception to this rule is for the claims where there is no further benefit activity after the final (FN) report has been accepted and the FN included all the indemnity and/or non-indemnity benefit data. If no payments were made in the previous calendar year, then an AN does not need to be filed for that year. By January 31 for the preceding year (starting in 2001) WCIS will only support the AN (annual) and the FN (final) periodic reports. Any other periodic reports will be rejected. MTC is the Maintenance Type Code. The MTC is included in all EDI transactions to identify the type of transaction that is being reported. Definitions and technical specifications for each MTC can be found in the IAIABC EDI Implementation Guide at HYPERLINK "http://www.iaiabc.org"http://www.iaiabc.org. #For non-indemnity claims, WCIS will accept substitution of a final AN (annual) for a FN (final), provided that the AN reports the claim status (DN73) as closed. Section K: Required Data Elements This section indicates the data elements that are to be included in EDI transmission of First Reports of Injury and Subsequent Reports of Injury. Specific requirements depend upon the type of transaction reported (original report, change, correction, etc.) The transaction type is identified by the Maintenance Type Code, or MTC. Definitions and technical specifications for each MTC and data element can be found in the IAIABC EDI Implementation Guide at HYPERLINK "http://www.iaiabc.org"http://www.iaiabc.org. To fully understand the reporting requirements for each data element, please see both the data requirement tables and the associated conditional rules and implementation notes. The Conditional Rules and Implementation Notes tables provide specific details on when conditional requirements for each data element apply, as well as California implementation notes. WCIS Data Requirement Codes The WCIS incorporates flexible data handling. Rather than requiring all data elements on all reports, WCIS specifies a minimal list of data items that must be provided in a given situation. Each data element is designated as Mandatory, Conditional, or Optional for each transaction type. Validity errors for required data elements are designated Fatal, Serious, or Minor. The table below describes the designations of data requirements in the WCIS. The data requirements tables that follow specify which designation applies for each data element on a given transaction. Code Description M/FMandatory/ FatalReporting is Mandatory. Validity errors are Fatal and will result in rejection of the faulty record.M/SMandatory/ SeriousReporting is Mandatory. Validity errors are Serious: WCIS will accept the faulty record but will produce an error message.M/MMandatory/ MinorReporting is Mandatory. Validity errors are regarded as Minor. No error message will be returned. Errors will be tracked internally and may be summarized periodically for each claims administrator.C/FConditional/FatalReporting is Conditional. Validity errors are Fatal when reporting conditions are present and will result in rejection of the faulty record.C/SConditional/ SeriousReporting is Conditional. Validity errors are Serious when the reporting conditions are present. WCIS will accept the faulty record, but will produce an error message.C/MConditional/ MinorReporting is Conditional. Validity errors are regarded as Minor, often because WCIS cannot detect the conditions under which these elements should be reported. No error message will be produced.OOptionalReporting is Optional. No error messages will be produced.Note: Error severity levels may evolve over time. Ample notification will be provided of any planned changes. Data Requirements for First Reports of InjuryMaintenance Type CodesOriginalAcquired / UnallocatedCancelDenialChange, CorrectionDN#Release 1 Data Element Name00AU0104* 02, COTransaction1Transaction Set IDM/FM/FM/FM/FM/F2Maintenance Type Code M/FM/FM/FM/FM/F3Maintenance Type Code Date M/FM/FM/FM/FM/FJurisdiction4JurisdictionM/FM/FM/FM/FM/FInsurer6Insurer FEINM/FM/FM/FM/FM/F7Insurer NameM/FM/FOM/FM/SClaim Administrator8Third Party Administrator FEINC/FC/FC/FC/FC/F9Third Party Administrator NameC/SC/SC/SC/SC/S10Claim Administrator Address Line 1M/MM/MOM/MM/M11Claim Administrator Address Line 2C/MC/MOC/MC/M12Claim Administrator CityM/MM/MOM/MM/M13Claim Administrator StateM/MM/MOM/MM/M14Claim Administrator Postal Code**M/FM/FOM/FM/FEmployer16Employer FEINM/SM/SOM/SM/S18Employer NameM/SM/SOM/FM/S19Employer Address Line 1M/MM/MOM/MM/M20Employer Address Line 2C/MC/MOC/MC/M NOTES: * Denial 04: If a claim is denied and no benefit was paid, then FROI MTC 04 Denial must be sent. ** DN14 is the 9-digit Postal Code of the physical location of the Claims Administrator handling this claim. Data Requirements for First Reports of InjuryMaintenance Type CodesOriginalAcquired / UnallocatedCancelDenialChange, CorrectionDN#Release 1 Data Element Name00AU0104* 02, COEmployer, continued21Employer CityM/MM/MOM/MM/M22Employer State M/MM/MOM/MM/M23Employer Postal CodeM/SM/SOM/SM/S24Self Insured IndicatorM/FM/SOM/FM/S25Industry CodeM/SM/SM/SM/SM/SAccident31Date of InjuryM/FC/FOM/FM/F32Time of InjuryOOOOO33Postal Code of Injury SiteM/SM/SOM/SM/S35Nature of Injury CodeM/SC/SOM/SM/S36Part of Body Injured CodeM/SC/SOM/SM/S37Cause of Injury CodeM/SM/SOM/SM/S38Accident Description/CauseM/MM/MOM/MM/M39Initial TreatmentOOOOO40Date Reported to EmployerM/SM/SOM/MM/S41Date Reported to Claim AdministratorM/SM/SOM/SM/SClaim5Agency Claim Number****** C/MC/FC/MC/F15Claim Administrator Claim NumberM/FM/FC/FM/FM/F26Insured Report NumberOOOOO28Policy NumberC/SC/SOC/SC/S29Policy Effective DateC/SC/SOC/SC/S30Policy Expiration DateC/SC/SOC/SC/SEmployee42Social Security NumberM/SM/SOM/SM/S43Employee Last NameM/FC/FOM/FM/F44Employee First NameM/FC/FOM/FM/F45Employee Middle InitialC/MC/MOC/MC/M46Employee Address Line 1M/MM/MOM/MM/M47Employee Address Line 2C/MC/MOC/MC/M Data Requirements for First Reports of InjuryMaintenance Type CodesOriginalAcquired / UnallocatedCancelDenialChange, CorrectionDN#Release 1 Data Element Name00AU0104* 02, COEmployee, continued48Employee CityM/MM/MOM/MM/M49Employee State M/MM/MOM/MM/M50Employee Postal CodeM/MM/MOM/MM/M51Employee Phone C/MC/MOC/MC/M52Employee Date of BirthM/SM/SOM/SM/S53Gender CodeM/SM/SOM/SM/S54Marital Status CodeC/SC/SOC/SC/S55Number of DependentsC/SC/SOC/SC/S56Date Disability BeganC/MC/MOC/MC/M57Employee Date of DeathC/MC/MOC/MC/M68Date of Return to WorkC/MC/MOC/MC/MEmployment58Employment Status CodeM/MM/MOM/MM/M59Class Code****M/SM/SOM/SM/S60Occupation DescriptionM/SM/SOM/SM/S61Date of HireM/MM/MOM/MM/M62WageC/MC/MOC/MC/M63Wage PeriodC/SC/SOC/SC/S65Date Last Day WorkedC/MC/MOC/MC/M67Salary Continued IndicatorM/MM/MOM/MM/MNOTES: * Denial 04: If a claim is denied and no benefit was paid, then FROI MTC 04 Denial must be sent. ** DN14 is the 9 digit Postal Code of the physical location of the Claims Administrator handling this claim. *** DN5 (Agency Claim Number/Jurisdiction Claim Number) must be blank on the 00 FROI. **** DN59 (Class Code) is the California-specific class code from the Workers Compensation Insurance Rating Bureau (HYPERLINK "https://wcirbonline.org/wcirb/Answer_center/classification_information.html"WCIRB) of California. The National Council on Compensation Insurance (NCCI) class codes are not accepted.  FROI Conditional Rules and Implementation NotesDN#Release 1 Data Element NameNotes or explanation of Conditional Requirements (C/F or C/S)Transaction1Transaction Set ID2Maintenance Type Code 3Maintenance Type Code Date Jurisdiction4Jurisdiction CodeCALIFORNIA EDIT: Must be "CA". Insurer6Insurer FEINIf self-insured, provide Employer FEIN in this field.7Insurer NameIf self-insured, provide Employer Name in this field.Claim Administrator8Third Party Administrator FEINIf not self-administered, then Mandatory9Third Party Administrator NameIf TPA FEIN provided, then TPA Name Mandatory10Claim Administrator Address Line 111Claim Administrator Address Line 212Claim Administrator City13Claim Administrator State 14Claim Administrator Postal CodeMust be a valid Postal code.Employer16Employer FEINIf employer has no FEIN or refuses to provide, send "000000006 ". Employer FEIN should not equal Insurer FEIN unless self-insured.18Employer Name19Employer Address Line 120Employer Address Line 221Employer City22Employer State 23Employer Postal CodeMust be a valid Postal code.24Self Insured Indicator25Industry CodeSee Section N for reporting guidelines on industry code.Accident31Date of InjuryIf MTC=AU AND Jurisdiction Claim Number (DN5) not provided, then Mandatory. 32Time of Injury33Postal Code of Injury SiteMust be a valid Postal code.35Nature of Injury CodeIf MTC=AU AND Jurisdiction Claim Number (DN5) not provided, then Mandatory. 36Part of Body Injured CodeIf MTC=AU AND Jurisdiction Claim Number (DN5) not provided, then Mandatory. 37Cause of Injury Code38Accident Description/Cause39Initial Treatment 40Date Reported to Employer41Date Reported to Claim Administrator Must be a valid date. FROI Conditional Rules and Implementation NotesDN#Release 1 Data Element NameNotes or explanation of Conditional Requirements (C/F or C/S)Claim5Jurisdiction Claim Number/ Agency Claim NumberFor FROI MTC=01, 02, CO and all Subsequent Reports: Self-administered Insurers: If Insurer FEIN (DN6) AND Claim Administrator Claim Number (DN15) are missing, then Agency Claim Number/Jurisdiction Claim Number (DN5) is Mandatory. Third Party-administered Insurers: If TPA FEIN (DN8) AND Insurer FEIN (DN6) AND Claim Administrator Claim Number (DN15) are missing, then Agency Claim Number/Jurisdiction Claim Number (DN5) is Mandatory.15Claim Administrator Claim NumberFor FROI MTC=01 and all Subsequent Reports (except 02 & CO): If JCN (DN5) is missing, then Claim Administrator Claim Number (DN15) is Mandatory. 26Insured Report Number28Policy NumberIf (MTC=00, AU, 04, 02, or CO) AND Self Insured Indicator (DN24)=N, then Mandatory.29Policy Effective DateIf (MTC=00, AU, 04, 02, or CO) AND Self Insured Indicator (DN24)=N, then Mandatory.30Policy Expiration DateIf (MTC=00, AU, 04, 02, or CO) AND Self Insured Indicator (DN24)=N, then Mandatory.Employee42Social Security NumberIf employee has no SSN or refuses to provide, send "000000006.43Employee Last NameIf MTC=AU AND Jurisdiction Claim Number (DN5) not provided, then Mandatory. 44Employee First NameIf MTC=AU AND Jurisdiction Claim Number (DN5) not provided, then Mandatory. 45Employee Middle Initial46Employee Address Line 147Employee Address Line 248Employee City49Employee State50Employee Postal CodeMust be a valid postal code.51Employee Phone 52Employee Date of Birth53Gender Code54Marital Status CodeIf Date of Death provided, then Mandatory. 55Number of DependentsIf Date of Death provided, then Mandatory. 56Date Disability Began57Employee Date of DeathMandatory if injured worker died.68Date of Return to WorkEmployment58Employment Status Code59Class CodeFor self-insureds (DN24=Y), send a valid WCIRB class code or send no code at all. For all others, a valid WCIRB class code must be sent. 60Occupation Description61Date of Hire62Wage63Wage PeriodIf Average Wage (DN62) provided, then Mandatory. 65Date Last Day Worked67Salary Continued Indicator Data Requirements for Subsequent Report of InjuryMaintenance Type CodeInitial PaymentAcquired PaymentFull SalaryCompen-sable DeathPartial DenialDenialChange in AmountChange in BenefitReduced EarningsPartial Suspen-sionsSuspen- sionsReinstate- ment of BenefitsChange, CorrectionPaymentFinalAnnualUpon RequestDN#Release 1 Data Element NameIPAPFSCD4P04*CACBREP1-9, PJS1-9, SJRB02, COPYFNANURTransaction1Transaction Set IDM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/F2Maintenance Type Code M/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/F3Maintenance Type Code Date M/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FJurisdiction4JurisdictionM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FInsurer6Insurer FEINM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FClaim Administrator8Third Party Administrator FEINC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/F14Claim Administrator Postal Code**M/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FAccident31Date of InjuryOOOOOOOOOOOOM/FOOOOClaim5Agency Claim NumberC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/F15Claim Administrator Claim NumberC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FC/FM/FC/FC/FC/FC/F26Insured Report NumberOOOOOOOOOOOOOOOOO73Claim StatusOOOOM/SM/SOOOOOOM/SM/SM/SOM/S74Claim TypeOOOOOOOOOOOOOOOOO76Date of RepresentationC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/M Data Requirements for Subsequent Report of InjuryMaintenance Type CodeInitial PaymentAcquired PaymentFull SalaryCompen-sable DeathPartial DenialDenialChange in AmountChange in BenefitReduced EarningsPartial Suspen-sionsSuspen- sionsReinstate- ment of BenefitsChange, CorrectionPaymentFinalAnnualUpon RequestDN#Release 1 Data Element NameIPAPFSCD4P04*CACBREP1-9, PJS1-9, SJRB02, COPYFNANUREmployee42Social Security NumberOOOOOOOOOOOOC/MOOOO55Number of DependentsOOOC/SOOOOOOOOC/SOOOO56Date Disability BeganC/SC/MC/SOOOOC/SOOOC/SC/SOOOC/S57Employee Date of DeathOOOM/SOOOOOC/SC/SOC/MOC/SOO70Date of Maximum Medical ImprovementOOOOOOOOOOOOOOC/FOC/F71Return to Work QualifierC/MC/MC/MOOOC/MC/MM/SC/SC/SOC/MOOOC/M72Date of Return/Release to WorkC/MC/MC/MOOOC/MC/MM/SC/SC/SOC/MOOOC/MEmployment62WageM/SM/SOOOOM/SM/SOOOOM/SOOOM/S63Wage PeriodC/SC/SOOOOC/SC/SOOOOC/SOOOC/S67Salary Continued IndicatorOOM/MOOOOOOOOOM/MOOOOPayments77Late Reason CodeC/MC/MC/MOOC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MOC/M Data Requirements for Subsequent Report of InjuryMaintenance Type CodeInitial PaymentAcquired PaymentFull SalaryCompen-sable DeathPartial DenialDenialChange in AmountChange in BenefitReduced EarningsPartial Suspen-sionsSuspen- sionsReinstate- ment of BenefitsChange, CorrectionPaymentFinalAnnualUpon RequestDN#Release 1 Data Element NameIPAPFSCD4P04*CACBREP1-9, PJS1-9, SJRB02, COPYFNANUR Variable Segment 78Number of Permanent ImpairmentsM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/F79Number of Payments/AdjustmentsM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/F80Number of Benefit AdjustmentsM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/F81Number of Paid to Dates/Reduced Earnings/RecoveriesM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/F82Number of Death Dependent/Payee RelationshipsM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FM/FPermanent Impairments83Permanent Impairment Body Part CodeC/SC/SOOOC/SOC/SOOOOC/SC/SC/SOC/S84Permanent Impairment PercentageOOOOOOOOOOOOOOC/FOC/F Data Requirements for Subsequent Report of InjuryMaintenance Type CodeInitial PaymentAcquired PaymentFull SalaryCompen-sable DeathPartial DenialDenialChange in AmountChange in BenefitReduced EarningsPartial Suspen-sionsSuspen- sionsReinstate- ment of BenefitsChange, CorrectionPaymentFinalAnnualUpon RequestDN#Release 1 Data Element NameIPAPFSCD4P04*CACBREP1-9, PJS1-9, SJRB02, COPYFNANURBenefit Payments85Payment/Adjustment CodeM/FM/FM/FC/FC/FC/FM/FM/FM/FM/FM/FM/FC/FM/SC/SC/SC/F86Payment/Adjustment Paid to DateM/FM/FM/FC/FC/FC/FM/FM/FM/FM/FM/FM/FC/FM/SC/SC/SC/F87Payment/Adjustment Weekly AmountM/FM/FM/FOC/FOM/FM/FM/FM/FM/FM/FC/FOC/FC/FC/F88Payment/Adjustment Start DateM/FM/FM/FC/FC/FC/FM/FM/FM/FM/FM/FM/FC/FC/FC/FC/FC/F89Payment/Adjustment End DateM/FM/FM/FC/FC/FC/FM/FM/FM/FM/FM/FM/FC/FC/FC/FC/FC/F90Payment/Adjustment Weeks PaidM/FM/FM/FOC/FOM/FM/FM/FM/FM/FM/FC/FOC/FC/FC/F91Payment/Adjustment Days PaidM/FM/FM/FOC/FOM/FM/FM/FM/FM/FM/FC/FOC/FC/FC/FBenefit Adjustments92Benefit Adjustment CodeOOOOOOOOOOOOOOOOO93Benefit Adjustment Weekly AmountOOOOOOOOOOOOOOOOO94Benefit Adjustment Start DateOOOOOOOOOOOOOOOOOPaid to Date95Paid to Date/Reduced Earnings/Recoveries CodeC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MOC/SC/SC/M96Paid to Date/Reduced Earnings/Recoveries AmountC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MC/MOC/SC/SC/MNOTES: * SROI 04 Denial: If a claim is denied and benefits were paid, then SROI MTC 04 Denial must be sent. ** DN14 is the 9 digit Postal Code of the physical location of the Claims Administrator handling this claim. SROI Conditional Rules and Implementation NotesDN#Release 1 Data Element NameNotes or explanation of Conditional Requirements (C/F or C/S)Transaction1Transaction Set ID2Maintenance Type CodeIf MTC = CB or RB, then must be preceded by at least one previous benefit event of any Payment/Adjustment Code. If MTC = FS, then must contain benefit record with Payment/Adjustment Code = 240 or 524. If MTC = FN, then all previously reported benefit periods should be closed. If MTC = VE, BM, BW, MN, QT, or SA reported transaction will be rejected.3Maintenance Type Code DateJurisdiction4JurisdictionCALIFORNIA EDIT: Must be "CA".Insurer6Insurer FEINIf self-insured, provide Employer FEIN in this field.Claim Administrator8Third Party Administrator FEINIf not self-administered, then Mandatory.14Claim Administrator Postal CodeMust be a valid postal code.Accident31Date of InjuryClaim5Jurisdiction Claim Number/Agency Claim NumberFor FROI MTC=01, 02, CO and all Subsequent Reports Self-administered Insurers: If Insurer FEIN (DN6) AND Claim Administrator Claim Number (DN15) are missing, then Agency Claim Number/Jurisdiction Claim Number (DN5) is Mandatory. Third Party-administered Insurers: If TPA FEIN (DN8) AND Insurer FEIN (DN6) AND Claim Administrator Claim Number (DN15) are missing, then Agency Claim Number/Jurisdiction Claim Number (DN5) is Mandatory.15Claim Administrator Claim NumberFor FROI MTC=01 and all Subsequent Reports (except 02 & CO): If JCN (DN5) is missing, then Claim Administrator Claim Number (DN15) is Mandatory.26Insured Report Number73Claim Status74Claim Type76Date of Representation SROI Conditional Rules and Implementation NotesDN#Release 1 Data Element NameNotes or explanation of Conditional Requirements (C/F or C/S)Employee42Social Security NumberIf employee has no SSN or refuses to provide, send "000000006"55Number of DependentsIf Date of Death provided, then Mandatory. 56Date Disability BeganIf reporting temporary disability benefits (DN85=050, 051, or 070), then Mandatory.57Employee Date of DeathIf MTC=P4 or MTC=S4 or [MTC=FN and transaction includes any Payment/Adjustment Code (DN85) = 010 or 510], then Mandatory.70Date of Maximum Medical ImprovementIf reporting and closing permanent disability benefits (DN85=020, 021, 030, 040, 090 or 520, 521, 530, 540, or 590), then Mandatory.71Return to Work QualifierIf MTC=S1 or MTC=P1 (returned to work), then Mandatory.72Date of Return/Release to WorkIf MTC=S1 or MTC=P1 (returned to work), then Mandatory. Must be a valid date.Employment62Wage63Wage PeriodIf Wage (DN62) provided, then Mandatory.67Salary Continued IndicatorPayments77Late Reason CodeVariable Segment78Number of Permanent ImpairmentsEDIT: Must be >0 if [MTC={IP, AP, AB, CB, PY, FN, SROI 02 or SROI CO} AND starting or updating PD benefits (i.e. DN86>0 AND DN85={020, 021, 030, 040 or 090})]; SERIOUS error, code = 62; required segment not present.79Number of Payment AdjustmentsFATAL EDIT: If [MTC={IP, AP, FS, CA, CB, RE, Px, Sx, or RB}] then DN79 must be >0; SERIOUS EDIT: If [MTC=4P or (MTC=PY and DN81 = 0) or (MTC={AN or FN} and Claim Administrator previously reported events with DN86>0) then DN79 must be > 0; error code = 62; Required segment not present.80Number of Benefit Adjustments81Number of Paid to Dates/Reduced Earnings/RecoveriesEDIT: If [(MTC=PY and DN79 = 0) or (MTC=AN and Claim Administrator previously reported events with DN96>0)] then must have DN81>0. FATAL Error, code = 062: Required segment not present.82Number of Death Dependent/Payee Relationships SROI Conditional Rules and Implementation NotesDN#Release 1 Data Element NameNotes or explanation of Conditional Requirements (C/F or C/S)Permanent Impairments83Permanent Impairment Body Part CodeUse Codes 90 (Multiple Body Parts) or 99 (Whole Body) to reflect combined rating for all impairments.If [MTC={IP, AP, SROI 04, CB, PY, FN, SROI 02, SROI CO or SROI UR} AND starting, denying or updating PD benefits (i.e. DN86>0 AND DN85={DN85=020, 021, 030, 040, 090 or 520, 521, 530, 540, or 590})] then Mandatory. 84Permanent Impairment PercentageReport percent for DN83=90 (Multiple Body Parts) or 99 (Whole Body) to reflect combined rating for any/all impairments.If [MTC={IP, AP, SROI 04, CB, PY, FN, SROI 02, SROI CO or SROI UR} AND PD benefits (i.e. DN86>0 AND DN85={DN85=020, 021, 030, 040, 090 or 520, 521, 530, 540, or 590})] then Mandatory. Benefit Payments85Payment/Adjustment CodeIf [MTC={AN, FN, CD, 4P, UR or SROI 04} AND database includes any open or closed benefit records with DN86>0], then Mandatory. If [(MTC = 02 or MTC = CO) AND indemnity payment previously. reported], then Mandatory. FATAL EDIT: If DN86 is reported, DN85 must be a valid Payment/Adjustment code.86Payment/Adjustment Paid to DateIf [MTC={AN, FN, CD, 4P, UR or SROI 04} AND database includes any open or closed benefit records with DN86>0], then Mandatory. If [(MTC = 02 or MTC = CO) AND indemnity payment previously reported], then Mandatory. FATAL EDIT: If DN85 is reported, DN86 must be >= 0. SROI Conditional Rules and Implementation NotesDN#Release 1 Data Element NameNotes or explanation of Conditional Requirements (C/F or C/S)Benefit Payments 87Payment/Adjustment Weekly AmountIf [MTC={AN, FN, UR, SROI 02 or CO} AND DN85 = 010, 020, 030, 040, 050, 051, 070, 080, 090, 240, 410}, then Mandatory88Payment/Adjustment Start DateNote: If using DN85/DN86 to report a lump-sum payment or settlement, MTC, Start and End Date is assumed to be settlement date. If {MTC=SROI 02, 04, 4P, CD, CO, PY, AN, FN, or UR) and (DN86 > 0)} then Mandatory. 89Payment/Adjustment End DateEDIT: Must be >= Ben. Period Start Date (DN88). Note: If using DN85/DN86 to report a lump-sum payment or settlement, MTC, Start and End Date is assumed to be settlement date. If {MTC=SROI 02, 04, 4P, CD, CO, PY, AN, FN, or UR) and (DN86 > 0)} then Mandatory. 90Payment/Adjustment Weeks PaidIf [MTC={4P, AN, FN, UR, SROI 02 or CO} AND DN85 = 010, 020, 030, 040, 050, 051, 070, 080, 090, 240, 410}, then Mandatory91Payment/Adjustment Days PaidIf [MTC={4P, AN, FN, UR, SROI 02 or CO} AND DN85 = 010, 020, 030, 040, 050, 051, 070, 080, 090, 240, 410}, then MandatoryBenefit Adjustments92Benefit Adjustment CodeFATAL EDIT: If DN93 is reported, DN92 must be a valid Benefit Adjustment code.93Benefit Adjustment Weekly AmountFATAL EDIT: If DN92 is reported, DN93 must be >= 0.94Benefit Adjustment Start DatePaid to Dates95Paid to Date/Reduced Earnings/Recoveries CodeIf MTC=AN or MTC = FN AND Claim Administrator previously reported events with DN96>0, then Mandatory. FATAL EDIT: If DN96 is reported, DN95 must be a valid Paid To Date code.96Paid to Date/Reduced Earnings/Recoveries AmountIf MTC=AN or MTC = FN AND Claim Administrator previously reported events with DN96>0, then Mandatory. FATAL EDIT: If DN95 is reported, DN96 must be >= 0. Section L: California-Specific Data Edits and Sorted Data Element Lists California-specific data edits supplement the standard IAIABC edits, which are a part of the WCIS system. See the IAIABC EDI Implementation Guide, available at HYPERLINK "http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3338"http://www.iaiabc.org for information on standard IAIABC edits. Current Edits At this time, data sent to the WCIS are subject to California-specific edits, such as Jurisdiction Code (DN4) must be CA. Additional edits are listed in the tables below. All Transactions DNData Element NameCA-Specific Data Edit(s)2Maintenance Type Code See Transaction Sequence Requirement tables in Section M System Specifications 3Maintenance Type Code DateMust be >= Date of Injury (dn31) Must be <= Current Date4Jurisdiction CodeMust = CA6INSURER FEINMust match insurer FEIN on INSURER/CLAIM ADMINISTRATOR ID list for Sender8THIRD PARTY ADMNISTRATOR FEINMust match TPA FEIN on INSURER/CLAIM ADMINISTRATOR ID list for Sender15CLAIM ADMINISTRATOR CLAIM NUMBERMust not contain special characters: *, ~ First Reports (FROIs) DNData Element NameCA-Specific Data Edit(s)5Agency CLAIM NUMBER/JURISDICTION cLAIM NUMBERMust be NULL for MTC 0010CLAIM ADMINISTRATOR ADDRESS LINE 1Must not consist solely any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a12claim administrator cityMust not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a18employer nameMust not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a19employer address LINE 1Must not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a21employer cityMust not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a First Reports (cont.) DNData Element NameCA-Specific Data Edit(s)31Date of injuryMust be >= Date of Hire (DN61) (Disregard IAIABC edit: Must be <= Date of Hire)42social security numberMust be 9 digits Must not equal 123456789 Must not be the same digits, e.g. 111111111, 222222222, etc. Must not equal 98765432143employee last nameMust not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a44employee first nameMust not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a46employee address LINE 1Must not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a48employee cityMust not consist solely of any of the following non-case sensitive strings: unk, unknown, dk, dont know, na, n/a51employee phone All digits cannot be the same56date disability beganMust be >= DATE LAST DAY WORKED (DN65)59CLASS CODEFor self-insureds: if a class code is sent, it must be a valid WCIRB class code. For all others: must be a valid WCIRB class code.65Date Last Day WorkedMust be <= DATE DISABILITY BEGAN (DN56)68DATE of return to workMust be >= DATE DISABILITY BEGAN (DN56) Subsequent Reports (SROIs) DNData Element NameCA-Specific Data Edit(s)70date of maximum medical improvementMust be >= DATE DISABILITY BEGAN (DN56)72DATE of return/RELEASE to work Must be >= DATE OF RETURN TO WORK (DN68) 85PAYMENT/ADJUSTMENT CODEBenefit Codes 021, 040, 051, 080, 410, 521, 541, 540, 551 and 580 should not be sent on most recent claims. *86PAYMENT/ADJUSTMENT PAID TO DATEMust be >= $0; Cannot be NULL88PAYMENT/ADJUSTMENT START DATEMust be a valid date format89PAYMENT/ADJUSTMENT END DATEMust be a valid date format 93benefit Adjustment WEEKLY amountMust be >= $0; Cannot be NULL 94benefit/Adjustment start dateMust be a valid date format 96PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODEMust be >= $0; Cannot be NULL *See Section N-Code Lists for more information California-adopted IAIABC Data Elements FROI Data Elements, Sorted by Data Element Number (DN) Release 1 - FROI - 148CATEGORY: FROI DataDNDATA ELEMENT NAMERequirements TableCA0001Transaction Set IDTransactionCA0002Maintenance Type CodeTransactionCA0003Maintenance Type Code DateTransactionCA0004Jurisdiction CodeJurisdictionCA0005Agency Claim Number/Jurisdiction Claim NumberClaimCA0006Insurer FEINInsurerCA0007Insurer NameInsurerCA0008Third Party Administrator FEINClaim AdministratorCA0009Third Party Administrator NameClaim AdministratorCA0010Claim Administrator Address Line 1Claim AdministratorCA0011Claim Administrator Address Line 2Claim AdministratorCA0012Claim Administrator CityClaim AdministratorCA0013Claim Administrator State CodeClaim AdministratorCA0014Claim Administrator Postal CodeClaim AdministratorCA0015Claim Administrator Claim NumberClaimCA0016Employer FEINEmployer0017Insured NameCA0018Employer NameEmployerCA0019Employer Address Line 1EmployerCA0020Employer Address Line 2EmployerCA0021Employer CityEmployerCA0022Employer State CodeEmployerCA0023Employer Postal CodeEmployerCA0024Self Insured IndicatorEmployerCA0025Industry CodeEmployerCA0026Insured Report NumberClaim0027Insured Location NumberCA0028Policy NumberClaimCA0029Policy Effective DateClaimCA0030Policy Expiration DateClaimCA0031Date of InjuryAccidentCA0032Time of InjuryAccidentCA0033Postal Code of Injury SiteAccident0034Employer's Premises IndicatorCA0035Nature of Injury CodeAccidentFROI Data Elements, Sorted by Data Element Number (DN), continued DNDATA ELEMENT NAMECATEGORYCA0036Part of Body Injured CodeAccidentCA0037Cause of Injury CodeAccidentCA0038Accident Description/CauseAccidentCA0039Initial Treatment CodeAccidentCA0040Date Reported to EmployerAccidentCA0041Date Reported to Claim AdministratorAccidentCA0042Social Security NumberEmployeeCA0043Employee Last NameEmployeeCA0044Employee First NameEmployeeCA0045Employee Middle Name/InitialEmployeeCA0046Employee Address Line 1EmployeeCA0047Employee Address Line 2EmployeeCA0048Employee CityEmployeeCA0049Employee State CodeEmployeeCA0050Employee Postal CodeEmployeeCA0051Employee Phone NumberEmployeeCA0052Employee Date of BirthEmployeeCA0053Gender CodeEmployeeCA0054Marital Status CodeEmployeeCA0055Number of DependentsEmployeeCA0056Date Disability BeganEmployeeCA0057Employee Date of DeathEmployeeCA0058Employment Status CodeEmploymentCA0059Class CodeEmploymentCA0060Occupation DescriptionEmploymentCA0061Date of HireEmploymentCA0062WageEmploymentCA0063Wage Period CodeEmployment0064Number of Days WorkedCA0065Date Last Day WorkedEmployment0066Full Wages Paid for Date of Injury IndicatorCA0067Salary Continued IndicatorEmploymentCA0068Date of Return to WorkEmployee FROI Data Elements, Sorted Alphabetically Release 1 - FROI - 148CATEGORY: FROI DataDNDATA ELEMENT NAMERequirements TableCA0038Accident Description/CauseAccidentCA0005Agency Claim Number/Jurisdiction Claim NumberClaimCA0037Cause of Injury CodeAccidentCA0010Claim Administrator Address Line 1Claim AdministratorCA0011Claim Administrator Address Line 2Claim AdministratorCA0012Claim Administrator CityClaim AdministratorCA0015Claim Administrator Claim NumberClaimCA0014Claim Administrator Postal CodeClaim AdministratorCA0013Claim Administrator State CodeClaim AdministratorCA0059Class CodeEmploymentCA0056Date Disability BeganEmployeeCA0065Date Last Day WorkedEmploymentCA0061Date of HireEmploymentCA0031Date of InjuryAccidentCA0068Date of Return to WorkEmployeeCA0041Date Reported to Claim AdministratorAccidentCA0040Date Reported to EmployerAccidentCA0046Employee Address Line 1EmployeeCA0047Employee Address Line 2EmployeeCA0048Employee CityEmployeeCA0052Employee Date of BirthEmployeeCA0057Employee Date of DeathEmployeeCA0044Employee First NameEmployeeCA0043Employee Last NameEmployeeCA0045Employee Middle Name/InitialEmployeeCA0051Employee Phone NumberEmployeeCA0050Employee Postal CodeEmployeeCA0049Employee State CodeEmployeeCA0019Employer Address Line 1EmployerCA0020Employer Address Line 2EmployerCA0021Employer CityEmployerCA0016Employer FEINEmployerCA0018Employer NameEmployerCA0023Employer Postal CodeEmployerCA0022Employer State CodeEmployer0034Employer's Premises Indicator FROI Data Elements, Sorted Alphabetically, continued DNDATA ELEMENT NAMECATEGORYCA0058Employment Status CodeEmployment0066Full Wages Paid for Date of Injury IndicatorCA0053Gender CodeEmployeeCA0025Industry CodeEmployerCA0039Initial Treatment CodeAccident0027Insured Location Number0017Insured NameCA0026Insured Report NumberClaimCA0006Insurer FEINInsurerCA0007Insurer NameInsurerCA0004Jurisdiction CodeJurisdictionCA0002Maintenance Type CodeTransactionCA0003Maintenance Type Code DateTransactionCA0054Marital Status CodeEmployeeCA0035Nature of Injury CodeAccident0064Number of Days WorkedCA0055Number of DependentsEmployeeCA0060Occupation DescriptionEmploymentCA0036Part of Body Injured CodeAccidentCA0029Policy Effective DateClaimCA0030Policy Expiration DateClaimCA0028Policy NumberClaimCA0033Postal Code of Injury SiteAccidentCA0067Salary Continued IndicatorEmploymentCA0024Self Insured IndicatorEmployerCA0042Social Security NumberEmployeeCA0008Third Party Administrator FEINClaim AdministratorCA0009Third Party Administrator NameClaim AdministratorCA0032Time of InjuryAccidentCA0001Transaction Set IDTransactionCA0062WageEmploymentCA0063Wage Period CodeEmployment SROI Data Elements, Sorted By Data Element Number (DN) Release 1 - SROI - A49CATEGORY: SROI DataDNDATA ELEMENT NAMERequirements TableCA0001Transaction Set IDTransactionCA0002Maintenance Type CodeTransactionCA0003Maintenance Type Code DateTransactionCA0004Jurisdiction CodeJurisdictionCA0005Agency Claim Number/Jurisdiction Claim NumberClaimCA0006Insurer FEINInsurerCA0008Third Party Administrator FEINClaim AdministratorCA0014Claim Administrator Postal CodeClaim AdministratorCA0015Claim Administrator Claim NumberClaimCA0026Insured Report NumberClaimCA0031Date of InjuryAccidentCA0042Social Security NumberEmployeeCA0055Number of DependentsEmployeeCA0056Date Disability BeganEmployeeCA0057Employee Date of DeathEmployeeCA0062WageEmploymentCA0063Wage Period CodeEmployment0064Number of Days WorkedCA0067Salary Continued IndicatorEmployment0069Pre-Existing Disability CodeCA0070Date of Maximum Medical ImprovementEmployeeCA0071Return to Work QualifierEmployeeCA0072Date of Return/Release to WorkEmployeeCA0073Claim Status CodeClaimCA0074Claim Type CodeClaim0075Agreement to Compensate CodeCA0076Date of RepresentationClaimCA0077Late Reason CodePaymentsCA0078Number of Permanent ImpairmentsVariable SegmentCA0079Number of Payments/AdjustmentsVariable SegmentCA0080Number of Benefit AdjustmentsVariable SegmentCA0081Number of Paid To Date/Reduced Earnings/RecoveriesVariable SegmentCA0082Number of Death Dependent/Payee RelationshipsVariable SegmentCA0083Permanent Impairment Body Part CodePermanent ImpairmentsCA0084Permanent Impairment PercentagePermanent ImpairmentsCA0085Payment/Adjustment CodeBenefit PaymentsSROI Data Elements, Sorted By Data Element Number (DN), continued DNDATA ELEMENT NAMECATEGORYCA0086Payment/Adjustment Paid to DateBenefit PaymentsCA0087Payment/Adjustment Weekly AmountBenefit PaymentsCA0088Payment/Adjustment Start DateBenefit PaymentsCA0089Payment/Adjustment End DateBenefit PaymentsCA0090Payment/Adjustment Weeks PaidBenefit PaymentsCA0091Payment/Adjustment Days PaidBenefit PaymentsCA0092Benefit Adjustment CodeBenefit AdjustmentsCA0093Benefit Adjustment Weekly AmountBenefit AdjustmentsCA0094Benefit Adjustment Start DateBenefit AdjustmentsCA0095Paid to Date/Reduced Earnings/Recoveries CodePaid to DateCA0096Paid to Date/Reduced Earnings/Recoveries AmountPaid to Date0097Dependent/Payee Relationship Code SROI Data Elements, Sorted Alphabetically Release 1 - SROI - A49CATEGORY: SROI DataDNDATA ELEMENT NAMERequirements TableCA0005Agency Claim Number/Jurisdiction Claim NumberClaim0075Agreement to Compensate CodeCA0092Benefit Adjustment CodeBenefit AdjustmentsCA0094Benefit Adjustment Start DateBenefit AdjustmentsCA0093Benefit Adjustment Weekly AmountBenefit AdjustmentsCA0015Claim Administrator Claim NumberClaimCA0014Claim Administrator Postal CodeClaim AdministratorCA0073Claim Status CodeClaimCA0074Claim Type CodeClaimCA0056Date Disability BeganEmployeeCA0031Date of InjuryAccidentCA0070Date of Maximum Medical ImprovementEmployeeCA0076Date of RepresentationClaimCA0072Date of Return/Release to WorkEmployee0097Dependent/Payee Relationship CodeCA0057Employee Date of DeathEmployeeCA0026Insured Report NumberClaimCA0006Insurer FEINInsurerCA0004Jurisdiction CodeJurisdictionCA0077Late Reason CodePaymentsSROI Data Elements, Sorted Alphabetically, continued DNDATA ELEMENT NAMECATEGORYCA0002Maintenance Type CodeTransactionCA0003Maintenance Type Code DateTransactionCA0080Number of Benefit AdjustmentsVariable Segment0064Number of Days WorkedCA0082Number of Death Dependent/Payee RelationshipsVariable SegmentCA0055Number of DependentsEmployeeCA0081Number of Paid To Date/Reduced Earnings/RecoveriesVariable SegmentCA0079Number of Payments/AdjustmentsVariable SegmentCA0078Number of Permanent ImpairmentsVariable SegmentCA0096Paid to Date/Reduced Earnings/Recoveries AmountPaid to DateCA0095Paid to Date/Reduced Earnings/Recoveries CodePaid to DateCA0085Payment/Adjustment CodeBenefit PaymentsCA0091Payment/Adjustment Days PaidBenefit PaymentsCA0089Payment/Adjustment End DateBenefit PaymentsCA0086Payment/Adjustment Paid to DateBenefit PaymentsCA0088Payment/Adjustment Start DateBenefit PaymentsCA0087Payment/Adjustment Weekly AmountBenefit PaymentsCA0090Payment/Adjustment Weeks PaidBenefit PaymentsCA0083Permanent Impairment Body Part CodePermanent ImpairmentsCA0084Permanent Impairment PercentagePermanent Impairments0069Pre-Existing Disability CodeCA0071Return to Work QualifierEmployeeCA0067Salary Continued IndicatorEmploymentCA0042Social Security NumberEmployeeCA0008Third Party Administrator FEINClaim AdministratorCA0001Transaction Set IDTransactionCA0062WageEmploymentCA0063Wage Period CodeEmployment Section M: System Specifications Agency Claim Number/Jurisdiction Claim Number (JCN) The Agency Claim Number is most often referred to as the Jurisdiction Claim Number (JCN). The JCN is created by WCIS to uniquely identify each claim. It is provided to the claims administrator on their acknowledgment of the First Report. Before the WCIS system was revised in July 2004 the original WCIS system created a 12-digit JCN. The revised system is backwards compatible and will continue to accept the 12-digit JCN for claims originally reported to the old system. All new claims reported to the revised system will receive a 22-digit JCN. Changed or Corrected Data The WCIS regulations require each claim administrator to submit to WCIS any changed or corrected data elements. Changed or corrected data for a claim are due by the time of the next submission for the claim. Correction reports (MTC=CO) are sent in response to a TE (transaction accepted witherror) acknowledgment from WCIS. Change Reports (MTC=02) are sent when the claim administrator becomes aware that the value of a data element has changed, e.g., Employee Address. If a claim administrator needs to make changes to some data elements while making corrections to other elements for a given claim, these can be combined on either a change or correction report with identical results. When submitting a change or correction report, the claim administrator should resubmit all known data elements, not just the data elements being changed or corrected. Data elements missing in a resubmission will not cause valid data already existing in the database to be overwritten; however the claim administrator will receive errors if the missing data elements are necessary for validation purposes. For example, if the Employee Date of Birth is absent on the change or correction report, WCIS will not delete the Date of Birth stored in the WCIS database, but the claim administrator will receive an error for having a mandatory data element missing. Transaction Processing and Sequencing General Rules The WCIS processes batches within a transmission in the order in which they are received. If submitting more than one transaction for a single claim in the same batch or transmission, it is important that WCIS receive the transactions in the proper sequence. Transactions should be submitted in logical business order or in the order they were entered into the claim administrators system, according to the following general rules: The First Report for a claim must be submitted and processed by WCIS before any Subsequent Reports are submitted for the claim. Subsequent Reports sent before the corresponding First Report has been received by WCIS will be rejected. First Report and Subsequent Report transactions must be submitted in separate batches by default. Combining First and Subsequent Reports in a batch is impossible because the two types of reports have different field layouts. If a First Report batch and Subsequent Report batch with the same claims are submitted to WCIS on the same day, the Subsequent Reports may be rejected. The WCIS will not automatically process the First Reports first. In order to avoid sequencing errors with First and Subsequent reports it is best to submit the reports on separate days. Incoming transactions with Maintenance Type Code (MTC) dates, DN3, that are later than the current processing date (system date) will be rejected. For example, a transaction with an MTC date of 11-01-03 that is processed on 10-31-03 will be rejected. In addition, the MTC date must be between '1900' and the current date. If the claim administrator is not sure of the business order, the following general sort orders are suggested: Primary sort order is MTC date. Multiple transactions for a claim should be sorted by MTC date so that WCIS processes the oldest MTC date first. This will help avoid unnecessary sequencing errors. Secondary sort order is MTC code. MTC codes should be sorted in business event order. See the next sections for further explanations specific to First Reports and Subsequent Reports. First Reports This section is intended to aid you in understanding the general sequence or order in which Maintenance Type Codes may be used to report claim events for First Reports. Maintenance Type Codes are used to define the specific purpose of a transaction. There are two types of First Report Maintenance Type Codes, initial First Reports, the very first report sent; and other First Reports, not the initial first report sent. Some Maintenance Type Codes belong in both groups; they can be the initial First Report sent or they can be sent after the initial First Report. Some Maintenance Type Codes can only be other First Reports and must be preceded by an initial First Report. First Report Maintenance Type Codes are grouped in the following tables to clarify their purpose and to demonstrate a logical order for their use. If transactions for a claim are not received in the proper sequence, whether they are submitted in one transmission or several, they will be rejected. If transactions are rejected due to processing/sequencing errors, then the claim administrator is responsible for resubmitting the transactions. Initial First Reports: These Maintenance Type Codes are used to report new claims. One of these Maintenance Type Codes must be the initial First Report sent to WCIS. MTC CodeMTC Name00Original04DenialAUAcquired/Unallocated* *Any existing indemnity benefits will automatically be suspended when the FROI Acquired Unallocated (MTC=AU) is accepted. Other First Reports: After the initial First Report has been filed, the following First Report Maintenance Type Codes can be submitted to reflect/report additional information about the claim not known at the time of original reporting. MTC CodeMTC Name01Cancel02Change04DenialCOCorrection First Report Transaction Sequencing Requirements Summary MTCDescriptionTypeSequence Requirements00OriginalInitialNoneAUAcquired/UnallocatedInitialNone04DenialInitialNone01CancelOtherMust follow initial First ReportCOCorrectionOtherMust follow initial First Report02ChangeOtherMust follow initial First Report Subsequent Reports For Subsequent Reports, each Maintenance Type Code identifies a Benefit Event an action occurring on one or more benefit types. Benefit Events are of three main types: (1) Open Benefits: the claim administrator is starting to pay ongoing benefits; (2) Close Benefits: the claim administrator is suspending ongoing benefit payments; (3) Update Benefit: the claim administrator is reporting a change to a benefit period that has already been reported to WCIS. In the tables below, Maintenance Type Codes are grouped by the Benefit Event Type or the action that is being performed on the benefit. The transaction sequencing rules in the next section are applied at the Benefit Event Type level and not the specific Maintenance Type Code. Open Benefits: These Maintenance Type Codes are used to report the start of a benefit period. MTC CodeMTC NameIPInitial Payment*APAcquired PaymentFSFull SalaryRBReinstatement of BenefitsCBChange Benefit * Only one IP transaction for the same Claim Number will be allowed. Close Benefits: These Maintenance Type Codes are used to report the ending of a benefit period. MTC CodeMTC NamePJ, P1-9Partial SuspensionSJ, S1-9Suspension04Denial4PPartial Denial*CBChange BenefitCDCompensatory Death** * 4P is sent when a specific benefit is being denied. If a benefit that has not been paid is being denied, the benefit should not be reported on the 4P, due to limits in the IAIABC specifications. ** CD automatically closes all open indemnity benefits. Update Benefits: These Maintenance Type Codes are used to report an update to a previously reported benefit period. MTC CodeMTC NameCAChange in Benefit AmountREReduced Earnings02ChangeCOCorrection Other: These Maintenance Type codes dont fall into the above categories. They dont open, close, or update benefits in the same manner as other Maintenance Type Codes, because (1) the MTC reports single, lump sum payments (PY) rather than the payment of ongoing benefits, or (2) the MTC has specific jurisdictional uses (UR) or (3) the MTC reports the closing of a claim (FN). MTC CodeMTC NamePYPayment ReportURUpon RequestFNFinal Report Reporting Advances and Settlements An Initial Payment (IP) should be sent to report an advance or settlement that is the first indemnity payment. The Payment Report (PY) can be used to report an advance or settlement after the IP. Advances should be reported using the appropriate Payment/Adjustment Codes (DN85). For example, a permanent disability advance would be reported using the payment/adjustment code 030 and a temporary disability advance for a Qualified Medical Evaluation (QME) appointment would be reported using the payment/adjustment code 050. Some settlements, such as those found in a Compromise and Release (C&R) or a commutation, are paid as a one-time, lump sum amount; others, such as a stipulated settlement, allow for a future, ongoing payment stream. Settlements should be reported using the appropriate 5xx compromised Payment/Adjustment (DN85) codes and, if applicable, the appropriate Paid to Date (DN95) codes for each portion of the settlement. Compromised codes used for settlements in the WCIS are listed in Section N Code Lists. It is important to understand that the sum of the 5xx codes submitted for a particular settlement should equal the total settlement amount. For example, if a total, lump sum C&R settlement of $20,000 consisted of $15,000 for compromised permanent disability, $3,000 for compromised medical and $2,000 for attorney fees, then the settlement should be reported under Payment/Adjustment Code 530 (DN85), using benefit type codes: 530, with the amount $15,000 501, with the amount $3,000 and 500, with the amount $2,000. Ideally, the attorney fees should also be reported under the Paid to Date Code (DN95) benefit type code 340, with the amount $2,000. If a C&R or a commutation settlement cannot be broken down by each portion of the settlement and assigned to compromised benefit codes, then the entire settlement amount of $20,000 should be reported under Payment/Adjustment Code DN85, benefit type code 500 Unspecified. For settlements that are paid as a lump sum, the Payment/Adjustment Start and End Dates (DNs 88 and 89) should equal the settlement date. For stipulated settlements that are ongoing, only the first and last payments need to be reported. On the initial stipulated settlement payment, the Payment/Adjustment Start Date should equal the settlement date and the End Date should be the last through date for the first payment period of the settlement. On the last stipulated settlement payment, the Start and End Dates should cover the last payment period of the settlement. Periodic Reports: Periodic Reports are required for every claim with any benefit type including medical. Periodic Reports should not be used to report that a benefit period is opening, closing, or being updated. Rather, they are sent at a specific time in the life of a claim to report the amount paid for all benefit types and other benefit types through that date. MTC CodeMTC NameANAnnual For non-indemnity claims, i.e., claims without indemnity payments, a sufficient final report would be the Annual transaction (AN) with the Claim Status (DN73) set to closed. A Final transaction (FN) need not be sent. NOTE: If submitting ANs in ANSI X12 format, be sure to include the proper ANSI frequency code. If you have any questions, contact your EDI liaison. Annual transactions must contain at least one type of benefit payment. Transaction Sequencing Requirements for Subsequent Reports A general principle for WCIS is that we only want to collect data that we can interpret. To assure this, Subsequent Reports are automatically subjected to a set of sequencing rules and related business rules when processed by WCIS. The sequencing requirements for Subsequent Reports are given in the table below. Sequencing Rules Benefit-Level MTCBenefit Event TypeBenefit Event Processing Rules to Be Applied02, COUpdateAllow AllAN, FN PeriodicAllow allUR, PY, CD*OtherAllow All* CD automatically closes all open indemnity benefits. Related Business Rules Rules Specific to Transaction-Level MTC These rules are applied at the transaction level of the Maintenance Type Code. If any of these rules are not met, the transaction will be rejected. Transaction MTCRuleCB, RB, (and MTCs 02, CO with benefit blocks present)Must be preceded by at least one previous benefit event of any Payment/Adjustment Code (DN85).FS Must contain a benefit record with Payment/Adjustment Code (DN85) = 240 or 524Any MTC not supported in Benefit Event Type Rules table (including VE)Reject transaction. Overall Transaction Structure Edits. (1) No benefit blocks (or other benefits, credits, adjustments, or reduced earnings blocks) are expected for First Report of Injury Reports (transactions with Maintenance Type Codes 00, 01, or AU). The transaction will be rejected if benefit blocks are reported on the First Report. (2) Benefit blocks within a transaction may not repeat the same benefit code. Transactions will be rejected if duplicate benefit codes are reported in the same transaction. WCIS Matching Rules and Processes Match Data for a Claim Primary: 1. Agency Claim Number/Jurisdiction Claim Number, DN5 Secondary Match for Reports OTHER THAN AU: 2a. Insurer FEIN (DN6) AND Third Party Administrator FEIN (DN8), if any, AND Claim Administrator Claim Number (DN15) Alternative Secondary Match for AU: 2b. Date of Injury (DN31) AND Nature of Injury Code (DN35) AND Part of Body Injured Code (DN36) AND Employee Last Name (DN43) AND Employee First Name (DN44) How WCIS Matches Incoming Transactions to Existing Claim Records The WCIS uses the Agency Claim Number/Jurisdiction Claim Number (JCN) as the primary means for matching transactions representing the same claim. Secondary match data will be used only if a JCN is not provided. For current JCN requirements please see Jurisdiction Claim Number earlier in this section. Transactions that can never be initial First Reports (MTC = 01, 02, CO, and all subsequent reports) will be rejected if they cannot be matched to existing claims on the WCIS database. This matching is based on the JCN, if provided. Otherwise, secondary match data #2a (described above) will be used. For transaction types that may or may not be initial First Reports (MTC = 00, 04), secondary match data is used to help avoid creation of duplicate records. Secondary match data #2a is used to prevent a given claim administrator from reporting multiple claims with the same Claim Administrator Claim Number and the same insurer. The claim administrator can only change the data elements in match data #2a and #2b when a JCN is provided. The case of a claim administrator acquiring existing claims from another administrator requires special handling. This is necessary because the claim administrator acquiring the claim may not know the JCN, and secondary match data #2a wont be useful for matching such transactions (because a new Third Party Administrator or Insurer FEIN and Claim Administrator Claim Number will generally be provided when transferring claim ownership). Therefore, for acquired reports (MTC=AU) only, the WCIS will use alternative match data #2b to determine if an AU transaction lacking the JCN matches to an existing claim on the database. Acquired Claims WCIS will support the transfer of claims from one claim administrator to another using the AU transaction. The AU will be processed as shown in the following chart.  Boxes with solid straight lines indicate a transmission from the Trading Partner to WCIS. Boxes with a wavy bottom line indicate acknowledgments from WCIS to the Trading Partner. Boxes with dashed lines - - - - indicate processing performed by WCIS. **Secondary match on 2b, fields: Date of Injury (DN31); AND Part of Body Injured Code (DN36); AND Nature of Injury Code (DN35); AND Employee First Name (DN44); AND Employee Last Name (DN43) Section N: Code Lists This Section lists valid codes for several data elements. The original source of each code list is noted. These valid code lists are provided as a convenience for our data providers, and are intended to be a simple repetition of code lists available elsewhere. In no case have codes been purposely omitted or deleted. If at any time you believe that WCIS is rejecting a valid code, please let us know by sending an e-mail to: HYPERLINK "mailto:wcis@dir.ca.gov"wcis@dir.ca.gov. Nature of Injury Codes (DN35) CODEDESCRIPTIONSPECIFIC INJURY01No Physical Injury02Amputation03Angina Pectoris54Asphyxiation04Burn07Concussion10Contusion13Crushing16Dislocation19Electric Shock22Enucleation (To Remove, Ex.: Tumor, Eye, etc)25Foreign Body28Fracture30Freezing31Hearing Loss or Impairment32Heat Prostration34Hernia36Infection37Inflammation40Laceration41Myocardial Infarction (Heart Attack)42Poisoning-General (Not OD or Cumulative Injury)43Puncture46Rupture47Severance49Sprain52Strain53Syncope55Vascular58Vision Loss59All Other Specific Injuries, NOC Nature of Injury Codes (DN35) - continuedCODEDESCRIPTIONOCCUPATIONAL DISEASE OR CUMULATIVE INJURY 60Dust Disease, NOC (All other Pneumoconiosis)61Asbestosis62Black Lung63Byssinosis64Silicosis65Respiratory Disorders (Gases, Fumes, Chemicals, etc.)66Poisoning-Chemical (Other than Metals)67Poisoning-Metal68Dermatitis69Mental Disorder70Radiation71All Other Occupational Disease Injury, NOC72Loss of Hearing73Contagious Disease74Cancer75Aids76VDT-Related Disease77Mental Stress78Carpal Tunnel Syndrome79Hepatitis C80All Other Cumulative Injuries, NOCMULTIPLE INJURIES90Multiple Physical Injuries Only91Multiple Injuries Including Both Physical and Psychological Source: IAIABC/NCCI/WCIO HYPERLINK "https://www.iisprojects.com/WCIO/pub/PNC/WCIO_Nature_Table.pdf"https://www.iisprojects.com/WCIO/pub/PNC/WCIO_Nature_Table.pdf Part of Body Codes: FROI (DN36) and SROI (DN83) FROI CODE (DN36)SROI CODE (DN83)CODE DESCRIPTIONHEAD1010Multiple Head Injury1111Skull1212Brain1313Ear(s)*1313ATotal Deafness of Both Ears*1313BTotal Deafness of One Ear*1313CWhere Worker Prior to Injury has Suffered a Total Loss of Hearing in One Ear, and as a Result of the Accident Loses Total Hearing in Remaining Ear*1414Eye(s)*1414AThe Loss of Eye by Enucleation (Including Disfigurement Resulting from Removal)*1414BTotal Blindness of One Eye*1414CBlindness in both Eyes*1515Nose1616Teeth1717Mouth1818Soft Tissue Head 1919Facial BonesNECK 20 20Multiple Neck Injury2121Vertebrae2222Disc2323Spinal Cord2424Larynx2525Soft Tissue Neck 2626TracheaUPPER EXTREMITIES3030Multiple Upper Extremities 31 31Upper Arm (Excluding Clavicle & Scapula)*3232Elbow*3333Lower Arm*3434Wrist*3535Hand*3636Finger(s)** These bilateral body part codes can be reported twice under DN83, when applicable. Part of Body Codes: FROI (DN36) and SROI (DN83) - ContinuedFROI CODE (DN36)SROI CODE (DN83)CODE DESCRIPTIONUPPER EXTREMITIES (continued)3636AThe Loss of an Index Finger and Metacarpal Bone*3636BThe Loss of an Index Finger at the Proximal Joint*3636CThe Loss of an Index Finger at the Second Joint*3636DThe Loss of an Index Finger at the Distal Joint*3636EThe Loss of a Second Finger and the Metacarpal Bone*3636FThe Loss of a Middle Finger at the Proximal Joint*3636GThe Loss of a Middle Finger at the Second Joint*3636HThe Loss of a Middle Finger at the Distal Joint*3636IThe Loss of a Third (Ring) Finger and Metacarpal Bone*3636JThe Loss of a Third (Ring) Finger at the Proximal Joint*3636KThe Loss of a Third (Ring) Finger at the Second Joint*3636LThe Loss of a Third (Ring) Finger at the Distal Joint*3636MThe Loss of a Little Finger and Metacarpal Bone*3636NThe Loss of a Little Finger at the Proximal Joint*3636OThe Loss of a little Finger at the Second Joint*3636PThe Loss of a Little Finger at the Distal Joint*3737Thumb*3737AThe Loss of a Thumb and Metacarpal Bone*3737BThe Loss of a Thumb at the Proximal Joint*3737CThe Loss of a Thumb at the Distal Joint*3838Shoulder(s)*3939Wrist(s) & Hand(s)*TRUNK4040Multiple Trunk4141Upper Back Area (Thoracic Area)4242Lower Back Area (including Lumbar & Lumbo-Sacral)4343Disc4444Chest (including Ribs, Sternum & Soft Tissue)4545Sacrum and Coccyx4646Pelvis4747Spinal Cord4848Internal Organs4949Heart6060Lungs6161Abdomen Including Groin6262Buttocks6363Lumbar and/or Sacral Vertebrae (Vertebrae NOC Trunk)* These bilateral body part codes can be reported twice under DN83, when applicable. Part of Body Codes: FROI (DN36) and SROI (DN83) - ContinuedFROI CODE (DN36)SROI CODE (DN83)CODE DESCRIPTIONLOWER EXTREMITIES5050Multiple Lower Extremities5151Hip*5252Upper Leg*5353Knee*5454Lower Leg*5555Ankle*5656Foot*5757Toe(s)*5757ALittle Toe Metatarsal Bone*5757BLittle Toe at Distal Joint*5757CThe Loss of any other Toe with Metatarsal Bone *5757DThe Loss of any other Toe at the Proximal Joint*5757EOther Toe at Middle Joint*5757FThe Loss of any other Toe at Second or Distal Joint*5757GOther Toe at Distal Joint*5858Great Toe* 5858AThe Loss of a Great Toe with Metatarsal Bone*5858BThe Loss of a Great Toe at the Proximal Joint*5858CThe Loss of a Great Toe at the Second (Distal) Joint *MULTIPLE BODY PARTS6464Artificial Appliance6565Insufficient Info to Properly Identify-Unclassified6666No Physical Injury9090Multiple Body Parts9191Body Systems and Multiple Body Systems9999Whole Body* These bilateral body part codes can be reported twice under DN83, when applicable. Source: IAIABC/NCCI/WCIO HYPERLINK "https://www.iisprojects.com/WCIO/pub/PNC/WCIO_Part_Table.pdf"https://www.iisprojects.com/WCIO/pub/PNC/WCIO_Part_Table.pdf HYPERLINK "https://www.iisprojects.com/WCIO/pub/PNC/InjuryDescriptionTableUpdateNoticeFINALA.pdf"https://www.iisprojects.com/WCIO/pub/PNC/InjuryDescriptionTableUpdateNoticeFINALA.pdf HYPERLINK "https://www.iisprojects.com/WCIO/bin/view/PublicView/ProductsWCIO"https://www.iisprojects.com/WCIO/bin/view/PublicView/ProductsWCIO Cause of Injury Codes (DN37) CODEDESCRIPTIONBURN OR SCALD-HEAT OR COLD EXPOSURE01Chemicals02Hot Objects or Substances11Cold Objects or Substances03Temperature Extremes04Fire or Flame05Steam or Hot Fluids06Dust, Gases, Fumes or Vapors07Welding Operations08Radiation14Abnormal Air Pressure84Electrical Current09Contact With, NOCCAUGHT IN OR BETWEEN10Machine or Machinery12Object Handled20Collapsing Materials (Slides of Earth)13Caught in, Under or Between, NOCCUT, PUNCTURE, SCRAPE INJURED BY15Broken Glass16Hand Tool, Utensil; Not Powered17Object Being Lifted or Handled18Powered Hand Tool, Appliance19Cut, Puncture, Scrape, NOCFALL OR SLIP INJURY25From Different Level (Elevation)26From Ladder or Scaffolding27From Liquid or Grease Spills28Into Openings29On Same Level30Slipped, Did Not Fall32On Ice or Snow33On Stairs31Fall, Slip, Trip, NOCMOTOR VEHICLE40Crash of Water Vehicle41Crash of Rail Vehicle45Collision or Sideswipe with Another Vehicle46Collision with a Fixed Object47Crash of Airplane48Vehicle UpsetCause of Injury Codes (DN37) - ContinuedCODEDESCRIPTIONMOTOR VEHICLE continued50Motor Vehicle, NOCSTRAIN OR INJURY BY52Continual Noise53Twisting54Jumping55Holding or Carrying56Lifting57Pushing or Pulling58Reaching59Using Tool or Machinery60Strain or Injury by, NOC61Wielding or Throwing97Repetitive Motion Carpal Tunnel SyndromeSTRIKING AGAINST OR STEPPING ON65Moving Parts of Machine66Object Being Lifted or Handled67Sanding, Scraping, Cleaning Operations68Stationary Object69Stepping on Sharp Object70Striking Against or Stepping on, NOCSTRUCK OR INJURED BY74Fellow Worker, Patient, or Other Person75Falling or Flying Object76Hand Tool or Machine in Use77Motor Vehicle78Moving Parts of Machine79Object Being Lifted or Handled80Object Handled by Others81Struck or Injured, NOC (Includes Kicked, Stabbed, Bit, and Etc.)85Animal or Insect86Explosion or Flare BackRUBBED OR ABRADED BY94Repetitive Motion95Rubbed or Abraded, NOCMISCELLANEOUS CAUSES82Absorption, Ingestion, or Inhalation, NOC87Foreign Matter (Body) in Eye(s)88Natural Disasters (Earthquake, Hurricane, Tornado, and Etc.)89Person in Act of a Crime (Robbery or Criminal Assault)90Other Than Physical Cause of InjuryCause of Injury Codes (DN37) - ContinuedCODEDESCRIPTIONMISCELLANEOUS CAUSES - continued91Mold96Terrorism98Cumulative, NOC99Other-Miscellaneous, NOCSource: IAIABC/NCCI HYPERLINK "https://www.iisprojects.com/WCIO/pub/PNC/WCIO_Cause_Table.pdf"https://www.iisprojects.com/WCIO/pub/PNC/WCIO_Cause_Table.pdf Late Reason Codes (DN77) CodesDescriptionDelaysL1No excuseL2Late Notification, EmployerL3Late Notification, EmployeeL4Late Notification, StateL5Late Notification, Health Care ProviderL6Late Notification, Assigned RiskL7Late InvestigationL8Technical Processing Delay/Computer FailureL9Manual Processing DelayLAIntermittent Lost Time Prior to First PaymentCoverageC1Coverage Lack of InformationErrorsE1Wrongful Determination of No CoverageE2Errors from EmployerE3Errors from EmployeeE4Errors from StateE5Errors from Health Care ProviderE6Errors from Other Claim Administrator/IA/TPADisputesD1Dispute Concerning CoverageD2Dispute Concerning Compensability in WholeD3Dispute Concerning Compensability in PartD4Dispute Concerning Disability in WholeD5Dispute Concerning Disability in PartD6Dispute Concerning ImpairmentSource: IAIABC, ANSI A9 Class Codes (DN59) Class codes (DN59) are required for insured employers and are optional for self-insured employers. These are California-specific codes from the Workers Compensation Insurance Rating Bureau (WCIRB) of California. The WCIRB updates these codes annually in January. They are available on the WCIRB website: HYPERLINK "https://wcirbonline.org/wcirb/Answer_center/classification_information.html"https://wcirbonline.org/wcirb/Answer_center/classification_information.html. The National Council on Compensation Insurance (NCCI) class codes are not accepted. All California businesses are classified using the Standard Classification System found in Part 3 of the WCIRBs Uniform Statistical Reporting Plan, which is part of the California Code of Regulations and is approved by the Insurance Commissioner. The Standard Classification System, which contains approximately 500 industry classifications, describes groups of employers whose businesses are relatively similar. Each classification reflects the type of operations common to that group of employers. Changes to class codes from the previous years codes are listed in Memorandum 1 of the Uniform Statistical Reporting Plan, which is found online at HYPERLINK "https://wcirbonline.org/wcirb/root/pdf/usrp_ic_regs_only.pdf"https://wcirbonline.org/wcirb/root/pdf/usrp_ic_regs_only.pdf. These changes are published as of January 1 of each year. All class codes should be submitted to the WCIS using a four-digit alpha-numeric format. The WCIS does not require trading partners to report information on subdivisions of class codes below the four-digit level, such as 0038 (1) stock farms, and 0038 (2) feed yards. In this example, only 0038 would need to be reported. Zeros are padded to the left, as the following examples show: CLASS CODE DESCRIPTION0005Nurseries--propagation and cultivation of nursery stock0016Orchards -- citrus and deciduous fruit0034Farms--poultry raising0035Florists--cultivating or gardening0036Farms--dairy farms0038Farms--stock farms and feed yards0040Farms--vineyards Payment/Adjustment and Paid to Date (DN85 and DN95) Benefit Type Codes Settlements are reported using compromised payment benefit type codes 5xx. Examples of settlement types are compromise and release, findings and award, findings and order, and stipulated settlements. See Section MSystem Specifications for more details on reporting settlements. Payment/Adjustment (DN85) Benefit Type Codes Used in the WCISBTCCode DescriptionBTCCompromised Payment Code Description500Unspecified501Medical010Fatal510Fatal020Permanent Total520Compromised Permanent Total030Permanent Partial Scheduled530Compromised Permanent Partial Scheduled050Temporary Total550Compromised Temporary Total070Temporary Partial570Compromised Temporary Partial090Permanent Partial Disfigurement590Compromised Permanent Partial Disfigurement240Employer Paid524Compromised Employer Paid Payment/Adjustment (DN85) Benefit Type Codes that, in most cases, should NOT be sent to the WCIS on recent claims:BTCCode DescriptionBTCCompromised Payment Code Description021Permanent Total Supplemental521Compromised Permanent Total Supplemental051Temporary Total Catastrophic551Compromised Temporary Total Catastrophic080Employer Liability580Compromised Employer Liability040Permanent Partial Unscheduled540Compromised Permanent Partial Unscheduled410Vocational Rehabilitation Maintenance541Compromised Vocational Rehabilitation MaintenanceNotes: For injuries that were permanent and stationary on or after 1/1/2005, PD payments have been scheduled using the 2005 Permanent Disability Rating Schedule, so unscheduled payment codes (040, 540) should not be sent. As of 1/1/2009, the vocational rehabilitation program was ended, so codes 410 and 541 are no longer applicable. Payments for the California Supplemental Job Displacement Benefit (SJDB) Program should be sent under DN95, BTC 390. Paid to Date/Reduced Earnings/Recoveries (DN95) Benefit Type Codes Used in the WCISBTCCode DescriptionBTCCode Description300Funeral Expenses PTD430Unallocated Prior Indemnity Benefits PTD310Penalties PTD440Unallocated Prior Medical PTD320Interest PTD450Pharmaceutical PTD330Employer's Legal Expense PTD460Physical Therapy PTD340Claimant's Legal Expense PTD600-624Actual Reduced Earnings350Total Payments to Physician PTD650-674Deemed Reduced Earnings360Hospital Costs PTD800Special Fund Recovery370Other Medical PTD810Deductibles Recovery380Vocational Rehabilitation Evaluation PTD820Subrogation Recovery390Vocational Rehabilitation Education PTD830Overpayment Recovery400Other Vocational Rehabilitation PTD840Unspecified Recovery420Expert Witness Fees PTDPayments for the California Supplemental Job Displacement Benefit (SJDB) Program should be sent under DN95, BTC 390 Industry Codes (DN25) The industry code should represent the primary nature of the employers business. If the employer is assigned multiple industry codes, use the code that relates to the specific business operation for which the employee was employed at the time of injury. Both Standard Industrial Classification (SIC) and North American Industry Classification System (NAICS) codes are accepted by WCIS, but NAICS codes are preferred. Per the IAIABC Release 1 specifications, the industry code (DN25) must be sent as a six-digit alpha-numeric code. According to WCIS data edits, the industry code (DN25) is a Mandatory/Serious data element. A list of valid industry codes can be found at the U.S. Census Bureau Website HYPERLINK "http://www.census.gov/epcd/www/naics.html"http://www.census.gov/epcd/www/naics.html. SIC codes were last updated in 1987. NAICS codes are updated every five years by the Census Bureau, for example: 1997, 2002, 2007 and 2012. The DWC encourages trading partners to submit the most recent six-digit North American Industry Classification System (NAICS) codes to the WCIS. For example, for Soy Bean Farming, the 2007 six-digit NAICS code is 111110. If the trading partner does not know the industry to the detailed six-digit level, but can submit the industry code at a higher level of aggregation, then the 2-digit, 3-digit or 4-digit NAICS code should be submitted to the WCIS in alpha-numeric format with zeros padded to the right. Using 2007 NAICS codes as an example: NAICS6-digit code111110Soy Bean Farming4-digit111100Oilseed and Grain Farming3-digit111000Crop Production2-digit110000Agriculture, Forestry, Fishing and Hunting If 1987 Standard Industrial Classification (SIC) codes are submitted, the four-digit SIC code needs to be joined with the letters "SC" in the last two positions. Four-digit codes without the "SC" suffix will be accepted with error, as there is no way to differentiate between a four-digit SIC and a four-digit NAICS code. For example, for the SIC code 0116 - Soybeans, the trading partner would submit 0116SC to the WCIS. Note that for SIC codes, the zeros are padded to the left. Section O: EDI Terminology Abbreviations and Acronyms Acronyms and AbbreviationsDefinitionAK1A flat file type used for sending detailed acknowledgmentsANSIAmerican National Standards InstituteDIRDepartment of Industrial RelationsBAISBasic Administrative Information SystemDLSRDivision of Labor Statistics and ResearchDOBDate of BirthDOIDate of InjuryDNData Number Identification number assigned to each data element in an IAIABC transactionDWCDivision of Workers CompensationEDIElectronic Data InterchangeE-mailElectronic mailFEINFederal Employer Identification NumberFROIFirst Report of InjuryFTPFile Transfer Protocol FTPSFile Transfer Protocol over SSLIAIABCInternational Association of Industrial Accident Boards and CommissionsICD9International Classification of Diseases 9th RevisionIPInternet ProtocolISPInternet Service ProviderJCNJurisdiction Claim Number (DN5)MTCMaintenance Type Code (DN2)PGPPretty Good PrivacySICStandard Industrial ClassificationS/MIMESecure/Multipurpose Internet Mail ExtensionsSROISubsequent Report of InjurySSLSecure Sockets LayerTATransaction Accepted (without errors)TETransaction Accepted with ErrorsTPAThird Party AdministratorTPTrading PartnerTRTransaction RejectedURLUniform Resource LocaterVANValue-Added NetworkWCABWorkers Compensation Appeals BoardWCIRBWorkers Compensation Insurance Rating Bureau of CAWCISWorkers Compensation Information System EDI Glossary Acknowledgment A file sent from WCIS to a trading partner in order to provide feedback on a first or subsequent report batch from that trading partner. This file indicates whether each transaction was accepted, accepted with errors, or rejected. Applicable error codes are provided for each data element. Agency Claim Release 1 flat-file name for Jurisdiction Claim Number Number (JCN), DN5. This claim identifier is generated by WCIS at the time a claim record is first created. It must be provided on most transactions throughout the life of the claim. ANSI X12 An EDI file format in which data elements are strung together continuously, with special data-element identifiers and separator characters delineating individual data elements and records. Batch A group of EDI records in ANSI or IAIABC flat format. Each batch consists of a header record, one or more transaction records containing claim data, and a trailer record. Benefit Event An event that triggers a report. Example: Benefits are starting and a first payment is made an IP Report would be sent. Benefit Period an uninterrupted period of benefit payments for a particular benefit code. Claim A self-administered insurer, third party administrator, or Administrator self-insured, self-administered employer legally responsible for proper handling of a workers compensation claims. Data Element A piece of information to be included in an EDI file. Examples include date of injury, last name, or Maintenance Type Code (MTC). An IAIABC flat-file data element can also be referenced by its data number (DN). For example, the Maintenance Type Code is also referred to as DN2. Digital Certificate Files issued by a certified security authority (such as VeriSign, Inc.), used to verify signatures on digitally signed mail and to send encrypted e-mail. Once the sender and receiver have exchanged valid digital certificates, all e-mail between them can be encrypted automatically. File Format The manner in which data elements are organized in a file. The two file formats accepted by WCIS are the IAIABC flat file and the ANSI X12 format. Flat File An EDI file format in which data elements are placed in assigned positions within each record. Different records are presented on separate lines of the EDI file. Proprietary flat file standards for use in workers compensation have been developed by the IAIABC. First Report of A class of EDI transactions that include the same data Injury (FROI) provided on the paper First Report of Injury or Illness (California Form 5020). Jurisdiction Claim This claim identifier is generated by WCIS at the time a Number (JCN) claim record is first created in the database. It is data element DN5 in the flat-file format. The JCN must be provided on most transactions throughout the life of the claim. In Release 1, this data element is called Agency Claim Number. Header Record The first record in a formatted EDI file, which identifies the sender, receiver, and file format version used. The header and trailer records combine to create an envelope surrounding a batch of transactions. IAIABC The HYPERLINK "http://www.iaiabc.org"International Association of Industrial Accident Boards and Commissions, an organization that develops Electronic Data Interchange standards for use in workers compensation. Maintenance Type The IAIABC flat-file data element that identifies the business Code (MTC) objective of a given EDI transaction. (ANSI equivalent is Purpose Code.) Parallel Phase The period during which a trading partners EDI data is cross-analyzed with hard copies. Pilot Phase The period during which a trading partner is demonstrating their ability to send data via EDI that is complete, valid, and accurate (see WCIS regulations). This stage begins when the trading partner has passed the test stage, and ends when the trading partner has been approved for Parallel status. Policy Year The same policy year as the one reported to the WCIRB (Workers Compensation Insurance Rating Bureau of California). Production Phase The period that begins when a trading partner has demonstrated the ability to send complete, valid, and accurate data for a given class of reports via EDI. This follows successful completion of the test and pilot phases. Claims administrators granted production status for First Reports are no longer required to send paper Employers Reports (Form 5020) to DLSR. Claims administrators granted production status for Subsequent Reports satisfy the requirement to submit paper Benefit Notices to the Division. Purpose Code The ANSI data element that identifies the business objective of a given EDI transaction. (IAIABC flat-file equivalent is Maintenance Type Code, MTC.) Receiver The trading partner receiving EDI transmissions. Release 1 A set of workers compensation EDI data specifications released by the IAIABC in August, 1995. Report Often used synonymously with transaction. Sender The trading partner sending EDI transmissions. Subsequent A class of EDI transactions that include the types of data Report of Injury provided on California benefit notices. WCIS regulations (SROI) stipulate when these transactions are required. For example, SROI are to be provided whenever indemnity benefit payments are begun or terminated. Test Phase The phase in which a trading partner sends test batches in order to ascertain whether WCIS can read their EDI files. At this phase, WCIS checks the header and trailer record and confirms basic record formats, but does not perform validations on individual data elements. Once this test phase is successfully completed, the trading partner advances to the pilot phase. Trading Partner One of the parties exchanging EDI transmissions, either the state jurisdiction, the claims administrator (insurer, self-insured employer, or third party administrator), or a collection of claims administrators. Each trading partner providing data to WCIS is expected to complete a Trading Partner Profile form. One such form can cover multiple Claim Administrators whose data will be combined in transactions and which will be considered together for testing, piloting, and data-quality reports. For example, a parent organization with multiple subsidiary claim administrator organizations may wish to combine all its data into transmissions sent from a central office. Trailer Record The last record in a formatted EDI file, which indicates a count of transactions contained within the batch. The header and trailer records combine to create an envelope surrounding a batch of transactions. Transaction A section of a batch file representing a single first report of injury or a single benefit notice for an individual claim. Transmission A file in ANSI or IAIABC flat format containing one or more batches of transactions. Appendix A: Revised WCIS System Updates Clarification of Issues: The Payment/Adjustment Paid to Date (DN86) refers to the cumulative paid-to-date amount of the benefit over the life of the claim, including any and all previous calendar years. The revised version of WCIS will continue to accept multiple MTCs for the same claim in the same batch file. MTC DATE: For most transactions, the IAIABC defines the MTC date as the date the transaction was moved to the transmission queue or flagged for transmission, except for the following MTCs: CO MTC date of the Original Transaction being corrected that contained non-critical error(s). AP Issue date of a check sent as the initial indemnity benefit payment after acquiring the claim. CA Date the change in Payment/Adjustment amount was effective. IP Issue date of check sent as the initial indemnity benefit payment. P1 through PJ The last date through which indemnity benefits are due. PY Issue date of payment. RB Issue date of the check reinstating indemnity benefits. S1 through SJ The last date through which indemnity benefits are due. Some Payment/Adjustment Codes (DN85) should not be sent to the WCIS on recent claims. Examples are Temporary Total Catastrophic (051) and (551) as well as Employers Liability (080) and (580); As of 1/1/2005, Partial Unscheduled (040) and (540); As of 1/1/2009, Vocational Rehabilitation Maintenance (410) and (541). Differences Between Version 2.1 and Version 3.0 of WCIS: The Receiver zip code for the WCIS is now 94612-1489. The FROI Original (MTC=00) reporting due date is now within 10 business days of claim administrator knowledge of the claim. For the Social Security Number (DN42) and Employer FEIN (DN16), a default value of 000000006 will be accepted if the employee has no SSN/FEIN or refuses to provide it. On any transaction, the Insurer FEIN (DN6), Third Party Administrator FEIN (DN8), if any, and Claim Administrator Postal Code (DN14) must match what was reported on the Insurer/Claim Administrator ID list for the Sender or the transaction will be rejected. The allowed methods of transmitting data from claim administrators to WCIS are: File Transfer Protocol (FTP) over SSL (Secure Sockets Layer), also known as FTPS, or FTPS with PGP (Pretty Good Privacy) encryption. The Policy Number (DN28), Policy Effective Date (DN29), and Policy Expiration Date (DN30) have been added to the FROI data requirement table. They are Conditional/Serious on the FROI 00, 02, 04, AU and CO. The Payment/Adjustment Weekly Amount, Weeks and Days Paid (DN87, 90 and 91) are Mandatory/Fatal on the SROI IP, AP, FS, CA, CB, RE, Px, Sx, and RB, Conditional/Fatal on the SROI 02, CO, 4P, AN, FN, and UR, and Optional on the SROI CD, 04 and PY. The Third Party Administrator FEIN (DN8) is now a Conditional/Fatal data element on the FROI and SROI. The Third Party Administrator Name (DN9) is now a Conditional/Serious data element on the FROI. The FROI Original (MTC=00) will not be accepted when sent with an Agency/Jurisdiction Claim Number (DN5). The Payment/Adjustment Paid To Date (DN86), when required, must be greater than or equal to zero. The Payment/Adjustment Start Date and Payment/Adjustment End Date (DN88 and 89), when required, must be a valid date. The Paid To Date/Reduced Earnings/Recoveries Amount (DN96), when required, must be greater than or equal to zero. The Benefit Adjustment Weekly Amount (DN93), when required, must be greater than or equal to zero. The Benefit/Adjustment Start Date (DN94), when required, must be a valid date. The Date of Maximum Medical Improvement (DN70) is now only required on the SROI Final (MTC=FN) and the SROI Upon Request (MTC=UR). The SROI Annual (MTC=AN) and SROI Final (MTC=FN) will now be accepted if a previously reported indemnity benefit is missing in the AN or FN. The SROI Annual (MTC=AN) and SROI Final (MTC=FN) will now be accepted if a previously unreported indemnity benefit is reported in the AN. Any existing indemnity benefits will automatically be suspended when the FROI Acquired Unallocated (MTC=AU) is accepted. The Secondary Match Logic for transactions other than the FROI Original (MTC=00) and Acquired/Unallocated (MTC=AU) that are sent without an Agency/Jurisdiction Claim Number (DN5) is now based on the Insurer FEIN (DN6) AND the Third Party Administrator FEIN (DN8), if any, AND the Claim Administrator Claim Number (DN15). The Class Code (DN59) table has been deleted from this Guide. Trading partners are referred to the WCIRB class code table available online. The Class Code (DN59) must be a valid HYPERLINK "https://wcirbonline.org/wcirb/Answer_center/classification_information.html"WCIRB class code when sent. The NAICS code (DN25) table has been updated for 2007 codes. The FN can and should be sent in when a claim is closed, even if no benefits have been paid. The Payment/Adjustment Codes 040, 051, 080, 540, 551 and 580 should not be sent. The parallel phase in Section G-Test, Pilot, Parallel and Production Phases of EDI is now optional. The sequencing edits Closes must follow opens for the same BTC and Update (open) must follow opens for the same BTC have been removed. The Industry Code (DN25) is now a Mandatory/Serious data element. The Permanent Impairment Percent (DN84) is now only required on the SROI Final (MTC=FN) and the SROI Upon Request (MTC=UR). Differences Between Version 2.0 and Version 2.1 of WCIS: The Jurisdiction Claim Number or JCN (DN05) has been increased from 12 digits to 22 digits. The IAIABC rules allow a JCN of 25 characters. The new system will continue to process all older claims submitted and processed prior to the switchover with the original 12 digit JCNs. Future Payment/Adjustment Start and End Dates (DN88 and DN89) will be accepted. The edit for error message #37, Must be <= MTC Date, has been removed for DN88 and DN89. FROI Cancel (MTC=01) will be accepted after a SROI transaction has been accepted. This process cancels the entire claim, including all FROI and SROI transactions. Even though the IAIABC Release 1 format has no SROI Cancel, this will perform that function. In addition, a 01 Cancel will be able to follow a 04 Denial, as documented in the EDI Guide. The Release 2 transaction format will no longer be accepted. MTC dates (DN3) must be <= current system date. IP: Only one IP transaction is allowed for each claim. Since a new benefit can be opened with a CB transaction, there is no need to report more than one IP. Error Messages: The February 15, 2002 revised edition of the IAIABC Edit Matrix (HYPERLINK "http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3338"http://www.iaiabc.org) error messages (Section 3) has been incorporated in the revised WCIS system. M/S: The following Mandatory/Serious (M/S) data elements, if sent with an invalid or blank USPS Postal Code or an invalid or blank date will result in a TE acknowledgment. DN23-Employer Postal Code DN33-Postal Code of Injury Site DN41-Date Reported to Claim Administrator DN72-Date of Return/Release to Work (Note: for MTC=RE only) M/F: DN14-Claim Administrator Postal Code is now a Mandatory/Fatal (M/F) data element; an invalid or blank USPS Postal Code will result in a TR acknowledgment. C/S: The following Conditional/Serious (C/S) data element, if sent with an invalid or blank date, will result in a TE acknowledgment. DN72-Current Return to Work Date (Note: For MTCs = S1 or P1 only). CD: The MTC Compensatory Death (CD) will automatically close all open BENs. RB: A suspension type MTC, such as S1 or P1, or an equivalent MTC, such as UR or CB, must precede an RB, which can open a new benefit or reopen an old one. An RB following an IP will no longer be accepted. This is consistent with the IAIABC Guide. AN/FN: Must report all previously reported indemnity and non-indemnity benefits. If any of these benefits are missing, the transaction will be rejected. The AN/FN cannot report any new indemnity benefits but can report new non-indemnity benefits. On FN, all previously reported indemnity benefits must be suspended first. * An AN cannot be used to close claims with indemnity benefits. The proper transaction is an FN, as explained in e-News 7: HYPERLINK "http://www.dir.ca.gov/DWC/WCISenews/WCISen7.htm"http://www.dir.ca.gov/DWC/WCISenews/WCISen7.htm AN/FN/SROI 04: Must contain some type of indemnity or non-indemnity payment information. ** *This difference has been revised in Version 3.0. See difference #18 in the Differences Between Version 2.1 and Version 3.0 of WCIS **This difference has been revised in Version 3.0. See difference #24 in the Differences Between Version 2.1 and Version 3.0 of WCIS Appendix B: Revision History Summary of Principal Changes from Previous Versions Version 3.0 Section A: Updated the FROI Original (MTC=00) reporting requirement from 5 to 10 business days. Removed references to VAN and e-mail transmission options. Section A: Corrected previous error: Subsequent Reports of Injury (SROIs) are submitted within 15 business days Section B: EDI Service Provider information in Section B was expanded to include information from the deleted Section J. The listing of EDI Service Providers is now available online. Section C: Updated references to new Sections (J,K,L,M,N,O,P) and to listing of EDI Service Providers, which is now provided online. Removed references to VAN and e-mail transmission options. Section F: Updated Part C2 and C3 of the Trading Partner Profile to use a WCIS-hosted FTP as the sole transmission mode. Included ID list in the Trading Partner Profile, E (Form DWC WCIS TP01 Revised 01/08). Added requirement for reporting claim administrator postal codes in ID list. Updated WCIS zip code to 94612-1491. Section G: Minor updates and corrections. Removed references to VAN and e-mail transmission options. Removed Crosswalk of Employers (Form 5020), Doctors (Form 5021), and EDI First Report. Section I: FTP transmission mode updated. Removed references to VAN and e-mail transmission options. Section J: Deleted. Information is available online so it can be updated more easily. Section K: Renamed Section J. Updated reporting requirement for First Reports of Injury (FROIs) to 10 business days. Corrected previous error: Subsequent Reports of Injury (SROIs) are submitted within 15 business days. Clarified language for Annual (AN) summary and Payment (PY). Section L: Renamed Section K Filled in blanks with optional in tables Corrected previous errors: DN58 deleted from FROI data requirements. Added DN54 to SROI Changed some data requirements. Clarified SROI and FROI conditional fields. Section M: Renamed Section L Added CA-specific edits for DN5, DN6, DN8 and DN86. Changed default value on Social Security Number. Added California-adopted IAIABC Data Elements, sorted various ways. Section N: Renamed Section M Clarified 4P, AN and FN reporting. Removed benefit sequencing rules. Clarified advances and settlement reporting including the reporting of attorney fees. Made WCIS secondary matching rules more precise. Corrected Acquired Claims diagram. Section O: Renamed Section N Added web links for code lists and make corrections. Part of Body Codes: Made table easier to read. Added note about bilateral body part reporting. Deleted WCIRB class code list, but added online reference. Added benefit type code tables for Payment Adjustment (DN85) and Paid to Date (DN95) codes to be reported to the WCIS Added industry code information and online reference. Section P: Renamed Section O Section Q: Renamed Section P Version 2.1 Section A: Deleted sections referring to the variance period for data submission as the variance period has expired. Section A: Eliminated manual data entry on the World Wide Web as a data transmission option. Section A: Added File Transfer Protocol (FTP) as a data transmission option. Section A: Clarified the implementation of EDI by adding an additional step. The Parallel Step now follows the Pilot Step creating a five step process. Section B: Updated Trading Partner contact information. Section C: Deleted references to the Release 2 format of EDI. Section C: Eliminated manual data entry on the World Wide Web as a data transmission option. Section D: Updated Labor Codes 138.6 and 138.7. Section E: Updated WCIS regulations. Section E: Replaced regulations pertaining to WCIS and First Reports of Injury with web-site addresses where regulations are posted. Section E: Added Industry Code (DN25) to the list of required FROI data elements. Section E: Removed Current Date Disability Began (DN144) from the list of required SROI data elements. Section F: Deleted references to the Release 2 format of EDI. Section F: Deleted reference to using the web site to submit claims data to the WCIS. Section G: Added Parallel Phase to EDI transmission steps. Section G: Updated Trading Partner contact information. Section H: Deleted references to the Release 2 format of EDI. Section J: Updated information on providers of EDI-related services. Section K: Deleted references to the Release 2 format of EDI. Clarified language concerning criteria for submitting final (FN) and annual (AN) Subsequent Reports of Injury. Section L: Deleted Release 2 data elements and references to the Release 2 format of EDI and deleted FROI UR data requirements. Section L: Changed Social Security Number (DN42) from Conditional/Minor to Mandatory/Serious and added Industry Code (DN25) as a Conditional/Serious data element. Section M: Deleted Release 2 data edits and references to the Release 2 format of EDI. Section N: Deleted duplicate batch logic from the general rules for transaction processing and sequencing. Deleted Release 2 Maintenance Type Codes and references to the Release 2 format of EDI. Section O: Updated Part of Body Codes for Subsequent Reports of Injury. Section Q: Updated abbreviations and acronyms. Deleted references to the Release 2 format of EDI. Appendix A: Deleted duplicate batch logic and references to the Release 2 format of EDI. Version 2.0 Section B: Updated the contact information. Section C: Language in sub-section 4 was updated to reflect the fact that Release 1 is the preferred file format even though WCIS still supports the Release 2 format. Section C: Language in sub-section 7 was deleted on how to apply for a variance (delay) as the time deadline for requesting a variance has passed. Section C: Modified title of current sub-section 7. Section G: Updated contact information on where to get Trading Partner (TP) Profile forms and where to send the completed form. Section G: Deleted the section that refers to a variance period as the variance period has expired. Section G: Updated contact information on where the paper forms will be sent for parallel pilot phase. Section G: Added two transmission mode options: Integrator and File Transfer Protocol (FTP). Section G: Added a reference pointing to the February 15, 2002 version of the IAIABC Edit Matrix for information on error messages. Section H: This section was modified to indicate that the mandatory switch to Release 2 has been postponed indefinitely. Section H: Added information on the specific version of ANSI X12 that is compatible with WCIS. Section I: Added detailed information on the FTP transmission mode option. Section J: Corrected information on providers of EDI-related services. Section K: Corrected the Trigger Event table to reflect a change in the revised WCIS system that Release 2 AQ MTC is not accepted. Alternatively, an AU MTC now needs to be sent. Section L: Updated the Conditional Rules and Implementation Notes FROI: Release 1 and Release 2 data requirements Tables (See Condition FROI worksheet) to reflect that the Release 2 AQ MTC is not accepted in the revised WCIS system. Section M: California-specific edits, noted in previous Implementation Guides as planned edits, are adopted. Section N: Updated to indicate that First Reports and Subsequent reports cannot be sent together in a single batch for Release 2 files. Section N: Updated to reflect the various differences between the revised WCIS system and the old system. This information was included in ENEWS #36 and #37. It is also detailed in Section R. Please note: - For new claims submitted to the revised WCIS system, TPs will receive a new JCN that will be 22 digits. Existing claims will continue to keep the original 12 digit JCN. Duplicate batches will not be processed. A duplicate batch has the same Sender ID (DN98), Date Transmission Sent date (DN100), and Time Transmission Sent time (DN101) as an earlier batch received and processed by WCIS. - The MTC date must be less than or equal to the current date. - Rules that apply to Release 2 AQ transactions have been removed. - Only one IP transaction for the same claim will be allowed. - Medical-only claims with no indemnity payments may be closed with an AN MTC (must include a Claim Status = closed. FN MTC not required to close this type of claim. - ANSI X12 ANs must include the proper ANSI frequency code. - Transaction-level MTC rule for FS MTC: Must contain benefit record with Payment/Adjustment Code=240 or 524. - Secondary Match for FROIs, other than AU transactions, also applies to SROIs. - Compensatory Death MTC automatically closes all Indemnity Benefits (BENs). MTCs that open these closed BENs will be rejected. Section O: Updates to various code tables. Section P: Removed the IAIABC EDI implementation Guide Order form as a free downloadable version is posted on the IAIABC web site. Section P: Removed explanation of differences between Release 1 and Release 2 data formats. Section Q: Deleted the description of full variance as the variance period has expired. Appendix A: New section added to detail differences that TPs need to note between the former and revised WCIS systems and past issues that may need clarification. Version 1.2 Section A: Updated information on paper reporting requirements to the Division of Labor Statistics and Research (DLSR) during production phase. Section B: Added description of WCIS eNews that is the WCIS e-mail newsletter. Section C: Added information on obtaining from the IAIABC a license to use the EDI transaction standards for transmitting data to a state. Section E: Added copy of letter from Department of Industrial Relations (DIR) stating that fulfilling the requirements of the WCIS regulations regarding transmission of First Reports satisfies the obligation to send paper Employers Reports (Form 5020) to DLSR. Added DLSR regulations pertinent to the filing of first reports. Section F: E-mail address of State updated in Section D of Trading Partner Profile Form. Section G: Information on paper reporting requirements to DLSR during production phase updated. Submission requirement of paper Doctors First Report (Form 5021) to WCIS during piloting phase changed to optional. Added that ANSI Trading Partners receive 997 Functional Acknowledgment in addition to 824 Detailed Acknowledgment. References to Section I Transmission Modes added for e-mail and web site Trading Partners. Statements that web site users be able to receive e-mail acknowledgments removed. Piloting procedures clarified. Section H: Modified to indicate that the ANSI X12 file format for First and Subsequent Reports of Injury Release 2 will be accepted as soon as an implementation guide has been approved by either ANSI or IAIABC. Updated WCIS schedule of Supported Transactions. Section I: Clarified the fact that the Division of Workers Compensation (DWC) will not pay VAN charges for either incoming or outgoing EDI transmissions. Added specific steps on how to send data as an e-mail attachment or through DWCs website. Section J: Added new EDI service providers to listing. Section K: Added Release 1 Subsequent Report table. Section L: Added Release 1 Subsequent Report table of required data elements and updated data requirements. Section M: Planned edit on Claim Administrator Claim Number (DN15) removed. Section N: Deleted reference to CO being preceded by an error message. Also deleted paragraph stating that claims administrators can only update First Report Data elements. Added Benefit Processing Rules and clarified sequencing rules for First and Subsequent Reports. Fixed matching rules table to indicate that Jurisdiction Claim Number must currently be provided on MTC=01, 02, CO, and all subsequent reports. Clarified description of when secondary match data are used. Section O: Added footnote to table of Employee Mailing Country Codes. Added code 99 whole body to Part of Body code list. Section P: Added information on obtaining from the IAIABC a license to use the EDI transaction standards for transmitting data to a state. Section Q: Added section on EDI Terminology. Version 1.1 Sections A and C: Includes minor updates to reflect final regulations. Section E: Contains updated WCIS regulations, as approved by the California Office of Administrative Law on October 6, 1999. Section F: Includes a new subsection on who needs to complete the Trading Partner Profile form. Section G: Introductory paragraph added. Updated to reflect current regulations. Section J: Includes updated list of EDI service providers. Section K: Specifies which Maintenance Type Codes are not accepted by WCIS. Section L: Minor updates to data element requirements and conditional statements. Section N: Updated Matching Rules and Processes table, and revised explanation in Changed or Corrected Data. Section O: Removed code lists for Application Acknowledgment Code, Denial Reason Code, and Employment Status Code. Version 1.02 Reporting deadlines have been revised throughout to match new timeline in proposed regulations dated June 22, 1999. Section G: Test, pilot, production process has been revised to provide simpler and more efficient movement through early phases of testing. Section H: WCIS support for Release 2 file formats has been changed, reflecting recent IAIABC approval of an ANSI X12 format for First and Subsequent Reports of Injury, Release 2. Version 1.01 Includes revised regulations, removing from the current rulemaking the requirements to submit Medical Bill/Payment Reports. References to medical reporting requirements are eliminated from throughout the current implementation materials. Version 1.00 The version previous to 1.00 was not numbered, but was released in February, 1999. Version 1.00 includes substantial modifications throughout. The most significant of these are: WCIS support for all Maintenance Type Codes has been added. A schedule has been added indicating what file formats (Release 1, Release 2, flat-file, ANSI X12) will be supported and when. Test, pilot, and production process has been specified. California-specific data edits have been specified. Matching rules and processes have been specified. Transaction sequencing requirements have been specified. Processing of acquired claims transactions has been specified. Lists of valid codes have been added.  8 C.C.R. 14000 defines computer input media as [t]echniques and means by which information or data can be entered into a computer system. Examples include magnetic tape, diskette, and telecommunications.     PAGE 120 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) PAGE  PAGE 17 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) PAGE i (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 6 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section A California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section A California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section B California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section B California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section C California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section C PAGE 13 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section D California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section D California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section E California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section E PAGE 24 February, 2006 January, 2008 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section F Form DWC WCIS TP01 (Revised DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE)  PAGE 28 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) California EDI Implementation Guide Section F Form DWC WCIS TP01 (Revised DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE)  PAGE 20 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section F California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section F California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section F PAGE 32 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section G PAGE 48 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 39 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section H PAGE 62 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section I California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section J PAGE 51 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 78 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section K PAGE 53 (DATE TO BE INSERTED BY OAL 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 82 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section K PAGE 66 (DATE TO BE INSERTED BY OAL- 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 84 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section K PAGE 90 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section L PAGE 75 (DATE TO BE INSERTED BY OAL- 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 98 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section M PAGE 84 (DATE TO BE INSERTED BY OAL- 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 108 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section N PAGE 95 (DATE TO BE INSERTED BY OAL- 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 119 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Section O PAGE 100 (DATE TO BE INSERTED BY OAL- 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 152 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Appendix A PAGE 113 (DATE TO BE INSERTED BY OAL- 12 MONTHS FOLLOWING APPROVAL AND FILING WITH SECRETARY OF STATE) PAGE 158 California EDI Implementation Guide for First and Subsequent Reports of Injury (FROI/SROI) Appendix B PAGE 163 State of California Department of Industrial Relations DIVISION OF WORKERS COMPENSATION AU JCN present JCN absent Valid JCN? No Yes Claims admin data updated (and any other fields with new information). AK1 Transaction Accepted AK1 Transaction Rejected "No match on database" AP Resubmit AU with correct JCN or resubmit AU with no JCN. **Secondary match on 2b? Yes No Claims admin data updated (and any other fields with new information) Create new claim. 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laytbT$$If!vh55:5 55)5m55P5 5 [5 5 5 5 555)5v5v5#v#v:#v #v#v)#vm#v#vP#v #v [#v #v#v#v)#vv#v:V l:,55n5Z555555 5 5 5.595559/ / / / ytbTTkdqk$$IfTlּ Hg3],"$'L+.2479$$nZ                                             .    9                    :PPPP44 laytbT$$If!vh55:5 55)5m55P5 5 [5 5 5 5 555)5v5v5#v#v:#v #v#v)#vm#v#vP#v #v [#v #v#v#v)#vv#v:V l:,55n5Z555555 5 5 5.595559/ / / / ytbTTkdp$$IfTlּ Hg3],"$'L+.2479$$nZ                                             .    9                    :PPPP44 laytbT$$If!vh55:5 55)5m55P5 5 [5 5 5 5 555)5v5v5#v#v:#v #v#v)#vm#v#vP#v #v [#v #v#v#v)#vv#v:V l:,55n5Z555555 5 5 5.595559/ / / / ytbTTkd v$$IfTlּ Hg3],"$'L+.2479$$nZ                                             .    9                    :PPPP44 laytbT$$If!vh55:5 55)5m55P5 5 [5 5 5 5 555)5v5v5#v#v:#v #v#v)#vm#v#vP#v #v [#v #v#v#v)#vv#v:V l:,55n5Z555555 5 5 5.595559/ / / / ytbTTkdX{$$IfTlּ Hg3],"$'L+.2479$$nZ                                             .    9                    :PPPP44 laytbT$$If!vh55:5 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