Tuesday 01st

EDI Forms Solution: Linking EDI Transactions with Filing Select Bureau Forms in WCAIS

On September 9, 2013, the Workers' Compensation Automation and Integration System (WCAIS) went live in Pennsylvania.  From day one, the Bureau of Workers' Compensation (Bureau) has been faced with addressing shortcomings in the WCAIS to resolve issues raised by all WCAIS users, including judges, attorneys, third-party administrators (TPAs), insurance carriers and employers.

One area of ongoing confusion for the TPAs and insurance carriers has been the relationship, or lack thereof, between filing Electronic Data Interchange (EDI) transactions and the understanding that initial Bureau forms also need to be filed in conjunction with EDI transactions.

On September 19, 2016, EDI Forms Solution went live in Pennsylvania.  The idea behind this program is to have select Bureau forms automatically generate out of Subsequent Report of Injury (SROI) transactions via EDI.  The specific forms that are now generated as a result of SROI are the Notice of Compensation Payable (NCP) (LIBC-495), the Notice of Temporary Compensation Payable (NTCP) (LIBC-501), the Notice of Workers' Compensation Denial (LIBC-496), and the Notice Stopping Temporary Compensation Payable (LIBC-502).  Depending on the selections made in the SROI completion form, the appropriate Bureau forms will be generated.  They are viewable on screen.  There are countless dropdown menus for selections in the SROI EDI transaction.

We expect significant errors in form generation as a result of the merging of the SROI and the select forms.  The SROI transactions generate forms when initial payments are made, resulting in an NCP or NTCP.  When a denial is selected in the SROI transaction, the Notice of Workers' Compensation Denial is generated.  A Notice Stopping Temporary Compensation Payable is also generated if a prior Notice of Temporary Compensation Payable was generated.  Finally, various changes selected in the SROI generate amended NCPs and NTCPs.

It is important to understand that these select forms can no longer be uploaded directly into WCAIS.  They must be generated by the EDI transaction.  Defense attorneys have no means to complete EDI transactions; therefore, defense attorneys can no longer file these forms on behalf of their clients.

While EDI Forms Solution will increase the necessary filings of an initial Bureau document being filed within the 21-day period, the automatic generations of denials and amended NCPs will create confusion and potential litigation.

What It Means to You

TPAs and insurance carriers must now complete EDI transactions in the nature of SROIs to file initial Bureau forms.  Defense attorneys can no longer file these forms on your behalf.  Be cautious when completing the SROI that contains a change in benefit status or changes the nature of the work injury, as an amended NCP or NTCP will be generated, which could cause confusion on the part of the claimants and prompt unnecessary litigation.

While these select forms are no longer uploadable in WCAIS and are automatically transferred from EDI transaction into WCAIS, TPAs and insurance carriers must also remember to send the claimant a hard copy of these forms.