e Claims for Claimant and Carrier Representatives June

e. Claims for Claimant and Carrier Representatives June 2013

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Overview of e. Claims � e. Claims: electronic reporting of data, re: � Initial Action on a Claim: reporting and filing � Subsequent Action on a Claim: start/stop payments; summarize payments; filings regarding certain events and actions � Be cognizant of: look and feel changes, procedural changes, availability of precise data. 3

FROIs and SROIs EDI means some paper forms will no longer be used to report claims events to the Board. Form ID EDI Submission C-2, VF-2, VAW-2* FROI C-669 FROI or SROI C-7 FROI or SROI C-8/8. 6 SROI Note: The C-11 and C-240 will still be paper forms. * Paper C 2 s will still be accepted, but in many cases are rendered unnecessary because of FROI filing. 4

e. Claims Benefits Process Data Accessibility • Establishes single, consistent format • Incorporates claims information quickly • Reduces costs • Streamlines WCB case assembly • Decreases duplicate filings • Increases quality and timeliness • Provides information on performance • Supplies data for policy decisions 5 Improves timely delivery of benefits to injured workers

IAIABC � International Association of Industrial Accident Boards and Commissions : www. iaiabc. org � Represents govt. agencies that administer WC systems � Develops standards for WC processes � 1990: developed standards for communicating data electronically between providers, payers, and state administrators via EDI. � 2005: Claims Release 3 � New York is state # 39 to implement this 20 th century technology. 6

Trading Partners Who is a Trading Partner? � An entity that enters into an agreement with WCB to exchange data electronically � Can be an Insurance Company, TPA, or Self. Insured Employer Note: All TPAs must already be licensed by the WCB Licensing Unit and already have an assigned "T" number in order to be able to submit data electronically. 7

Basic Terminology � EDI: Electronic Data Interchange � First Report of Injury (FROI) � may contain information on Claim Administrator, employee, employer, accident information � Subsequent � Report of Injury (SROI) – may contain information on indemnity payments, non-indemnity payments, reason(s) why claim is not being paid � Maintenance Type Code (MTC) � Used to report business (claim) events � Example: In FROI-04 and SROI-04, 04 is the MTC that indicates this is a denial.

Today’s Process vs Tomorrow’s EDI Process Today’s Process Carrier Notified Alleged Accident; Claimant is Injured and Out of Work Carrier filed C-669 indicating payments have begun. WCB receives and scans document; searches for matching existing claim. If no match, WCB manually searches for any docs previously received that match and manually assembles case. Notice of Assembly sent to all parties notifying of WCB case #. Tomorrow’s EDI Process Carrier must file FROI-00 and SROI-IP WCB validates submission; automatically searches for existing case. If none found, WCB automatically assembles case and sends acknowledgment of submission with WCB Case # and Notice of Assembly.

Today’s Process vs Tomorrow’s EDI Process Today’s Process Carrier Receives Information Indicating Claimant Returned to Work. Carrier files C-8/8. 6 indicating payments stopped, claimant returned to work. WCB scans document and matches to existing case. Tomorrow’s EDI Process Carrier must file SROI-S 1 (S-one) Once transaction is validated, information floods into the case file.

Submission Options Flat Files from Vendor Flat Files from Claim Administrator WCB's web application Submissi on to WCB 11

Implementation Timeline • “dual world” during staggered implementation (paper and e. Claims) 12

Examples from Implementation Schedule � Mitsui Sumimoto � Nationwide June 17, 2013 June 24, 2013 Utica Mutual � Travelers � Allstate � Chubb � AIG � Zurich July 22, 2013 August 26, 2013 September 23, 2013 November 4, 2013 � State Insurance Fund December 2, 2013 � CNA December 9, 2013 � Liberty Mutual March 3, 2014 Full Implementation Schedule available at WCB Web Site. � 13

Initial Filing � C 2: employer’s report of an injury [think § 110] � FROI: carrier’s initial filing regarding a claim. It is gateway communication from the entity administering the claim. [think §§ 25(1)(c) and 25(2)(a), and new reg] � Some Claim Admins already file C-2 s as Employer’s designee � The paper C-2 will not satisfy the e. Claims filing requirement Ø If timely for § 110 purposes, the FROI can serve as the employer report of injury too (new reg). 14

Initial Filing/ the C-2 F C 2 F has data necessary for reporting. Ø See Subject Number 046 -546 (May 16, 2013) Ø Allows for carriers/TPAs to take the C 2 F via portal, and transport into FROI for quick filing Ø The C-2 F is convenient for employers and trading partners. We encourage carriers to engage in outreach to the employers about the benefits of using the electronic portal for their C-2 F filing. Ø � Lets 15 look at the FROI….

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Legacy Claims �A legacy claim is any claim that already exists in the WCB database and has been assigned a WCB# at the time the claim administrator begins the use of EDI. � The WCB will provide each trading partner with data files w/ their legacy claims before their EDI implementation date. � Prior to reporting an event for a legacy claim, the Claim Administrator will file a FROI followed by a SROI summarizing payments to date. 19

Regulatory Framework Ø Proposed regulation is on our website Ø Comment period ends 6 -8 -13 Ø New 300. 22 Ø Ø Disability event Mandatory FROI/SROI Filing Mandatory Reports Electronic filing standard – one day Ø Other 20 reg amendments, including 300. 38.

New 300. 22 Ø Disability event: Ø ” means any accident, including death resulting therefrom, occurring in the course of employment or any alleged accident, including death resulting therefrom, that results in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident or alleged accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid; or any disease or alleged disease, including death resulting therefrom, claimed to have been caused by the nature of the employment and 21 contracted therein. ”

New 300. 22 Ø Mandatory Ø Ø Ø Ø 22 FROI e-filing A carrier obligation, memorialized via Trading Partner Agreements with TPAs and vendors File w/in 18 days of Disability Event, or w/in 10 days of knowledge of Disability Event Past 18/10? Still must file Medical Only case? Must file FROI (need not file SROI and decide stance on case, unless and until action is necessary) Must be electronic! Notice of Controversy may be in a FROI, but if carrier taking any other action on a claim, controversy must be in a SROI. Acquired claims

New 300. 22 Ø Mandatory Ø Ø Ø 23 SROI e-filing; 18 & 10 Initial Controversy [see § 25(2)(a)] Not controverted; payment has begun Not controverted; payment has not begun Initial Controversy from Notice of Indexing [§ 25(2)(b) and 300. 37], 25 days from N of I Pay w/o prejudice [§ 21 -a]

New 300. 22 Ø SROI Ø Reports of Payments Notice w/in 16 days of: Modification of comp payments, where claim not disputed Ø Suspension of comp payments Ø Payments following acquisition of claim Ø § 25(1)(d): stopped payments reported w/in 16 days Ø Ø Periodic reports (every 180 days) All payments of comp made Ø All payments of medical care Ø All payments of wages in undisputed claim Ø Until case is closed beyond 180 days Ø Ø 24 Summary of other payments, including penalties paid

Servable Documents Ø Data in, document created, carrier serves • FROI • SROI Data comes in to Bd 25 Bd creates servable document • Available on server • Carrier grabs • View in CIS • PDF in e. Case Carrier serves document

Servable Documents Ø See Subject Number 046 -522, issued April 16, 2013 Ø EDI equivalents of todays C-669 and C-7, and notice of cease or modify payments Ø Electronic filing and service timing under reg Ø Documents as PDFs in CIS and e. Case Ø Evidentiary value 26

Servable FROI 04 27

Servable FROI 04 p. 2 28

Servable SROI 04 29

Servable FROI 04 p. 2 30

Controverted Claims Ø Full Denial reasons, on FROI-04 or SROI-04 Ø There were no substantive legal changes Ø Defenses arise from statute and case law, as memorialized in the C-7 form of today Ø Must serve on claimant and legal representative Ø Must certify under 300. 38 (revised) Ø NY defenses fully represented; IA did add one new code; Board declined to use others. 31

Translation: C 7 to Denial Codes C-7 Denial Reason Prima facie medical evidence Accident within the meaning of WC Law Accident arising in the course of employment Full Denial Reason 2 D - No medical evidence of injury 1 D - Does not meet statutory definition of accident 2 C - Stress non-work related 1 C - Willful intent to injure oneself 1 F - Recreational/social activity 1 I – Presumption does not apply Accident arising out of the course of employment 1 A - Coming and going 1 E - Deviation from employment 1 B - Horseplay Occupational disease within the meaning of WC Law 1 D - Does not meet statutory definition of accident Occupational disease arising out of and in the course of employment Notice (Section 18) Notice (Section 45) Employer-Employee relationship Causally related accident or occupational disease Causally related death Proper employer entity Cancelation of coverage Proper carrier Subject matter jurisdiction Timely filing (Section 28) 32 1 I - Presumption does not apply 5 A - Failure to report accident timely 3 A - No employer/employee relationship 3 B - Independent contractor 3 C - Does not meet statutory definition of employee 3 G - Statutory exemptions 2 E - No injury per statutory definition Use codes for Causally related accident or OD 3 A - No employer/employee relationship 3 E - No policy in effect on date of accident 3 D - No jurisdiction 3 F - Statute of limitation expired

Translation: Denial Codes to C 7 33

Certification Ø Amendment to 300. 38 accommodates inability to certify electronically Ø See revised form 400. 5, which will allow for attorney to certify at the PHC. Ø SN 046 -547 May 31, 2013 Ø Traditional C-7 cases still certified on the C-7. Ø Bottom line: during transition you will see both 34

E-Case: Latest Values screen 35

E-Case: Summary of Benefits screen 36

E-Case: Cumulative Benefits screen 37

E-Case: Case Folder screen, servable docs 38

Questions/Comments? Contact us � � 39 eclaims@wcb. ny. gov regulations@wcb. ny. gov