EDI Implementation Guide - Montana

EDI Trading Partner AgreementMontana Department of".rf}.u: }!1 !R t } ! ;'RYWorkers’ Compensation Claims Assistance Bureau/Data Management UnitELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENTObjective: To initiate, implement and maintain First Reports of Injury (FROI) andSubsequent Reports (SROI) through electronic filing.We, the undersigned, as representatives of our respective organizations, corporations orgovernmental entity, do hereby agree to the following:1. The Montana Department of Labor and Industry, Employment Relations Division("the Division") is the regulatory agency for workers' compensation and occupationaldisease laws in Montana. is an insurer providing workers'compensation insurance in Montana or the third party administrator for an insurer. TheDivision, the receiver, and , the sender, agree that the senderwill report workers’ compensation information to the receiver via the national standardsfor Electronic Data Interchange (EDI) developed by the International Association ofIndustrial Accident Boards and Commissions (IAIABC) EDI Project.2.You are a (circle one) mandatory/voluntary Trading Partner. This agreement willcommence upon the approval of the Division’s Claims Assistance Bureau, DataManagement Unit Supervisor, as demonstrated by his/her signature on thisdocument.3.The Trading Partners agree to use the IAIABC Claims Release 1 Flat File format.4.The Trading Partners will perform a test of the reporting system to determinewhether the transmission mechanism is acceptable. Trading Partners must meet alltechnical requirements as outlined in the State of Montana, EDI ImplementationGuide. The term of the test is sixty days from the commencement of this agreementunless the Division approves an extension.5.Once the testing requirements are met and production status granted the sender isno longer required to file paper forms.6.Once production status is granted, the sender is required to maintain a 95%acceptance rate.

7. The format of data elements and definitions will conform to the IAIABC datadictionary, including future amendments, unless otherwise agreed between theTrading Partners. The Division will provide the sender with a minimum of thirtydays notice prior to implementing amendments.8.Technical requirements, data elements, and codes specific to Montana are found inthe State of Montana EDI Implementation Guide.9. Any error in transmission will be timely identified by the Division, and sent to thesender via the acknowledgment record. The sender will correct the identified errorsand resubmit the record within 14 days of receiving the acknowledgment record.10.The sender will pay any and all EDI transmission costs.11.This agreement may not be modified or terminated except by the written agreementof the Trading Partners, with either party giving at least thirty days written notice tothe other party.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement asdated below:Trading PartnerDoug Roope, Unit Manager, Data ManagementName and TitleMontana Department of Labor and IndustryAddressCity, State Zip CodePhoneEmployment Relations Division1805 ProspectHelena, MT 59601Ph: (406) 444-1600FaxFax:(406) 444-4140e-mailEmail: doug.roope@mt.govSignatureSignatureDateDate

ELECTRONIC DATA INTERCHANGE (EDI) TRADING PARTNER AGREEMENTThird Party Administrator AttachmentThird party administrators often send reports to DLI/ERD for several insurers. Please completethe following for each insurer Federal Employer Identification Number (FEIN).Insurance company name:FEIN:Insurance company name:FEIN:Insurance company name:FEIN:Insurance company name:FEIN:Insurance company name:FEIN:

DLI/ERD Trading Partner ProfileTrading Partner Type:Master Trading Partner Name:Master FEIN:JurisdictionState of Montana, Employment Relations Division81-0302402Physical Address:City:State:Postal Code:1805 ProspectHelenaMontana (MT)59601Mailing Address:City:State:Postal Code:P.O. Box 8011HelenaMontana59604-8011Contact Information:EDI Business Contact:Doug Roope(406) 444-1600(406) 444-4140Doug.Roope@mt.govPhone:FAX:E-mail:EDI Contact:Mike Bartow(406) 444-3089(406) 444-4140MBartow@mt.govTransmission Profile –DLI/ERD Receiver SpecificationsReceiver Name:Master FEIN:State of Montana, Employment Relations Division81-0302402Postal Code: 59604-8011Transaction Information: Transactions 148, A49, and AK1 – Flat File ReleaseFlat File Record Delimiter: Carriage return line feed.Acknowledgement Information: Response period 24 Hours, Monday through FridayTransmission Frequencies: May transmit Monday through Friday.Electronic Mailbox(s) for this Profile:TypeAccount IDAerie EDI GroupEBIX (formerly Claims Harbor/Claimport)IVANS/AdvantisMitchell Regulatory Reporting SolutionsHealth TechISO wcPrism SolutionsDirect Reporting sFTPAs assignedUNICOMMTUNICOMMTWCSTAs assignedAs assignedAs assignedAs assignedUser IDAs assignedN/AWCST014As assignedAs assignedAs assignedAs assigned

Trading Partner ProfileTrading Partner Type:D Carrier D Third Party AdministratorSender Name:Sender’s FEIN:D Employer D Service BureauSender’s Postal Code:(Must have 9 digits)Physical Address:City:StatePostal Code:Mailing Address:City:State:Postal Code:Contact Information:Name:Title:Phone:Fax:E-mail:Receiver Name:Master FEIN:Business Contact:Technical Contact:Transmission Profile – Sender’s ResponseState of Montana, Employment Relations Division81-0302402Postal Code:59604-8011Transaction Information: Transactions 148, A49, AK1 – Flat File Release (IAIABC Claims Release 1)Transmission Frequencies: May transmit Sunday - Saturday. Acknowledgments processed Monday - Friday.Select one :Electronic Mailbox(s) for this itchell Regulatory Reporting SolutionsHealth TechDirect Reporting sFTPISO wcPrism Solutions

First Report of Injury - Release 1 - MCO TableDATA 00370038003900400041ELEMENTSTransaction Set IDMaintenance Type CodeMaintenance Type Code DateJurisdictionAgency Claim NumberInsurer FEINInsurer NameThird Party Administrator FEIN 1Third Party Administrator NameClaim Administrator Address LINE 1Claim Administrator Address LINE 2Claim Administrator CityClaim Administrator StateClaim Administrator Postal CodeClaim Administrator Claim NumberEmployer FEINInsured NameEmployer NameEmployer Address LINE 1Employer Address LINE 2Employer CityEmployer StateEmployer Postal CodeSelf Insured IndicatorIndustry Code 2Insured Report NumberInsured Location NumberPolicy NumberPolicy EffectivePolicy ExpirationDate of InjuryTime of InjuryPostal Code of Injury SiteEmployers Premises IndicatorNature of Injury CodePart of Body Injured CodeCause of Injury CodeAccident Description/Cause 1Initial TreatmentDate Reported to EmployerDate Reported to Claim MMMOOOO

00670068Social Security NumberEmployee Last NameEmployee First NameEmployee Middle InitialEmployee Address Line 1Employee Address Line 2Employee CityEmployee StateEmployee Postal CodeEmployee PhoneEmployee Date of Birth 1Gender Code 1Marital Status CodeNumber of DependentsDate Disability BeganDate of DeathEmployment Status CodeClass CodeOccupation DescriptionDate of HireWageWage PeriodNumber of Days WorkedDate Last Day WorkedFull Wages Paid for Date of Injury IndicatorSalary Continued IndicatorDate of Return to WorkAlthough Third Party Administrator FEIN, Employee Date of Birth, Gender Code andAccident Description/Case are listed as Optional fields, we respectfully request thesefields to be sent with valid values. The fields aid us in workers’ compensation studiesand data quality endeavors.1If you send Industry Code, please only send NAICS. If you do not know the NAICScode, please leave it blank. (Effective 4-1-09).2MMMOOOMMMOOOOOOOOMOOOOOOOOO

Subsequent Report of Injury - Release 1- MandatoryConditional Optional (MCO) TableDATA 00860087ELEMENTSREQTransaction Set IDMaintenance Type CodeMaintenance Type Code DateJurisdictionAgency Claim NumberInsurer FEINThird Party Administrator FEINClaim Administrator Postal CodeClaim Administrator’s Claim NumberInsured Report NumberDate of InjurySocial Security NumberNumber of DependentsConditional with 57, 82, 97Date Disability BeganEmployee Date of DeathConditional with 55, 82, 97WageWage PeriodNumber of Days WorkedSalary Continued IndicatorPre-existing DisabilityDate of Maximum Medical ImprovementReturn to Work QualifierConditional with 72Date of Return/Release to WorkConditional with 71Claim StatusClaim TypeAgreement to Compensate CodeDate of RepresentationLate Reason CodeNumber of Permanent ImpairmentsNumber of Payment/Adjustments Conditional with 85 if 0Number of Benefit ReductionsConditional with 92 if 0Number of Paid to Date/Reduced Conditional with 95 if 0Number of Death Dependent/Payee RelationshipsConditional with 55,57, 97Permanent Impairment Body Part Code Conditional with 84Permanent Impairment PercentConditional with 83Payment/Adjustment CodeSee belowPayment/Adjustment Paid to DateSee belowPayment/Adjustment Weekly AmountSee belowCCCCCCC

0088008900900091009200930094009500960097M - MandatoryPayment/Adjustment Start DateSee belowPayment/Adjustment End DateSee belowPayment/Adjustment Weeks PaidSee belowPayment/Adjustment Days PaidSee belowBenefit Adjustment CodeSee belowBenefit Adjustment Weekly Amount Conditional with 92,94Benefit Adjustment Start DateConditional with 92,93Paid to Date/Reduced Earnings/Recoveries Code See belowPaid to Date/Reduced Earnings/Recoveries Amount See BelowDependent/Payee RelationshipConditional with 55 & 57CCCCCCCCCCLij Nov 09C - ConditionalO - OptionalExplanation of Conditionals:If Employee Date of Death DN57 has data, then DN55, DN82, and DN97 must have data and viceversa.If Return to Work Qualifier DN71 has data, then DN72 must have data and vice versa.If Permanent Impairment Body Part Code DN83 has data, then DN84 must have data and viceversa.For Payment Adjustment Codes 010 (Fatality):If a fatality has occurred due to injury/OD, report the occurrence in DN85 as code 010 or 510.If Payment/Adjustment Code DN85 has data, then DN57 must have data.For Payment Adjustment Codes 070 (TPD)If Payment/Adjustment Code DN85 is 070, the following Payment/Adjustment fields must be sentwith valid data: Paid to Date DN86, Start Date DN88, End Date DN89, Weeks Paid DN90 and DaysPaid DN91. Weeks Paid DN90 is a 4N and Days Paid is a 1N field – 4 and 1 character (spaces),respectively in Number format. Number Format: Unsigned, right justified, zero fill.For Payment Adjustment Codes 010, 020, 030 (pre 7-1-87 Date of Injury), 040, 050, 090, 240,and 410:If Number of Payment/Adjustments DN79 (the counter) is greater than 0, then DN85 through DN89must have valid data. Weeks Paid DN90 is a 4N and Days Paid is a 1N field – 4 and 1 character(spaces), respectively in Number format. Number Format: Unsigned, right justified, zero fill.If Payment/Adjustment Code DN85 has data, then DN79 (the counter) must be greater than 0.If any data element 0085 through 0089 has data, then all data elements 0085 through 0091 musthave data.For Payment Adjustment Codes 500 through 570 (Lump Sums):If Number of Payment/Adjustments DN79 (the counter) is greater than 0, thenPayment/Adjustment Code DN85, the amount paid to date DN86, end date DN89, and days paidDN91 must have data.Enter 1 for one lump sum, a 2 for two lump sums etc. inPayment/Adjustment Days Paid DN91.If DN85 has data, then DN79 (the counter) must be greater than 0.If any data element 0085 through 0091 has data, then data elements 0085, 0086, 0089, and 0091must have data.If Number of Benefit Adjustments DN80 (the counter) is greater than 0, then DN92 throughDN94 must have data. Payment/ Adjustment Code DN85 must have data.

If Benefit Adjustment Code DN92 has data, then DN80 (the counter) must be greater than 0.If any data element 0092 through 0094 has data, then 0092 through 0094 and DN85 must havedata.If Number of Paid to Date/Reduced Earnings/ Recoveries DN81 (the counter) is greater than0, then the code DN95 and the amount DN96 must have data.If Paid to Date/Reduced Earnings/ Recoveries Code DN95 has data, then DN81 (the counter) mustbe greater than 0.If the code DN95 has data, then the amount DN96 must have data and vice versa.Explanations of Mandatory Field Maintenance Type Code DN0002:If Maintenance Type Code DN02 is SA, then DN73 must be either O (open), R (reopen). X(reopen/closed), or C (closed) depending on the status of the claim.If Maintenance Type Code DN02 is FN, then 0073 must be X (reopen/closed) or C (closed).Lij/ Nov 2009Detail Acknowledgement – Release 1DATA ction Set IDRecord Sequence NumberDate ProcessedTime ProcessedInsurer FEINClaim Administrator Postal CodeThird Party Administrator FEINAcknowledgement Transaction Set IDApplication Acknowledgement CodeInsured Report NumberClaim Administrator Claim NumberAgency Claim NumberMaintenance Type Code (from original transaction)Maintenance Type Date (from original transaction)Request Code (purpose)Free form textNumber of ErrorsElement NumberElement Error NumberVariable Segment NumberREQMMMMCCCMMCCOCCOOMMMM

Header and Trailer – Release 1ELEMENTSDATA 05Transaction Set IDSender IDReceiver IDDate Transmission SentTime Transmission SentOriginal Transmission DateOriginal Transmission TimeTest/Production IndicatorInterchange Version IDMMMMMOCOCMM00010106Transaction Set IDDetail Record CountMMTrailer:OC denotes that the field is optional. If you enter a date and/or time in the respectivefield, then the field becomes conditional. It must be a valid date and time.Montana Report Submission TableReportMTCDescriptionReport Submission CriteriaWhen Due148/FROI00 Original FROIAll First Reports of Injury30 days from date thecarrier is notified ofaccident or occupationaldisease (OD)SA Semi-AnnualSix month anniversaryof date of injury or OD,while the claim is openClosure of claimWithin 14 calendar days ofeach six month anniversaryfrom date of injury or ODWithin 14 calendar days ofsix month anniversary ofdate of injury or OD afterclaim is closed or at time ofclaim closure14 calendar days fromrequest of Department orExecutive BranchA49/SROI(Claim Status ‘O’ or‘R’)SA Semi-Annual or FNFinal(Claim Status ‘C’ or‘X’)UR Upon RequestWhen Department needs up-to-datecost of claim data

Montana Subsequent Report CodesMaintenance Type Codes (DN2)SA – Semi Annual (Claim Status Open, Reopen/Closed, or Closed)FN – Final (Claim Status Reopen/ Closed or Closed)UR – Upon RequestIP – Initial PaymentWage Period (DN63)1 WeeklyRTW Qualifier (DN71)1 – RTW Without Restrictions2 – RTW With Restrictions5 – Released RTW Without Restrictions6 – Released RTW With RestrictionsClaim Status (DN73)O – OpenC – ClosedR – ReopenX – Reopen/CloseClaim Type (DN74)I – IndemnityZ – Occupational DiseaseAgreement to Compensate (DN75)W – Without LiabilityL – With LiabilityLate (payment to claimant) Reason Codes (DN77)C1 - Lack of coverage informationE4D1 - Dispute concerning coverageE5D2 - Dispute concerning compensability in wholeE6D3 - Dispute concerning compensability in partL1D4 - Dispute concerning disability in wholeL2D5 - Dispute concerning disability in partL3D6 - Dispute concerning impairmentL4E1 - Wrongful determination of no coverageL5E2 - Errors from employerL8E3 - Errors from employeeL9- Errors from state- Errors from health care provider- Errors from other claim administrator/TPA- No excuses- Late notification, employer- Late notification, employee- Late notification, state- Late notification, health care provider- Tech processing delay/computer failure- Manual processing delayPermanent Impairment Body Part Code (DN83): 99Compensation Payment Codes (DN85)010- Fatality020- PTD021- PTD, Supplemental030- PPD, Scheduled040- PPD, Unscheduled050- TTD070- TPD090- PPD, Disfigurement240- Employer Paid410- Vocational RehabilitationMaintenance500- Lump Sum Other501- Medical Lump Sum510- Lump Sum Fatality520- Lump Sum PTD524- Lump Sum Employer PaidBenefits Paid To FamiliesPermanent TotalCost of Living AdjustmentsPermanent Partial Benefits (Pre 7-1-87 Date of Injury)Permanent Partial BenefitsTemporary Total BenefitsTemporary Partial BenefitsPermanent Partial Benefits paid for disfigurementSalary Paid By The Employer In Lieu Of CompensationRetraining, Total & Partial Rehab Benefits, AuxiliaryBenefitsNot Otherwise Classified or Combination of Benefits.Paid To Claimant As A Settlement Of Medical Liability

umSumSumSumPPD, Scheduled (Pre 7-1-87 Date Of Injury)PPD, UnscheduledVocational Rehabilitation MaintenanceTTDTPDPPD, DisfigurementBenefit Adjustment Codes (DN92)A – Apportionment/ContributionH – Court Ordered Lien Against Workers’ Compensation BenefitsB – SubrogationP – Prepaid Benefit/AdvancesC – Overpayment CreditS – Social Security DisabilityPaid to Date/Reduced Earnings/Recoveries Codes (DN95)300 - Funeral Expenses Paid To Date400 - Other vocational rehabilitation paid to date330 - Employer’s Legal Expenses Paid To Date420 - Consultant/expert witness fees paid to date byinsurer350 - Total Payments To Physicians Paid To Date430 – Unallocated Prior Indemnity BenefitsPaid to Date(Including Reimbursement To Claimant)440 – Unallocated Prior Medical Paid to Date360 - Hospital Costs Paid To Date450 – Pharmaceutical Paid to Date(Including Reimbursement To Claimant)800 – Special Fund Recovery370 - Other Medical to Medical Provider Paid to810 – Employer’s Deductibles Recovery(Includes Reimbursement to Claimant)820 – Subrogation Recovery380 - Vocational Rehabilitation evaluation paid to date830 – Overpayment Recovery390 - Vocational Rehabilitation education paid to date840 – Unspecified RecoveryDependent Payee Relationship (DN97)2 – Widow3 – Widower4 – Son or Daughter5 – Brother or Sister6 – Mother or Father7 – Disabled Child Over 1

EDI Test Policy and Process Selecting a Transmission Type EDI Overview Montana Law 39-71-225, Link Montana Administrative Rules, Link Glossary ***This guide contains Montana specific EDI information. It is a companion to the International Association of Industrial Accident Boards and Commissions (I.A.I.A.B.C), E.D.I. Implementation Guide .