Answers to FAQs for WCIS FROI/SROI Reporting version 3.1

Here are answers to some of the questions we have received from WCIS trading partners. Please contact us if you have additional questions or comments. Our e-mail address is wcis@dir.ca.gov.

About regulations and deadlines

Q: When did electronic reporting to WCIS begin?

A: Electronic reporting to WCIS began in 2000. The WCIS regulations (Title 8, California Code of Regulations [CCR] sections 9700 through 9704) require first reports of injury (FROI) to be sent via electronic data interchange (EDI) for any claim with a date of injury on or after March 1, 2000. Electronic subsequent reports of injury (SROI) are required for any claim with a date of injury on or after July 1, 2000. Claims with dates of injury before March 1, 2000, are accepted by WCIS but are not required.

Q: What are the penalties for failure to comply with EDI reporting requirements described in section 9702?

A: At this time, the Division of Workers’ Compensation (DWC) is focusing its efforts on encouraging voluntary compliance, rather than on enforcement. However, Labor Code section 129.5(a)(3) authorizes the administrative director to impose penalties for failure to comply with any DWC rule or regulation. If necessary, the division may use these enforcement powers in the future to further encourage compliance with EDI reporting requirements.

Q: Will WCIS data be used for selecting claims administrators to be audited?

A: Yes. WCIS data may be used to target claims administrators for audits. Under Labor Code section 129, insurers, self-insured employers, and third-party administrators must be audited at least once every five years and on additional occasions as indicated by target audit criteria. DWC’s Audit Unit may select a claims administrator for a target audit based on WCIS data if the data indicate that the claims administrator is failing to meet its obligations. Possible violations indicated by WCIS data include high percentages of apparently late first or subsequent indemnity payments, either overall or by class of indemnity, or high ratios of denied claims to indemnity claims.

About WCIS reporting requirements

Q: How do claim administrators get an SFTP (secure shell file transfer protocol) account and user name for reporting FROI/SROI version 3.1 data to the WCIS?

A:  SFTP accounts are assigned and managed by the WCIS. Trading partners must send a California FROI/SROI version 3.1 Trading Partner Profile Agreement to receive an SFTP username and password. Claims administrators that use a vendor to report data should ask the vendor to send a profile form to the WCIS so that they can register for the SFTP account.

Q: Are new trading partner profile agreements required for California FROI/SROI version 3.1 reporting?

A: For the California FROI/SROI Implementation Guide Version 3.1, all trading partners must submit a copy of the 3.1 Trading Partner Profile Agreement to their assigned WCIS contact or to wcis@dir.ca.gov.

Q: How can we improve our timeliness measurement in the timeliness of payment report?

A: Here are a few suggestions:

  1. Send timely, complete, and accurate EDI reports to avoid processing delays, rejections, and data inconsistencies.
  2. Ensure that the maintenance-type code date (DN3) on the initial payment (MTC=IP) is the issue date of the initial indemnity check.
  3. If the initial indemnity payment is late, send an applicable late reason code (DN77) on the IP.

Q: For the timeliness of payment calculation, can we send a late reason code (DN77) on a change report (MTC=02) if the code was not sent on the initial payment report (MTC=IP)?

A: No. It would be difficult to tell to which indemnity benefit the late reason code applies when multiple indemnity benefits are paid on a claim. The late reason codes should be sent on the IP on new claims when applicable.

Q: How can we improve the comparison of our claim counts in the WCIS with the claim counts in the ARI (the DWC Audit Unit’s Annual Report of Inventory)?

A: Here are a few suggestions:

  1. Send timely, complete, and accurate EDI reports to avoid processing delays, rejections, and data inconsistencies.
  2. Send accurate FEIN data. If the claim is handled by a third party administrator (TPA), send the TPA FEIN (DN8) and TPA Name (DN9) on all transactions. The ARI includes a field for the FEINs of companies adjusted at each claim administrator adjusting location and this field is used to match WCIS data with ARI data.
  3. Ensure that both indemnity and non-indemnity claims are reported correctly. For example, the annual (MTC=AN) reports should be sent for both indemnity and non-indemnity claims. For details, see WCIS eNews 63.

Q: Is each trading partner required to send a list of FEINS for claims administrators whose data will be sent under its sender ID?

A: Yes. The WCIS uses the claims administrator’s FEIN to process individual transactions. Transactions for unknown claims administrators will be rejected by the WCIS 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 FEINs for claims administrators whose data are reported under a given sender ID. This list can be downloaded in Microsoft Excel format from the WCIS Web page. If a list is not provided, the WCIS will assume that the only claims administrator’s FEIN reportable by that trading partner is the master FEIN from the trading partner’s sender ID. To prevent rejections, an updated list must be sent to your WCIS EDI contact each time there is a change.

Q: What types of claims must be reported to the WCIS?

A: A reportable claim under the WCIS regulations is defined as an injury that occurred on or after March 1, 2000, that has resulted in the receipt of one or more of the following by a claims administrator:

  1. an employer’s report of occupational injury or illness (Form 5020)
  2. a doctor’s first report of occupational injury or illness (Form 5021)
  3. an application for adjudication filed with the Workers' Compensation Appeals Board (WCAB) and
  4. any information indicating that the injury requires medical treatment by a physician as defined in Labor Code section 3209.3. See Title 8, CCR, section 9701. If treatment is required by a physician, then the injury qualifies as a claim and must be reported. Under California workers' compensation law, a "physician" includes licensed medical doctors, doctors of osteopathy, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners.

Q: Will the WCIS accept first reports of injury on claims that require only first-aid treatment?

A: It depends. If the first-aid treatment is provided by someone other than a physician, or the necessary treatment is not required to be provided by a physician, the injury should not be reported to the WCIS. Note that “first aid” is defined in Labor Code section 5401(a) as “any one-time treatment, and any follow up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and follow up visit for the purpose of observation, is considered first aid even though provided by a physician or registered professional personnel.” An employers' report of occupational injury or illness is not required for injuries that require only first-aid treatment. See Title 8, CCR, section 14001(a).

Q: Do I need to provide an annual report of inventory to the Audit Unit if I comply with the WCIS reporting obligations?

A: No. Title 8, CCR, section 9702(i)(3), states that, on or after September 22, 2006, a claims administrator’s obligation to provide an annual report of inventory under Title 8, CCR, section 10104, is satisfied if FROI and SROI reporting is accurate.

Q: When can our organization stop submitting paper copies of the employer’s report of occupational injury or illness (Form 5020) to the Division of Labor Statistics and Research?

A: You are authorized to stop submitting paper copies of the employer’s report of occupational injury or illness, Form 5020, to the Division of Labor Statistics and Research (DLSR) when you are in production status for reporting to the WCIS. Your WCIS contact person will inform you when the data-quality criteria of the pilot phase have been met. You will then receive written authorization from the DWC to submit production status data to the WCIS. Electronic reporting to the WCIS of first report of injury data will qualify as "use of computer input media, prescribed by DLSR" (see Title 8, CCR, section 14001(c)). Please keep in mind you will still be required to submit the doctor’s first report of occupational injury or illness (Form 5021) to the DLSR.

Q: Can an employer report occupational injuries in California to the claims administrator using a form other than the employer’s report of occupational injury or illness (Form 5020)?

A: No. Labor Code section 6409.1(a) and Title 8, CCR, section 14001(a), state that every employer shall report injuries that result in loss of time beyond the date of injury or that require medical treatment beyond first aid on Form 5020. Individual claims administrators can add additional data to Form 5020, consistent with Title 8, CCR, section 14005, as needed to facilitate EDI reporting.

Q: How will backlogged data be submitted?

A: First-report data will be reported with the most current and best information on a single transaction using an original (00) maintenance-type code. Subsequent report data will be reported using the upon request (UR) maintenance-type code. Each benefit type paid will be reported on a single UR transaction, including the starting and ending date of benefits and the cumulative amount paid. For more detailed information, see eNews #32, 04-17-03, “The upon request (UR) option now available.” The only change in this process is that the IP should be sent before the UR.

Q: Since the final (FN) and annual (AN) transactions are similar, is it sufficient to use either one at the time a claim is closed?

A: It depends on whether indemnity payments have been made on the claims. For medical-only claims with no indemnity payments, it is sufficient to send an annual (AN) transaction with claim status ”closed.” For claims with indemnity benefits, a final (FN) transaction must still be sent when a claim with indemnity benefits closes. For additional information, see eNews #63, 12-01-06, “Annual Reports.”

Q: Will there be separate test and pilot periods for each type of transaction (first reports of injury, subsequent reports, etc.)?

A: In general, a trading partner completes the test and pilot process for first reports before testing and piloting subsequent reports. The WCIS cannot process subsequent reports for a claim without having first accepted the corresponding first report. However, claims administrators may begin piloting subsequent reports before reaching production status for first reports, as long as the EDI portion of the data quality criteria for piloting first reports has been fulfilled (see section G of the California EDI Implementation Guide), and the corresponding first report data have already been accepted by the WCIS.

Q: Do I need to report FROI and SROI data for claims that are under the alternative dispute resolution (ADR) provisions of a carve-out program?

A: Yes. Labor Code sections 3201.5 and 3201.7 allow unions and employers to enter into labor-management agreements, called “carve-out” programs, which establish ADR procedures for workers’ compensation claims. These agreed-upon ADR procedures can either supplement or replace the dispute resolution provisions generally required by the Labor Code (such as bringing a case before the Workers’ Compensation Appeals Board [WCAB]). Although approved carve-out programs are exempt from many WCAB procedures, claims administrators who adjust claims under these programs must comply with the WCIS reporting requirements. See Title 8, CCR, sections 10201(g)(1) and 10102(i)(1).

Q: What are the WCIS reporting requirements for companies A and B when an adjuster from insurance company A paid $X to insurance company B as an agreed contribution to indemnity payments and another $Y for medical payments? Company A did not make any payments directly to the injured worker but did make the contribution payments to company B. Company B made the payments for both medical and indemnity benefits in full to the injured worker.

A: Only company B needs to report payments to the WCIS. The reported payments would be for the full amounts of all benefits and include the contributions ($X and $Y) from company A.

Q: Do “no coverage” claims need to be reported?

A:  No.  Claims identified as having no coverage upon knowledge of the claim need not be submitted to the WCIS. Claims identified as having no coverage after submitting an FROI Original (00) must be canceled with an FROI Cancellation (01).

Q: Should disaster relief worker injury cases be reported?

A: Yes. Injuries to disaster service workers (DSW) covered under division 4, part 1, Chapter 10, of the Labor Code (beginning with section 4350) should be reported to the WCIS. While the Labor Code’s definition of “employee” (section 3351) expressly excludes DSWs, an exception is made for those covered under Chapter 10. See Labor Code section 3352.94 for more details. Note that an injury to “unregistered” DSWs may also need to be reported if they are “impressed into service during a state of war emergency, a state of emergency, or a local emergency by a person having authority to command the aid of citizens in the execution of his or her duties.” See Labor Code section 3211.92 for more details.

Q: Should claims filed against a homeowner's policy be reported?

A: Yes.

Q: Do longshoremen or federal railroad workers’ injury claims need to be reported?

A: Claims that are exclusively administered under the federal workers' compensation statutes, such as the Longshore and Harbor Workers' Compensation Act, are exempt from WCIS reporting. In cases of concurrent jurisdiction, where the injury falls within the jurisdiction of both a federal statute and California’s workers' compensation laws, claim information and benefit payments should be reported to the WCIS, especially if a case is opened with the WCAB and a settlement is brought for approval.

Q: How should the insurer and employer information for claims that are covered by a self-insured pool be reported?

A: The pool’s FEIN and name should be reported under the insurer FEIN (DN6) and insurer name (DN7). The employer's FEIN and name should be reported under the employer FEIN (DN16) and employer name (DN17), and the self-insured indicator (DN24) should be set to “Yes.” Only the pool's information should be reported on the trading partner's insurer/claims administrator ID list. It is not necessary to include all employers in the pool on the ID list. For more information, see Office Of Self Insurance Plans.

Q: How are child support payments that are withheld from temporary disability benefits reported?

A: These payments can be included in the temporary disability benefit amount paid.

Q: Do claims adjusting costs, such as stamps, photocopying, and overnight mailing fees, need to be reported?

A: They do not need to be reported.

Q: Should foreign postal codes for covered injuries be reported?

A: Yes. Although the WCIS validates only US and Canadian postal codes, all foreign postal codes should be reported when applicable. A transaction accepted with an error (TE) acknowledgment may be sent to the trading partner, but if the foreign postal code is valid, the TE acknowledgment can be ignored.

Q: Do the benefit amounts reported on the annual (AN) transaction cover the total paid for the previous year or the total paid over the life of the claim?

A: Benefit amounts on all SROIs should cover the total paid over the life of the claim, as of the end of the reporting period. For additional information, see eNews #63, 12-01-06, “Annual Reports.”

Q: What data elements are used to calculate “timeliness” in the WCIS timeliness of payments reports?

A: For indemnity claims, timeliness is calculated from the date disability began (DN56) to the date of initial payment (DN3, maintenance-type code date, on MTC=IP). Regulations concerning the timeliness of benefit payments and notices are published in Title 8, California Code of Regulations section 9812.

About security and confidentiality

Q: Are data transmitted to the WCIS secure?

A: Yes. All data are stored on secure computers in state facilities. Transmitted data are kept secure through the use of the secure shell file transfer protocol (SSH FTP), which provides authentication and encryption.

Q: Does the DWC use individually identifiable information internally?

A: Yes. The WCIS regulations specify that the division "may obtain and use individually identifiable information for the following purposes: to create and maintain the WCIS, to help select claims administrators for audits, to report the promptness with which claims administrators make payments, and to electronically import names, addresses, and other information into the Division of Workers’ Compensation case files."

Q: Does any other public agency obtain individually identifiable information from the WCIS?

A: Yes. Title 8, CCR, section 9703, specifies that: the Division of Occupational Safety and Health may use WCIS information to help select employers for health and safety consultations and inspections the Division of Labor Statistics and Research may use WCIS data to carry out its research and reporting responsibilities; the Department of Public Health may use WCIS data to carry out its occupational health and occupational disease prevention responsibilities; the Department of Health Care Services to obtain and use individually identifiable information from the WCIS for the purposes of seeking recovery of Medi-Cal costs incurred by the state for treatment provided to injured workers that should have been incurred by employers and insurance carriers; and, researchers employed by or under contract to the Commission on Health and Safety and Workers’ Compensation may use WCIS data for the purpose of conducting bona fide statistical research.

Q: Will individually identifiable information concerning any employee, employer, or claims administrator be made available to persons or groups outside the DWC and the government agencies mentioned above?

A: Yes, but only with stringent restrictions. The data may be made available for the purpose of bona fide statistical research by public or private entities that obtain approvals by both the DWC and an institutional review board. These provisions are required by Labor Code section 138.7 and are detailed in Title 8, CCR, section 9703 of the WCIS regulations.

About acknowledgments and errors

Q: Will missing data result in error messages on acknowledgments? What about missing data that are allowable within the first 60 days if the data are not yet available to claims administrators?

A: It depends. Missing data will result in error messages under most circumstances. Section L in the California EDI Implementation Guide explains the various levels of WCIS data requirements. A few core data elements have an error-level designation of "fatal," meaning that their presence is necessary for the WCIS to create a claim record. Transactions with missing values for these core elements will be rejected and will have to be resubmitted with the missing "fatal" items filled in. If items with an error level of "serious" are missing from a given transaction, the transaction will be accepted but “transaction accepted with error” (TE) error messages will be sent in the acknowledgment. These missing "serious" data elements should be filled in when available, using a "correction” (CO) transaction, and must be supplied within the 60-day period. No error messages will be sent for data elements with an error level of “minor.” Claims administrators should leave the data element blank until the correct data are obtained and submitted. Missing data will be noted on data-quality reports that will be provided to each data provider upon request.

Q: How long does it take to receive acknowledgments?

A: In general, the WCIS sends acknowledgments within three business days after the receipt of data. This time frame can vary, depending on the volume of incoming data or unanticipated system issues. Please contact your WCIS trading partner contact if you have not received an acknowledgment within five business days of a transmission.

Q: Will the WCIS put any free-form text messages in its acknowledgments?

A: No. We do not anticipate putting any free-form text messages in acknowledgments.

Q: What do I do when a transmission or transaction has been rejected?

A: If an entire transmission is rejected, this generally indicates a problem with either the batch header or the trailer. The error code(s) on the acknowledgment indicate the nature of the problem. Make the necessary corrections and resubmit the entire transmission. If an individual transaction is rejected, this probably indicates that the claims administrator failed to provide a usable value for a data element labeled mandatory/fatal (M/F) or conditional/fatal (C/F) (see section L, Required Data Elements, in the California EDI Implementation Guide), sent a transaction out of sequence, or sent a duplicate transaction (see section N, System Specifications, in the California EDI Implementation Guide). For cases other than duplicate transactions, the claims administrator must resubmit the transaction (same maintenance type code) with the errors fixed for the WCIS to process.

Q: What does error code 061 mean?

A: Error code 061, event criteria not met, can be generated under various circumstances. The most common examples are:

  1. A FROI Original (00) was submitted with a jurisdiction claim number JCN. 
  2. A SROI such as the initial payment (IP), acquired payment (AP), reinstatement of benefit (RB), change in benefit type (CB), change in benefit amount (CA), full salary (FS), or suspension, returned to work (S1) is sent in without indemnity benefit information.
  3. A SROI annual (AN) is sent for an indemnity claim with a “closed” claim status (DN73) and a final (FN) has not been previously accepted. Indemnity claims must be closed with the FN.

Q: What does error code 063 mean?

A: Error code 063, invalid event/sequence relationship, can be generated under various circumstances. The most common examples are:

  1. A SROI is sent in without any benefit indemnity or non-indemnity benefit information.
  2. A reinstatement of benefit (RB) is sent without a previous suspension, e.g., S1 or S3.
  3. An initial payment (IP) is sent when a previously accepted IP already exists. Additional benefits can be opened with change in benefit (CB), reinstatement of benefit (RB), payment (PY), or full salary (FS) maintenance type codes.
  4. A SROI change in benefit amount (CA), change in benefit type (CB), partial suspension (Px), reinstatement of benefit (RB), reduced earnings (RE), suspension (Sx), change (02), or correction (CO) is sent when there has not been a previously accepted SROI.
  5. A SROI acquired payment (AP) is sent without a previously accepted FROI acquired (AU).

Q: What does error code 064 mean?

A: Error code 064 is generated on the Employer FEIN (DN 16) when the Employer FEIN is the same as the Insurer FEIN on a FROI but the Self Insured Indicator is reported as “No”. If the Employer is self insured, the Indicator must be set to “Yes”. See the conditional rule on the Employer FEIN in section K of the California FROI/SROI guide for more information.

Q: What should I do if a valid US or Canadian postal code and it receives a transaction accepted with error (TE) acknowledgment?

A: The WCIS validates US and Canadian postal codes. In the case of US zip codes, please verify the code at the United States Postal Service zip code lookup Web site. In the case of Canadian postal codes, please verify the code at the Canada Post postal code lookup Web site. If the postal code is valid, provide your trading partner contact with the street address, postal code, and claim number so that we can update our database. The TE error on valid postal codes can be ignored.

Q: If a FROI cancel (01) receives a TE acknowledgment, does the system expect a FROI correction (CO) to be filed to correct the errors? Also, if a previous FROI or SROI received a TE acknowledgment before the claim was cancelled, should a FROI or SROI CO be filed to correct these errors?

A: No, the TE errors do not need to be corrected on cancelled claims.

Q: How does the WCIS handle subsequent reports for claims on which no electronic first reports have been submitted?

A: All data submitted to the WCIS are subjected to a set of transaction sequencing rules, including a rule that a subsequent report must be preceded by a valid first report. For this reason, any subsequent report transactions without a preceding first report will be rejected. See sections N and L in the California EDI Implementation Guide for details.

About EDI transmission

Q: What transmission modes are available to claims administrators for transmitting data to WCIS?

A: The only transmission mode allowed is  via SFTP also known as SSH (secure shell) file transfer protocol.

Q: What is the IP address for submitting to SFTP?

A: The WCIS SFTP server address is provided to trading partners after they have submitted their 3.1 Trading Partner Profile Agreement to their assigned WCIS contact or to wcis@dir.ca.gov.

Q: Does the WCIS accept a first report and a subsequent report (such as an initial payment transaction) within a single transmission?

A: No. The first report and subsequent report transactions must be sent in separate batches. Combining first and subsequent reports in a batch is not possible in release 1 file formats because the two types of reports have different field layouts. Transaction sequencing rules apply across the batches. Therefore, because the WCIS must process the first report for a claim before any subsequent reports, the first report batch must precede the subsequent report batch.

Q: What is the file naming convention for files submitted under the California FROI/SROI version 3.1?

A: File names must be unique and cannot contain spaces.

Sample 148_123456789_946125698_20140113_135012_T_001.txt

  • 1st through 3rd characters: File Type 148, A49, or AK1, followed by an underscore “_.”
  • 5th  through 13th characters: Trading Partner’s Sender FEIN followed by an underscore “_.”
  • 15th through 23rd characters: Trading Partner’s 9-digit Sender zip code followed by an underscore “_”.
  • 25th through 32nd characters: Date Stamp of the 148, A49, or AK1 file (8-digit date, CCYYMMDD) followed by an underscore “_.”
  • 34th  through 39th characters: Time Stamp of the 148, A49, or AK1 file (6-digit time, HHMMSS) followed by an underscore “_.”
  • 41st character: Test/ Production indicator: a “T” for Test or a “P” for Production followed by an underscore “_.”
  • 43rd through 45th characters: Unique 3-digit counter (001-999) for 148 and A49 files,

Or

  • 43rd  through 51st  characters are a unique 9-digit counter for AK1 files.
  • All files will be named with a .txt extension. Files with any other file extensions will not be processed.

An error will occur if a file is submitted with a name that is the same as that of a file already in the WCIS folder.

About data element reporting

Q: What code should be sent under the class code (DN59) for claims filed against a homeowner's policy?

A: Report the class code that best represents the industry/occupation of the injured worker.

Q: Where can the Nature of Injury (DN35), Part of Body (DN36), and Cause of Injury (DN37) code lists be found?

A: They can be found on the Workers Compensation Insurance Organization (WCIO) website.

Q: Why are some data elements designated as "mandatory" but the associated data errors as "minor" with no error messages returned? Are these data elements essentially the same as what most states would designate as "optional"?

A: Yes. The WCIS processes these "mandatory/minor" data elements the same as "optional" data elements in terms of acknowledgments and other follow-up. From a legal standpoint, however, they are required. We have simply suppressed error messages to reduce the volume of reported errors on less-important data elements.

Q: What IAIABC release version is accepted by WCIS? Are there any plans to go to release 3?

A: We are only accepting release 1 files. There are no plans to go to release 3.

Q: Which employer FEIN should be used for employers with complex corporate relationships?

A: This should be the FEIN of the corporate entity that has the legal responsibility for handling a given worker’s compensation case under the California Labor Code.

Q: What is the JCN (Jurisdiction Claim Number)?

A: The JCN is a computer-generated number sent to claims administrators after their first submission on a claim is accepted. The JCN, also known as the Agency Claim Number (DN 5), is the primary key used by the WCIS to uniquely identify a claim.

Q: Is the jurisdiction claim number (JCN) required on all transactions after the original first report?

A: The JCN is required on all FROI/SROI transactions except the Original (00), Acquired (AU), or Denial (04).  

Q:  How can a trading partner or claims administrator find the existing JCN on a claim?

A: If the trading partner has the Insurer FEIN, Claim Number, and Date of Injury, the WCIS Jurisdiction Claim Number (JCN) Search can be used to find existing JCNs within the WCIS.

Q: What is the WCIS number on the Application for Independent Medical Review (IMR) Form?

A: The WCIS number is the Jurisdiction Claim Number (JCN). For claims with dates of injury prior to March 1, 2000, a JCN or WCIS numbers may not be available. Missing WCIS numbers for claims with date of injury prior to March 1, 2000 will not stop the processing of the IMR application.

Q: Which benefit payment codes are accepted by WCIS?

A: All IAIABC release 1 payment/adjustment (DN85) and paid to date (DN96) codes are accepted. However, the following payment/adjustment codes, in most cases, should not be sent on recent claims:

  • 040 – Permanent partial unscheduled
  • 080 – Employers liability
  • 410 – Vocational rehabilitation maintenance
  • 540 – Compromised permanent partial unscheduled
  • 580 – Compromised employers liability
  • 541 – Compromised vocational rehabilitation maintenance

Q: How is the claims administrator postal code (DN14) reported?

A: In California, DN14 is the postal code of the physical location of the claims administrator handling the claim. It is not a post office box address.

Q: Do the Claims Administrator FEIN (DN 8) and Claims Administrator Name (DN 9) need to be reported?

A: The California FROI/SROI Implementation Guide version 3.1 requires both data elements. The Claims Administrator FEIN (DN 8) is a mandatory/fatal element and must be reported on all FROI/SROI transactions. Failure to report the Claims Administrator FEIN will cause the transaction to be rejected with a Transaction Rejection (TR). The Claims Administrator Name (DN 9) is a Mandatory/Serious element on FROI Original (‘00’), Acquired (‘AU’), Denial (’04’) and Change/Correction (‘02’/’CO’) transactions.  Failure to report will result in a Transaction Accepted with Error (‘TE’). 

Labor Code section 9702(f) defines a claim administrator as either a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, California Insurance Guarantee Association (CIGA), or a third party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.

Q: Is the industry code (DN25) required?

A: Yes. For dates of injury after March 27, 2018, the North American Industry Classification System (NAICS) code must be sent on FROI transactions. NAICS Industry Codes can be downloaded at census.gov. The submission rules for NAICS Codes are that the Industry Code must be submitted as a six digit code.  WCIS encourages trading partners to submit the most recent six-digit code.

If a Trading Partners cannot submit the full 6-digit code, WCIS encourages the trading partner to submit as many digits as possible.  The minimum number of digit code a trading partner can submit is a 2-digit code.  Submissions of 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:

NAICS
6-digit code 111110 Soy Bean Farming
4-digit 111100 Oilseed and Grain Farming
3-digit 111000 Crop Production
2-digit 110000 Agriculture, Forestry, Fishing and Hunting

For dates of injury after March 27, 2018, trading partners can submit industry codes using the Standard Industrial Classification (SIC) code. If SIC codes are submitted, the 4-digit SIC code needs to include 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 4-digit SIC and a 4-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 added to the left.

Q: Is there a default value for the social security number (SSN)?

A: A value of 000000006 will be accepted if the employee has no SSN.

Q: Is the Time of Injury (DN 32) required?

A: Yes. The Time of Injury (DN 32) must be reported on all non-cumulative trauma, non-acquired transactions. The Time of Injury (DN 32) must be reported using the 24-hour military time format (HH24MM).

Q: Where can I find a list of class codes (DN59) accepted in California?

A: The class codes are based on the California Worker’s Compensation Insurance Rating Bureau (WCIRB) standard classification codes. The codes are updated every January and are listed by alphabet and by classification code number.

Q: How are utilization review and medical interpreter fee expenses reported?

A: Utilization review and medical interpreter fee expenses can be reported under the paid to date code 370 (other medical).

Q: How are supplemental job displacement benefits (SJDB) reported?

A: They should be reported using the paid to date code (DN95) 390 (vocational rehabilitation education paid to date).

Q: How are life pension payments reported?

A: Life pension payments should be reported under the payment/adjustment code 030 (permanent partial/scheduled).

Q: Should the paid to date/reduced earnings/recoveries code, 310 (penalties paid to date), take into consideration any refund or rebate paid by a claims administrator to an employer based on a penalty assessed against the claims administrator for mishandling a claim?

A: No. The amount reported should include all assessed penalties paid on a claim, regardless of whether the claims administrator refunded any penalty amounts to the employer.

About maintenance type code reporting

Q: How is a reopened claim reported?

A: For non-indemnity claims, nothing needs to be sent until an indemnity payment is made, the annual (AN) is due, or the claim is closed again, in which case a final (FN) could be sent. For indemnity claims, send the appropriate SROI when the next indemnity payment is made, e.g. reinstatement of benefit (RB) or payment report (PY), or if only additional non-indemnity payments are made, send the AN or FN as required.

Q: What maintenance type code should a trading partner use to report missing data on a previously submitted but incomplete transaction?

A: IAIABC protocols indicate that maintenance type code CO (correction) is used to correct or fill in data elements in response to a TE (transaction accepted with error). Message maintenance type code 02 (change) is used for changes that are not in response to an error message. If both corrections and changes need to be sent for a given claim, they can be transmitted together using either of these maintenance type codes. See section N in the California EDI Implementation Guide for details on changes and corrections.

Q: What maintenance type codes are accepted by the WCIS?

A: All IAIABC release 1 Maintenance Type Codes are accepted except for SROI VE, BM, BW, MN, QT, and SA.

Q: Can the date of injury (DN31) be updated if it is found to have been reported incorrectly?

A: Yes. The date of injury can be updated by sending a transaction with maintenance-type code 02 (change). Be sure to include all other FROI data elements as well, because they will be needed for data validation. The WCIS will overwrite existing data elements with the current data elements sent on a 02 (although missing values on the new transaction will not overwrite existing values in the WCIS database). For further explanation of changes or corrections, see section N in the California EDI Implementation Guide.

Q: How is the SROI partial denial (4P) reported?

A: The 4P is sent when a specific indemnity benefit has been denied. If the denied benefit has not been paid yet, the benefit should not be reported on the 4P, per section 5 in the IAIABC release 1 guide.

Q: How is the SROI reduced earnings (RE) reported?

A: The RE is sent when the injured worker has returned or has been released to return to work with reduced earnings. The RE is used to report changes in earnings due to variations in hours worked. A change in the benefit type paid is reported on an SROI change benefit (CB). A change in the weekly benefit amount is reported on a SROI change amount (CA). The paid to date (DN95) codes 600-624 (actual reduced earnings) are filed to report the reduced weekly wages. Only the first occurrence of reduced earnings needs to be reported.

Q: How do we change incorrectly-reported indemnity benefit type codes, such as with voided checks? For example, a check for permanent disability (PD) was issued to the claimant and reported to WCIS but the check should have been for temporary disability (TD).

A: There are two options:

  • Send a zero amount for the incorrectly reported benefit on all future SROIs until the incorrectly reported benefit is actually paid.
  • Cancel the entire claim with an FROI cancel (01) and then resend the FROI original (00), the SROI initial payment (IP) and a SROI upon request (UR), if additional indemnity payments need to be reported.

Q: How are overpayments reported? For example, a check for temporary disability (TD) in the amount of $200 was issued to the claimant and reported to the WCIS but the correct amount should have been $100.

A: If indemnity benefits are recovered, send a SROI change (02) with the updated benefit amounts and use the paid to date (DN95) code 830 - overpayment recovery to report the recovered amount.

If the overpayment was credited instead of recovered, send a SROI change (02) with the updated benefit amounts and use the benefit adjustment (DN92) code C - overpayment credit, to report the credited amount.

Q: How are settlements reported?

A: For compromise & release (C&R), commutations and stipulated settlements, send a SROI initial payment (IP) if this is the first indemnity payment, using the appropriate compromised payment/adjustment codes (DN85), e.g. 530, 550, and 570. If an IP has already been accepted, send a SROI payment (PY). For stipulated settlements, only the first and last payments need to be reported, along with the annual (AN) or final (FN) transactions as required.

The payment/adjustment start and end dates (DNs 88 and 89) should equal the settlement date of the payment for C&R and commutation settlements. For stipulated settlements, the payment/adjustment start and end dates should cover the payment period for the SROI transaction.

Q: Concerning settlements such as stipulations or compromise and release (C&R) awards, should claims administrators report only the total settlement amount, or should the settlement amount be broken down by benefit-type code (e.g., for medical, death, temporary disability, permanent disability, unspecified)?

A: The WCIS prefers that claims administrators report the settlement breakdown by specific benefit-type code. This is especially important for permanent disability settlements. Two sample scenarios for reporting a settlement of $20,000 are shown below:

  • The claims administrator knows the exact breakdown for the settlement:
    • report $10,000 in DN85, benefit-type code 530 compromised PD,
    • report $7,000 in DN85, benefit-type code 501 compromised medical,
    • report $3,000 in DN85, benefit-type code 500 compromised unspecified, of which $1,000 was for lawyers’ fees, and $2,000 was for other expenses.
  • The claims administrator only knows the total settlement amount and does not know the breakdown between benefit types:
    • report $20,000 in payment/adjustment 500 compromised unspecified

The main point is that researchers will add up the 5xx codes sent in for a particular settlement, so the total of the amounts for benefit-type codes sent for a settlement on a particular date should equal the total settlement amount paid.

Q: How should lawyers’ fees in a settlement amount be reported?

A: Ideally, the DWC needs to know the total lawyers’ fees reported on a claim as well as the total settlement amount. Thus, lawyers’ fees in a settlement amount should be reported using two DNs and codes: using payment/adjustment code (DN85) 500 compromised unspecified and also using the paid to date code (DN95) 340 claimant’s legal expenses paid to date. In the example cited above, the $1,000 in lawyers’ fees for the settlement should be reported in DN85, benefit-type code 500, and in DN95, benefit type code 340. Due to system limitations, if a claims administrator is only able to report lawyers’ fees in a settlement amount using one code, then the settlement amount (under DN85, code 500) should be used. It is important for the DWC to be able to aggregate the 5xx codes and obtain the total settlement amount.

Q: How are Employment Development Department (EDD) reimbursements reported?

A: If this is the first indemnity payment, send a SROI initial payment (IP), using the payment/adjustment code (DN85) 050 - temporary total. If an IP has already been accepted, send a SROI payment (PY).

Q: How are the Medicare set aside portions of a settled claim reported?

A: If this is the first indemnity payment, send a SROI initial payment (IP), using the payment/adjustment code (DN85) 501 - compromised medical. If an IP has already been accepted, send a SROI payment (PY).

Q: Do payments for the waiting period need to be reported?

A: Yes. If a SROI initial payment (IP) has not been accepted, the waiting period payment can be reported on the IP. If the IP has already been accepted, the waiting period payment can be reported on a SROI change (02).

Q: How are advances for permanent disability reported?

A: If this is the first indemnity payment, send a SROI initial payment (IP), using the payment/adjustment code (DN85) 020 or 030, as appropriate. If an IP has already been accepted, send a SROI payment (PY).

Q: How is an advance for a one-day Qualified Medical Examiner (QME) appointment reported?

A: QME advances are non-indemnity payments which can be reported under the Paid to Date Code (DN 95), 370 – Other Medical, using the SROI Annual (AN) or Final (FN), as appropriate.

Q: If a payment is both the first and final payment, how is it reported?

A: Send the SROI initial payment (IP) and then the final (FN).

Q: What is the difference between a FROI denial (04) and a SROI denial (04)?

A: The FROI and SROI denials are both used to report that a claim is being entirely denied. If indemnity payments have been made and reported on the denied claim, the SROI denial should be sent. If no indemnity payments have been made, the FROI denial should be sent.

Q: When is the deadline to send the SROI Annual (AN)?

A: The deadline is no later than January 31 of each year.

Q: Under what circumstances is the SROI Annual (AN) sent?

A: The SROI Annual (AN) must be sent for any claim with any payment in any benefit category in the previous calendar year. The exception to this rule is for claims where there is no further benefit activity after the Final (FN) has been accepted and the Final (FN) included all the indemnity and/or non-indemnity benefit data.

Q: What needs to be reported on the SROI Annual (AN) transaction?

A: Annual transactions must report a sweep of information for all benefits, including indemnity and/or non-indemnity.

Q: What kind of sequencing rules are used for processing (AN)?

A: Each SROI Annual (AN) must be preceded by an initial FROI such as the Original (00) or the acquired/unallocated (AU). All previously accepted benefits must be reported on the SROI Annual (AN) and no new indemnity benefits can be reported.

Q: Can a claim be closed using the SROI Annual (AN)?

A: Only a non-indemnity claim can be closed using the SROI Annual (AN). This is done by sending the SROI Annual (AN) with a "closed" claim status (DN 73). Indemnity claims must be closed with the FN report.

March 2018