90- 351 C.M.R. ch. 3, § 4

Current through 2024-51, December 18, 2024

Section 351-3-4 - Electronic Data Interchange Filing

1.General

A.First Reports of Injury. Unless a waiver has been granted pursuant to subsection (1)(D)(1) or (2) of this section, all First Reports of Injury and all changes or corrections to First Reports of Injury shall be filed by using the International Association of Industrial Accident Boards and Commissions (IAIABC) Claims Release 3 format.

B.Notices of Controversy. Except as otherwise provided in this paragraph, effective July 1, 2006, unless a waiver has been granted pursuant to subsection (1)(D) (1) or (2) of this section, all Notices of Controversy and all corrections to Notices of Controversy shall be filed using the International Association of Industrial Accident Boards and Commissions (IAIABC) Claims Release 3 format. Changes to Notices of Controversy that have been filed electronically must be made by filing WCB-9 (1/12/06) (Notice of Controversy). Changes to Notices of Controversy filed prior to July 1, 2006 using WCB-9 (10/98) (Notice of Controversy) must be made by filing an amended WCB-9 (10/98) (Notice of Controversy).

C. Waivers

(1)Waivers due to hardship. The Board, at its discretion by majority vote of its membership, may grant an employer, insurer or third-party administrator a waiver of the filing requirements of this section if the employer, insurer or third-party administrator establishes to the satisfaction of the Board that compliance with these requirements would cause undue hardship. For purposes of this section, undue hardship means significant difficulty or expense. Requests for waivers should be submitted in writing and addressed to the Chair of the Workers' Compensation Board, 27 State House Station, Augusta, Maine 04333-0027.

(2)Waiver in an individual case. A First Report of Injury or a Notice of Controversy can be filed by paper or fax in an individual case if the Executive Director or the Executive Director's designee finds that the employer or claim administrator was prevented from complying with this section because of circumstances beyond the control of the employer or claim administrator. A decision by the Executive Director or the Executive Director's designee may be appealed to the Board of Directors. The appeal must be in writing; must set forth the reasons why the appealing party believes the decision should be reversed; and must be filed within 7 (seven) days of the date of the decision appealed from.

D.Board file. The Board file shall include all accepted electronic transactions regardless of whether a paper copy is physically in the file.

2.Definitions for filing using IAIABC Claims Release 3

A.Application acknowledgement code. A code used to identify whether or not a transaction has been accepted by the Board. A sender will receive one of the following codes after submitting a transaction:

(1)TA (Transaction accepted). The transaction was accepted and the First Report of Injury or Subsequent Report of Injury is filed.

(2)TE (Transaction accepted with errors). The transaction was accepted with errors and the First Report of Injury or Subsequent Report of Injury is filed. The error or errors will be identified in the acknowledgement transmission that is sent by the Board. All identified errors must be corrected within 14 days after the date the acknowledgement transmission was sent by the Board or prior to any subsequent submission for the same claim, whichever is sooner.

(3)TR (Transaction rejected). The entire transaction has been rejected and the First Report of Injury or Subsequent Report of Injury is not filed.

B.Claim administrator. An insurer, self-insured employer, group self-insurer, third-party administrator or guaranty association.

C.Data element. A single piece of information (for example, date of injury). Each data element is assigned a name and a number. Except as modified in this rule, data element names and numbers are as defined in IAIABC Claims Release 3.0 Standards, Data Dictionary January 1, 2010 Edition (Appendix V).

D.Data element requirement code. A code used to designate whether or not a data element has to be included in a transaction. Each data element is assigned one of the following data element requirement codes:

(1)M (Mandatory). The data element must be present and must be in a valid format or the transaction will be rejected.

(2)MC (Mandatory/Conditional). The data element is mandatory if the conditions defined in the Maine Workers' Compensation Board Claims Release 3 First Report Conditional Requirement Table (Appendix II) or the Maine Workers' Compensation Board Claims Release 3 Subsequent Report of Injury Conditional Requirement Table (Appendix IV) exist.

(3)E (Expected). The data element is expected when a transaction is submitted. The transaction will be accepted without the data element and the First Report of Injury or Subsequent Report of Injury is filed but is incomplete. The entity submitting the transaction will receive a message indicating the transaction was accepted with errors and identifying the missing or incorrect data element or elements. The First Report of Injury or Subsequent Report of Injury must be completed by submitting the missing or corrected data element or elements within 14 days after the error message is sent by the Board or prior to any subsequent submission for the same claim, whichever is sooner.

(4)EC (Expected/Conditional). The data element is expected if the conditions defined in the Maine Workers' Compensation Board Claims Release 3 First Report Conditional Requirement Table (Appendix II) or the Maine Workers' Compensation Board Claims Release 3 Subsequent Report of Injury Conditional Requirement Table (Appendix IV) exist. The transaction will be accepted without the data element and the First Report of Injury or Subsequent Report of Injury is filed but is incomplete. The entity submitting the transaction will receive a message indicating the transaction was accepted with errors and identifying the missing or incorrect data element or elements. The First Report of Injury or Subsequent Report of Injury must be completed by submitting the missing or corrected data element or elements within 14 days after the error message is sent by the Board or prior to any subsequent submission for the same claim, whichever is sooner.

(5)IA (If Available). The data element should be sent if available. If the data element is sent, the Workers' Compensation Board may edit the data to ensure valid value and format. A filing will not be rejected if the only error is a missing data element designated IA.

(6)NA (Not Applicable). The data element does not apply to the maintenance type code and does not have to be sent. The Board will not edit these data elements.

(7)F (Fatal Technical).Data elements that must be sent. If a data element designated F is not present and in a valid format, the filing will be rejected.

(8)X (Exclude). The data element does not apply to the maintenance type code and does not have to be sent. The Board will not edit these data elements.

(9)FY (Fatal Yes Change). If a data element designated FY changes after a First Report of Injury or Subsequent Report of Injury has been filed, the claim administrator must report the change to the Board within 14 days after the data element changes.

(10)N (No Change). This data element cannot be changed, but it must be reported, if applicable.

(11)Y (Yes Change). Data elements designated Y may be changed.

(12)FC (Fatal/Conditional). This data element must be populated with previously reported values if the segment has previously been reported on the claim.

(13)YC (Yes Change/Conditional). The data element must be changed if the conditions defined in the Maine Workers' Compensation Board Claims Release 3 First Report of Injury Conditional Requirement Table (Appendix II) or the Maine Workers' Compensation Board Claims Release 3 Subsequent Report of Injury Conditional Requirement Table (Appendix IV) exist.

E.Maintenance type code. Maintenance type codes define the specific purpose of individual records within the transaction being transmitted.

F.Record. A defined group of data elements that is identified by the transaction set identifier.

G.Report. A report is equivalent to a transaction.

H.Transaction. The communication of data that represents a single business event. A transaction consists of one or more records.

I.Transaction set identifier. A code that identifies the transaction being sent.

(1) 148 - First Report of Injury

(2) R21 - First Report Companion Record

(3) A49 - Subsequent Report

(4) R22 - Subsequent Report Companion Record

(5) AKC - Claims Acknowledgement Detail Record

(6) HD1 - Transmission Header Record

(7) TR2 - Transmission Trailer Record

J.Transmission. One or more sets of records sent to the Board.

3.Requirements for filing using IAIABC Claims Release 3.

A.Maintenance type codes for First Reports of Injury. One of the following maintenance type codes shall be used when transmitting a First Report of Injury:

(1)00 (Original): Used to file an original First Report of Injury or to re-transmit a First Report of Injury that was previously rejected or cancelled.

(2)01 (Cancel): Used to cancel an original First Report of Injury that was sent in error.

(3)02 (Change): Used to change a data element.

(4)04 First Report Of Injury (First Report of Injury/Full Denial): Used to file an original First Report of Injury and simultaneously deny a claim in its entirety.

(5)CO (Correction): Used to correct a data element or elements when a filing is accepted with errors ("TE").

(6)AQ (Acquired Claim): Used to report that a new claim administrator has acquired the claim.

(7)AU (Acquired/Unallocated): Used to file an initial First Report of Injury by a new claim administrator when an AQ transaction has been rejected because the claim was not previously reported, or when the acquiring claim administrator is reopening a claim that was previously cancelled.

(8)UR (Upon Request): Submitted in response to a request from the Board. Responses must be filed no later than 14 days after the request is made by the Board.

B.Maintenance type codes for Subsequent Reports of Injury. One of the following maintenance type codes shall be used when transmitting a Subsequent Report of Injury.

(1)04 (Notice of Controversy - Full Denial): Used when a claim is being denied in its entirety after any First Report of Injury or Subsequent Report of Injury has been filed.

(2)PD (Notice of Controversy -- Partial Denial): Used to file a Notice of Controversy denying a specific benefit or benefits. A Notice of Controversy -- Partial Denial may not be filed unless a First Report of Injury has been filed.

(3)CO (Correction): Used to correct a data element or elements when a Subsequent Report of Injury has been accepted with errors ("TE").

C.Data element requirements and modifications.

(1)Data element requirements are as set forth in the Maine Workers' Compensation Board, Claims Release 3 First Report of Injury Element Requirements Table contained in Appendix I of this rule, and the Maine Workers' Compensation Board, Claims Release 3 Subsequent Report of Injury Element Requirements Table contained in Appendix III of this rule.

(2)Modifications.

(a) Data number 270, Employee ID Type Qualifier. When submitting a First Report of Injury, data number 270 is mandatory conditional. However, if the claim administrator is unable to obtain an employee identification number from an employer prior to transmitting a First Report of Injury, the claim administrator must obtain an employee ID assigned by jurisdiction number from the Board. The claim administrator shall file the First Report of Injury using the employee ID assigned by jurisdiction number obtained from the Board. A First Report of Injury submitted with an employee identification number obtained from the Board is filed but is incomplete. The claim administrator must either establish that it is unable to obtain an employee identification number from the employer or complete the First Report of Injury by submitting an employee identification number obtained from the employer within 14 days after the First Report of Injury was filed or prior to any subsequent submission for the same claim, whichever is sooner. Unless the claim administrator obtains and submits an employee identification number obtained from the employer, the employee ID assigned by jurisdiction number obtained from the Board must be used on all future filings regarding the same claim.

(b) Data number 200, Claim Administrator Alternative Postal Code. Data number 200, Claim Administrator Alternative Postal Code shall be M (Mandatory) effective April 1, 2007.

4.Paper distribution of forms filed electronically

A.First Report of Injury

(1) Form WCB-1 (First Report of Injury) shall be used when a copy of the First Report of Injury is mailed pursuant to this subsection.

(2) Form WCB-1 shall be mailed to the employee and the employer within 24 hours after the First Report of Injury is transmitted to the Board.

(3) Unless a waiver has been granted pursuant to subsection (1)(D) of this section, a First Report of Injury sent to the Board in a paper as opposed to electronic format shall not be considered filed.

B.Notices of Controversy

(1) Form WCB-9 (1/12/06) (Notice of Controversy) shall be used when a copy of the Notice of Controversy is mailed pursuant to this subsection.

(2) Form WCB-9 (1/12/06) (Notice of Controversy) shall be mailed to the employee, the employer and, if required by W.C.B. Rules Ch. 5 §7(2) or Ch. 8 § 2, the health care provider, within 24 hours after the Notice of Controversy is transmitted to the Board.

(3) Except as provided in subsection (1)(B) of this section, unless a waiver has been granted pursuant to subsection (1)(D) of this section, a Notice of Controversy sent to the Board in a paper as opposed to electronic format shall not be considered filed.

90- 351 C.M.R. ch. 3, § 4