Advisory 98-02

Subsequent (TWCC-21) Reporting via Electronic Data Interchange (EDI)

The Commission is expanding the Electronic Data Interchange (EDI) initiative to include electronic reporting for all Subsequent Report (A49/TWCC-21) Maintenance Type Codes (MTCs). The additional A49 Subsequent Report MTCs (CA, CB, FN, RB, RE, S1, S4, S5, S6, S7, & S8) for change in benefit types, reductions, resumptions, and suspension of benefits, which correspond to the TWCC-21 (A2 & A3 Blocks), are now in production. Definitions and record layouts for these codes (copyright protected material) can be found in the International Association of Industrial Accident Boards & Commissions (IAIABC) EDI Implementation Guide, Release I. Insurance carriers are required to use the IAIABC Release I Maintenance Type Codes (MTCs) for the A49 payment and claim status information in addition to the required electronic submission of the First Report of Injury.

EDI REPORTING REQUIREMENTS & IMPLEMENTATION PLAN:

This EDI implementation mandate for the First Report of Injury (IAIABC Flat File or ANSI 148 record) and the Subsequent Report (IAIABC A49 Flat File or ANSI 148 record) includes:

• Current requirement - electronic submission of all First Report of Injury MTCs: AU, CO, 00, 01, 02, 04;

• Current requirement - electronic submission of the Subsequent Report MTCs: AP, CD, CO, FS, IP, 02, 04; and

• New requirement - electronic submission of the Subsequent Report of Injury reports as applicable for claims requiring MTCs: CA, CB, FN, RB, RE, S1, S4, S5, S6, S7, & S8.

• Waivers for Subsequent Reporting are not applicable and will not be granted.

Recognizing that a managed EDI implementation will provide greater customer service to our trading partners, the Commission is using an assigned schedule approach that most efficiently uses EDI testing and production capacity. In order to maximize the impact to the system and increase the volume of EDI, the Commission will assign dates and testing capacity to bring 50 of the largest carriers/carrier groups (by claim volume) into full EDI reporting production between July 1998 and July 1999. The schedule is based on the carrier’s 1997 claim volume and the carrier’s current status of EDI reporting. Carriers with a smaller claim volume or other carriers authorized to write workers’ compensation after 1/1/98, may be scheduled to implement EDI in the second phase, which should be after July 1999.

The Commission has determined that 90 days notice is adequate for a carrier to prepare for EDI reporting using internal or external resources. Carriers should be in a state of readiness for EDI testing within 90 days of this Advisory. Carriers will be notified in writing of their individual schedule/test date and provided with new test requirements. Carriers are responsible for distribution of this schedule notice to all entities submitting electronic data on their behalf. Carriers or trading partners that want to test earlier than July 1998, or before their assigned scheduled date, may contact the Records Division, EDI Development, MS-99 or 512-440-3996 to be considered for an accelerated schedule.

Each scheduled carrier should be prepared for the following EDI action/outcome:

Assigned Test Date (TD): the Assigned Test Date will be indicated on the carrier’s individual schedule letter, but will not be earlier than 6/1/98. The carrier is expected to begin testing no later than 5 days after TD.

Expected Approval for EDI Production Date (EPD): the expected EDI Authorization for Production Date is the Assigned Test Date (TD) +30 calendar days.

EDI Benchmark Audit Date (BMA): the carrier is expected to be in production and must file at least 25% of eligible reports electronically during the 30 day period covered by the BMA (EPD +30).

Subsequent EDI Compliance Audits : Subsequent EDI Compliance Audits may be conducted as early as 60 days after the EDI Benchmark Audit.

The following table provides a summary of key dates, performance standards, and penalty exposure based on EDI reporting requirements, implementation dates, and potential noncompliance as outlined above.

NOTE: Requirements for timely filing of the first and subsequent reports and timely initiation of payments to the injured worker have not changed.

AUDITS AND ENFORCEMENT:

Audits will measure noncompliant reporting issues involving First Reports of Injury and Subsequent Reports. Noncompliance as indicated on the above EDI Action/Outcomes table may subject the carrier to penalties. Failure to achieve and maintain EDI performance requirements may subject the carrier to subsequent EDI audits until EDI standards are achieved.

Performance Requirements:

• Expected Approval for EDI Production Date: The carrier is expected to complete EDI testing and gain authorization for EDI Production (EPD) within the Assigned Test Date (TD) period. If the carrier fails to gain EDI approval within the 30 days allotted, the penalty amount may be increased to reflect this delayed compliance per Texas Labor Code section 415.021 at time of audit.

• EDI Production Status: The carrier has been approved for production and is processing all applicable MTCs for the First Report of Injury and the Subsequent Report via EDI.

• Benchmark Audit (BMA): The carrier must reach EDI Production Status and file at least 25% of eligible reports electronically by the Benchmark Audit (BMA) or carrier is in noncompliance and is subject to penalties. This requirement will allow carriers to bring on multiple offices within a 30 day period.

• Monthly Requirement: After the EDI Benchmark Audit date, the carrier is expected to report 80% of their eligible reports for the month via EDI.

• First Year Requirement: In addition to the Monthly Requirement, the carrier is expected to report 80% of their eligible reports for the first year via EDI. This period is defined as the Benchmark Audit date plus 365 days. (BMA+365).

• Second and Subsequent Year(s) Requirement: The carrier is expected to report 100% of their eligible reports for each month of the second and each subsequent year.

Data Quality and Accuracy Requirements:

• In order to be authorized for EDI production, it is essential to meet established TWCC quality standards. During the test/pilot phase of EDI, the minimum quality standard is the receipt of transmissions with an error free rate of 90% on mandatory data elements and 75% on conditional elements .

• Once authorized for production, the carrier is expected to improve data quality as their business processes mature. If data quality does not improve, data quality and accuracy will be added to the scope of scheduled audits and inaccurate/missing data will be subject to non-compliance penalties.

• In accordance with the Trading Partner Agreement, all identified errors, corrections, missing data, and changes must be re-transmitted to the Commission in order to maintain correct/updated information. Rejected reports are not loaded to the Commission’s database. Therefore, to satisfy filing requirements, rejected reports must be corrected, re-transmitted, and accepted by the Commission.

Texas Labor Code §409.005 and Rule 124.1 allow for penalties not to exceed $500 for each failure by the carrier to properly file the Employers’ First Report of Injury data by EDI. Texas Labor Code §409.021 & 409.024 and Rules 124.2 & 124.4 allow for penalties not to exceed $5000 for each failure to file Notices of Initiation, Termination or Reduction of Benefits by EDI. In addition, the Commission may assess administrative penalties of up to $10,000 as provided by §415.021 of the Texas Labor Code for business practices that allow repeated violations.

EDI EXCEPTIONS:

The following circumstances require paper filings rather than EDI reporting:

• The carrier is filing a dispute notice (denied or disputed claim): Carriers are instructed to submit an EDI 148 or A49 MTC 04 electronically followed by submission of a TWCC-21 with block 43 completed. Submission of MTC 04 is NOT a properly filed dispute.

• The carrier is filing a dispute notice regarding a dispute of disability: Carriers are instructed to submit an EDI 148/00 electronically followed by submission of a TWCC-21 with block 43 completed in accordance with Advisory 97-02.

• The carrier is filing multiple injuries for same claimant, same date of injury, and same employer: Carriers are instructed to report the first injury of the day via EDI and the subsequent injuries via TWCC-1 form. Carriers should note on the TWCC-1 form that this is a separate injury from the claim being filed electronically. NOTE: The system will reject multiple EDI records for the same claimant with the same date of injury as duplicate transmissions. This requires the use of the TWCC-1 form for subsequent injuries occurring on the same day.

• The carrier is awaiting the Commission assigned test/production date: Carriers are instructed to continue to submit all paper reports on the TWCC-1 and TWCC-21 until they are authorized for EDI production. Carriers in partial EDI production (i.e., only authorized for 148 MTCs or only authorized for 148/A49 IP MTCs) must continue to submit applicable TWCC-21s until authorized to file additional MTCs electronically.

The Commission specifically requests a paper copy of a document.

ADDITIONAL INFORMATION/REQUIREMENTS:

The structured implementation process is to ensure that the industry achieves a predictable reduction in paper reporting. Test requirements will be distributed to carriers with their assigned schedule test date via Austin Carrier Representatives. The new scheduled implementation criteria require a carrier to complete the test process within 30 calendar days from test start date.

The required EDI reporting format, form, and content are defined in the Commission’s EDI agreement documents and TWCC EDI specifications. Trading partners must have the Commission Edit package, dated August 1997, on their system to decrease the need for re-transmissions due to errors or rejected transactions. Also, trading partners must use the IAIABC Implementation Guide which contains the data element dictionary, record layouts, and other EDI information.

This Advisory supplements Advisories 95-05, 95-06, 97-03, and previous Commission correspondence to carriers relating to EDI implementation requirements. For assistance, documentation, specifications, and information to implement EDI, please contact the TWCC Records Division, EDI Development & Implementation, at 512-707-5895 or 512-440-3996.

Signed this 13th day of March, 1998.

Robert Marquette, Acting Executive Director

Distribution:
Austin Carrier Representatives
TWCC Staff
Public Information List

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