Department of Labor: 2002-02-15 Release 1 Guide

IAIABC
EDI IMPLEMENTATION
GUIDE
for
First, Subsequent, Acknowledgment Detail,
Header, & Trailer Records
Release 1
February 15, 2002
Includes
Flat File, Hard Copy and ANSI Formats
International Association of Industrial Accident Boards and Commissions

This page is meant to be blank.
IAIABC First Report and Subsequent Report of Injury © Release 1 February 15, 2002
TABLE OF CONTENTS
FOREWORD
Introduction .......................................................................................................................... 3
Data Collection Objectives.................................................................................................... 5
Entities Responsible for Workplace Data.............................................................................. 7
Current Data Initiatives....................................................................................................... 11
ANSI ASC X12 Alliance ....................................................................................................... 13
IAIABC Electronic Data Interchange (EDI) Project .............................................................. 15
SECTION 1: THE EDI PROJECT

Introduction .......................................................................................................................... 1-3
EDI Philosophy ..................................................................................................................... 1-5
IAIABC Project Mission Statement........................................................................................ 1-7
Antitrust Statement............................................................................................................... 1-7
IAIABC EDI Committees........................................................................................................ 1-9
SECTION 2: EDI CONTACTS

Contacts List ......................................................................................................................... 2-3
SECTION 3: SYSTEMS IMPLEMENTATION GUIDE (Including Forms and Tables)

Systems Guide...................................................................................................................... 3-3
Process Model Record Layouts............................................................................................ 3-35
Electronic Data Interchange Partnering Agreement.............................................................. 3-47
Master Trading Partner Profile.............................................................................................. 3-51
Transmission Profile – Receiver’s Specifications................................................................. 3-53
Transmission Profile – Sender’s Response .......................................................................... 3-55
Event Table........................................................................................................................... 3-57
Element Requirement Table (Part I ....................................................................................... 3-61
Element Requirement Table (Part II)..................................................................................... 3-65
Payment/Adjustment Element Requirement Table................................................................ 3-69
Edit Matrix Table................................................................................................................... 3-71
SECTION 4: TRANSACTION STANDARDS

Hard Copy Form and Instructions......................................................................................... 4-5
IAIABC Flat File Record Layouts
Acknowledgment Record (AK1)..................................................................................... 4-11
First Report of Injury (148)............................................................................................. 4-13
Subsequent Report of Injury (A49) ................................................................................ 4-15
Trailer Record (TR1) ...................................................................................................... 4-17
Header Record (HD1) ..................................................................................................... 4-19
ANSI X12 N Formats ............................................................................................................. 4-23
SECTION 5: ELECTRONIC SCENARIOS

Release 1 Limitations............................................................................................................ 5-3
Scenarios.............................................................................................................................. 5-7
SECTION 6: DEFINITIONS, GLOSSARY, AND CODE LISTS

Data Format.......................................................................................................................... 6-5
Definitions ............................................................................................................................ 6-6
Glossary ............................................................................................................................... 6-47
Appendix – Code Lists
Part of Body Codes....................................................................................................... 6-63
Nature of Injury Codes................................................................................................... 6-65
Cause of Injury Codes................................................................................................... 6-67
FIPS Codes.................................................................................................................... 6-71
IAIABC First Report and Subsequent Report of Injury © Release 1 February 15, 2002
FOREWORD
Foreword
IAIABC First Report and Subsequent Report of Injury © Release 1 1 Revised February 15, 2002
IAIABC First Report and Subsequent Report of Injury © Release 1 2 February 15, 2002
INTRODUCTION
Welcome and thank you for participating in the IAIABC Electronic Data
Interchange (EDI) Project.
This manual has been created to help your organization implement the IAIABC
EDI Standards. It should be noted as states implement the standard, systems
and reporting environments may vary between trading partners which could
limit the ability to process some transactions as originally designed. It contains
sections of documents that target your management, technical, and information
systems staff.
The Foreword provides an in-depth background on Workers’ Compensation

data collection activities, and provides the rationale for developing National
Standards and EDI.
Section 1, the EDI Project, provides project philosophy, and organizational

documents that will provide assurance and confidence in the project’s direction.
Section 2, EDI Contacts, provides jurisdiction and EDI committee participant

information from which opinions, assistance, and EDI partners can be found.
Information is also provided to enable you to access the IAIABC website to
provide you with a host of project and continual updates information.
Section 3, Systems Implementation Guide, will assist you through the

implementation process. It contains a brief implementation primer. It also
contains an EDI Partnering Agreement, Trading Partner and Transmission
Profiles, Event Tables, Element Requirement Tables and Edit Matrix Tables.
Section 4, Transaction Standards, includes IAIABC Release 1 data

requirements as expressed in hard copy, flat file and ANSI ASC X12 formats.
These documents identify the technical positioning of the data in the data
vehicle. ANSI ASC X12 format transactions provide both X12 and IAIABC data
names.
Section 5, Electronic Scenarios, contains scenarios that define the approved

usage and scope/limitations of this report. Expansions or alterations are not
authorized unless coordinated through the appropriate IAIABC EDI Committee
Work Group by willing participants for the intent of pre-release testing, or
developing enhancements of interest to our participants.
Section 6, Definitions, Glossary & Codes Lists, provides definitions and

formats for all data referenced in the transactions and scenarios.
Together these documents should provide the initiative and information

necessary to get started in IAIABC Workers’ Compensation EDI. Thank you for
joining us in our effort to improve Workers’ Compensation.
DATA COLLECTION OBJECTIVES
The need for reliable information regarding workers’ compensation has been recognized virtually since the birth
of the system. In 1914 the Commission on Workmen’s Compensation Laws stated that:
“No real knowledge of the operation of Workmen’s Compensation Acts can be acquired until
complete statistics have been gathered . . . injustices that may exist through the law cannot be
remedied until the facts are known, and the facts cannot be known until complete statistics have
been compiled.”
Later the drafters of the 1970 Occupational Safety and Health Act (OSHA) recognized the lack of suitable data
and called for the effective compilation and analysis of injury statistics. Subsequently, the National Commis-
sion on State Workmen’s Compensation Laws noted the deficiencies of the current level of data and stated that
such failings handicapped the effective evaluation and administration of state programs.
The passage of time has not alleviated the need for uniform and reliable information regarding the operation of
the workers’ compensation program. Time has, however, served to solidify the objectives of any effort to expand
data collection. These objectives include:
• Measure aggregate system costs,

• Establish a uniform means to identify the causes of workplace injury/illness,
• Develop management information to measure the effectiveness of benefit delivery systems,
• Provide information for comparing experience across jurisdictional lines,
• Identify cost drivers in the system, and
• Measure the impact of legislative and regulatory change.
As the objectives for collecting workers’ compensation data have become more focused, there has been a corre-
sponding recognition for the two forms of statistical data being requested most frequently.
• RATE-SETTING DATA — This data is collected by rating organizations and insurance

departments for purposes of setting rates and allocating costs to policy, class, etc. While
utilized primarily for that purpose, this type of data is also collected by program adminis-
trators to monitor payments by injury type and establish the amounts paid or incurred for
medical and vocational rehabilitation services.
• MANAGEMENT DATA — Management data is comprised of those data elements which

demonstrate proof of coverage, ascertain the type of claims being compensated, and mea-
sure the effectiveness of the program in terms of the timeliness in delivering benefits.
While the two forms of data furnish unique perspectives of what is occurring within the system, in combination
they furnish a complete description of both the efficiency and the cost of the benefit delivery system program.
There is considerable redundancy in these two forms of data. While some redundancy is unavoidable, it should
be eliminated wherever possible to reduce costs and improve data reliability and consistency.
Notwithstanding the objectives of an expanded data collection capability, it is important to reaffirm the goal of
achieving the collection of necessary and accurate data through the most cost effective means possible. Any
effort to enhance the data collection process must weigh the need for the data versus the anticipated cost of
collecting the data and ensuring that its accuracy is sufficient to meet the intended purposes.
ENTITIES RESPONSIBLE FOR WORKPLACE DATA
While there is frequent reference to the lack of adequate and credible workers’ compensation data, there is no
question that data is being gathered by various entities for select purposes. Each of these entities collect data
for unique purposes with a focus toward either management or financial data. The following identifies the
major entities engaged in the collection of workplace data and includes an abbreviated review of the purpose of
the effort and the type of data being collected.
A. OCCUPATIONAL SAFETY AND HEALTH (FEDERAL AND STATE)

The principal facility identified at the federal level for collecting statistics on workplace injuries or
illnesses was established by the Occupational Safety and Health Act (OSHA) of 1970. OSHA requires
covered employers to prepare and maintain records of occupational injuries and illnesses. Covered
employers include all employers except those with fewer than 5 employees, or employers in low hazard
industries (e.g. retail trade, finance, insurance and real estate).
The Bureau of Labor Statistics (BLS), through a sample of employers, conducts an annual occupational
injury and illness survey. This survey is used to develop national occupational injury and illness
estimates by the 4-digit Standard Industrial Classification (SIC) codes in most industries and at the 2-
digit code in most non-industrial industries. Annually published exhibits illustrate experience by
nature of injury, part of body affected and injury source, and include the number of lost workday cases
and the number of lost workdays.
Recordable injuries and illnesses are occupational fatalities, non-fatal occupational illnesses, or non-
fatal occupational injuries which involve loss of consciousness, restriction of work or motion, transfer
to another job, or medical treatment other than first-aid.
State OSHA facilities compile individual state experience for state reporting purposes, and submit the
same data to the federal organization for compilation of national statistics. Data is used at both the
state and federal level to target safety programs.
B. WORKERS’ COMPENSATION INSURANCE ORGANIZATIONS (WCIO)

The WCIO is a voluntary association of statutorily authorized or licensed rating, advisory or data ser-
vice organizations collection workers' compensation insurance information in or more states. Members
of the WCIO include the independent rating bureaus, NCCI, Inc. and Insurance Services Office (ISO).
The members of these organizations are the insurers writing workers' compensation in their respective
jurisdictions.
Carriers and insurers provide the rating bureaus and/or advisory organizations with policy, premium
and claim information as well as specific data needs in their respective states. The information col-
lected is used for a variety of purposes such as ratemaking, experience rating, lost cost analysis, etc.
Additionally, many of these organizations provide proof of coverage information to state jurisdictions.
The WCIO has developed standards for the electronic transmission of information between insurance
carriers and rating/advisory organizations. These specifications are available for policy information,
unit statistical reporting, experience modifications, detailed claim information and individual case re-
ports. A subcommittee of WCIO maintains the specifications manual.
ENTITIES RESPONSIBLE FOR WORKPLACE DATA (cont.)
C. STATE WORKERS’ COMPENSATION ADMINISTRATIVE AGENCIES

Many state workers’ compensation agencies — identified as industrial commissions, accident boards,
divisions, etc. — have extended their role beyond that of dispute resolution to include monitoring the
benefit delivery process, assisting injured workers in understanding their rights and obligations under
the law and collecting statistical data regarding the program’s operation.
State agencies require employers, insurers and medical providers to file reports containing claim and
payment activity information. This generally originates with the Employers First Report of Injury. This
report provides information regarding the identification of the employer and injured worker, the time
and location of the accident, and details relative to how the injury occurred, the part of body involved,
and the extent of the injury.
Many states require the filing of subsequent reports which detail the time when indemnity benefits
begin, the type of benefits being paid, and the amount of prior earnings subject to replacement. A
number of states collect payment information on a periodic basis and a summary of payments by type
of benefit when the claim is concluded. A few states also collect detailed data on medical treatment
expenses and amounts paid and outcomes of vocational rehabilitation.
State agencies use this information to monitor the benefit delivery process and informally assist work-
ers by explaining rights and entitlements under the law. Separate information is generally tracked
internally to monitor the status of adjudication and dispute outcomes. Many states compile detailed
data on lost-time injuries and publish annual statistical reports on claim experience. Often times, they
cooperate through the network established by the IAIABC to publish national and multi-national re-
ports on claim experience.
D. OTHER SOURCES OF WORKPLACE DATA

In addition to data collection that takes place by those entities previously described, independent
efforts exist to collect workplace injury data. Two of the more prominent efforts include individual
employer or insurer data systems, and independent claim surveys.
Individual employers and insurers have developed sophisticated computer systems to retrieve informa-
tion in order to monitor claim experience and cost development. This data begins with the coverage
information entered when the policy is issued and is supplemented with loss information filed at the
time the claim is reported. This loss information is designed to capture payment data with detail at the
level of benefits paid by injury type, the medical paid by procedure code, and litigation status. Addi-
tionally, these systems track development and compare experience over time.
The second source, used frequently at the state level, involves the compilation of information through
survey forms. Frequently, in response to proposed legislative activity, claim surveys are conducted to
elicit specific information in order to document the extent of a perceived problem. Such surveys generally
focus on cases closed during a specific period of time or on claims involving select injury type claims (e.g.
permanent partial disability cases). Surveys are usually conducted through a sample of cases.
Data collected both through individual employer and carrier claim files, and claim survey forms, is
utilized by research organizations such as the Workers’ Compensation Research Institute (WCRI) or the
California Workers’ Compensation Institute (CWCI). These research organizations identify system char-
acteristics and develop information that assists legislators and program reformers to focus on specific
problems and issues. Claim surveys are also used by regulators and statistical agencies to augment
the data collected through other mechanisms.
ENTITIES RESPONSIBLE FOR WORKPLACE DATA (cont.)
SUMMARY
The foregoing demonstrates in an abbreviated fashion the types and purposes of the data collected by
the major entities involved including governmental entities as well as other interest groups. While each
entity may be collecting data for distinct purposes, there is a significant amount of overlap in informa-
tion collected during the life of the claim or period of program coverage.
In similar fashion, there is the potential for these different entities to develop jurisdictional unique
terms or definitions for purposes of describing certain benefit types. As these entities develop the
capability to transmit information electronically, there also exists the possibility of developing multiple
data formats for the same data element.
All of these entities are interested in collecting complete and accurate data in a timely manner. The
most efficient and accurate form in which to collect this information requires uniformity and standard-
ization. Where possible, duplicate collection should be eliminated and the data needs should be ana-
lyzed to ensure that the information can be used to compare experience across jurisdictional lines.
CURRENT DATA INITIATIVES
Recognizing the multiple purposes for which data is being collected, a number of efforts have been undertaken
to refine and improve this collection capability. The International Association of Industrial Accident Boards
and Commissions (IAIABC), the National Association of Insurance Commissioners (NAIC), the National Council
on Compensation Insurance Inc. (NCCI), the independent rating bureaus, the Bureau of Labor Statistics (BLS),
and the United States Department of Health and Human Services are the principal organizations engaged in
these data collection efforts.
Through efforts that began independently, working groups from each of these organizations now work jointly to
recommend the collection of certain basic data elements in order to understand and monitor developments in
the workers’ compensation arena.
A. THE INTERNATIONAL ASSOCIATION

OF INDUSTRIAL ACCIDENT BOARDS AND COMMISSIONS (IAIABC)
The IAIABC is an association of administrators from state workers’ compensation agencies. One of
their objectives is to develop and recommend standards for improving and strengthening workers’
compensation laws and their administration. Since 1914, the IAIABC has been examining appropriate
collection and use of industrial accident data.
As a result of an effort that began in 1987, the Statistics Committee of the IAIABC compiled a listing of
recommended management and payment data elements for state administrators to collect on each lost-
time claim. This proposal was adopted by the IAIABC membership in 1990. Subsequent to that
activity, the IAIABC has embarked on a project to develop standards for communicating data electroni-
cally between providers, payers, and state administrators through Electronic Data Interchange (EDI).
Common formats and data reporting specifications are being developed for the First Report of Injury,
the subsequent payment reports, medical information, vocational rehabilitation, litigation activity, and
proof of coverage.
The IAIABC EDI project includes representation from state administrative agencies, insurance carriers,
rating bureaus, research organizations, self-insured employers, standards organizations and vendors.
The background and current status of the EDI project will be more fully described in the following section.
B. WORKGROUP FOR ELECTRONIC DATA INTERCHANGE (WEDI)

A committee under the direction of the Secretary of the United States Department of Health and Human
Services is examining standardization of medical reports and the electronic transfer of medical infor-
mation for all lines of health insurance. The IAIABC EDI working group has entered into discussions
with the WEDI task force in order to ensure that the efforts are coordinated and that the concerns for
workers’ compensation are recognized.
C. WORKERS’ COMPENSATION INSURANCE ORGANIZATIONS (WCIO)

The WCIO is an organization comprised of the managers of the various boards and bureaus. Their
objective is to provide to their members, standards for the exchange of informations. One of their major
publications is the WCIO Workers’ Compensation Data Specifications Manual. This manual contains
magnetic tape specifications for reporting policy (WCPOLS), unit statistical information (WCSTAT), and
claim information (WCCDCI), in addition to other products. Recently, the WCPOLS segment was re-
vised to include the IAIABC Proof of Coverage (POC) data elements. This permits the organizations’
members to submit their POC data using WCPOLS, which could then be reformatted, if necessary, and
provided to the industrial accident boards and commissions.
CURRENT DATA INITIATIVES (cont.)
D. NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS (NAIC)

The NAIC is an association of state insurance commissioners responsible for all lines of insurance
including workers’ compensation. The NAIC established a working group of the Workers’ Compensa-
tion Statistical (D) Task Force to examine the subject of workers’ compensation data collection. Utiliz-
ing the listing of data elements developed through a series of meetings, the NAIC adopted a Workers’
Compensation Insurance Data Reporting Model Regulation at their December 1989 meeting.
The model regulation provides that insurance carriers, state funds and self-insured employers are to
report their statistical experience to at least one of the statistical agents designated by the Commis-
sioner. The model regulation calls for an annual data report to be completed on a selected sample of
workers’ compensation claims.
E. INSURANCE DATA MANAGEMENT ASSOCIATION WORKGROUP (IDMA)

A working group, sponsored by the Insurance Data Management Association (IDMA) is currently re-
viewing the different injury coding schemes that have evolved over time with the goal of devising a
standard injury coding format. This group is composed of representatives from OSHA, the Bureau of
Labor Statistics (BLS), state workers’ compensation administrators, the IAIABC, the workers’ compen-
sation rating bureaus and member insurance companies. This effort will permit a better interface
between industry and federal data.
SUMMARY
This overview of ongoing data collection activities clearly demonstrates that there is both a tremendous amount
of interest and activity directed to the collection of credible, accurate data in a timely manner. This activity
speaks to the need for coordination in the area of workers’ compensation data collection.
ANSI ASC X12 ALLIANCE
AMERICAN NATIONAL STANDARDS INSTITUTE

Accredited Standards Committee for Electronic Data Interchange Insurance (ANSI ASC X12N)
The IAIABC EDI Committee has been working with ANSI ASC X12N since June 1991. Both organizations
provide different qualities that are helpful. Currently, there are ANSI compatible versions of Release 1 First and
Subsequent Reports, Proof of Coverage and the Medical Bill/Payment Report. ANSI accredits national standard
setting bodies in the United States. Traditionally these standards have been used to set product design and
safety standards. These standards provide both manufacturer and consumer with confidence and thus im-
prove commerce.
Working with ANSI ASC X12 provides the following benefits:
Standards: Standards provide vendors with confidence that will attract them to produce
products and services that enhance EDI. The involvement of vendors reduces
the individual effort required by companies and ultimately lowers implementa-
tion and operation costs.
Translators: Are used to map sender and receiver data to ANSI designed transactions. This
can simplify revisions and coordination of trading partner differences.
Connectivity: Provides compatibility with Trading Partners and intermediaries who offer data
storage, forwarding, and inter-operability services.
Software: Off the shelf solutions often cost less. Because ANSI is used for other business
requirements, i.e. purchase orders, the software may be readily available or
easily adapted.
IAIABC ELECTRONIC DATA INTERCHANGE (EDI) PROJECT
INTRODUCTION
Over the past decade, many developments in computer technology have had extensive articles written about
them. In recent years a technology topic that has grown in popularity and usage is EDI. It seems to be the
acronym or “buzz” word of choice in many technology and insurance magazines. EDI, short for Electronic Data
Interchange, represents the electronic exchange of information, without the element of human intervention.
EDI has grown out of the need to pass data quickly between trading partners and had its genesis as far back as the
1960s when magnetic media was the most effective choice available. However, due to recent improved computer
and data communication technology, it has helped speed the trend toward EDI solutions. The expanded usage of
EDI has resulted in greatly increased transfer of information and reduced clerical and data entry costs.
Electronic Data Interface (EDI) in Workers’ Compensation represents an extension of an earlier International
Association of Industrial Accident Boards and Commissions (IAIABC) project which focused on the identifica-
tion of data elements for Workers’ Compensation system participants to collect. This listing of recommended
data elements was compiled over a period of time during which insurance regulators, state program adminis-
trators, insurance carriers, and self-insured employers, identified those articles of information that would
develop a core of data elements in order to provide credible management and financial information.
The EDI stage of that project simply moves the discussion on data collection to the next natural level. After establish-
ing a listing of recommended data elements for collection, the next issue to address is the identification of the most
cost efficient and accurate manner in which to collect that data. EDI represents that next natural phase.
State workers’ compensation agencies, responsible for monitoring the benefit delivery process, represent the most
practical location for collecting that data. Those agencies presently utilize paper forms to monitor the claim
process on each lost-time claim. Rather than utilizing those various forms (e.g. first injury reports, memorandum
of payment, case progress reports, closed claim information, etc.) the EDI effort is intended to replace such forms
through an electronic link whereby a standardized listing of data elements can be communicated electronically.
EDI simply represents the use of current capabilities to effectively transmit data deemed appropriate.
POINTS FAVORING EDI

When proposing EDI for Workers’ Compensation, it is beneficial to first identify those features which favor its
adoption. Those features have application whether we are discussing the employers, the carriers, or the per-
spective of the state agency and include the following:
• The principal reason in support of EDI is the cost efficiencies associated with the same.
Reduced cost can be realized through the elimination of data entry at the state agency level
when the state system is directly linked to an external data source. While state agencies
realize an immediate benefit through accepting First Reports of Injury electronically, sub-
sequent payment reports filed via electronic means represent significant savings for em-
ployers and carriers. Additional savings are connected with reduced filing space require-
ments and reductions in the expenditures for postage and mail sorting and delivery time.
• Along with savings associated with the direct transfer of data through electronic means,
there is the separate issue of improved data accuracy. Information entered or “key-
punched” a number of times is subject to error. The fewer times it is necessary to enter
information, the greater will be the degree of accuracy. There is little value in collecting
and utilizing data unless there is a strong assurance that the data is accurate.
• The ongoing collection of appropriate financial data in a timely fashion provides the op-
portunity to continually monitor and measure changes in the workers’ compensation
environment. The electronic submission of data on all claims can permit comparison of
experience at different points in time and across jurisdictional lines. This will afford the
opportunity to identify systemic problems.
IAIABC EDI PROJECT (cont.)
• A concluding reason to support EDI is that it will culminate in the creation of comprehen-
sive data bases at the state level that are standardized among states in the type and format
of data being collected. Standardized formats assist benefit providers to manage one stan-
dard rather than fifty systems to respond to the needs of fifty different states.
The potential for cost savings through the elimination of duplicative entry processes and the efficiencies asso-
ciated with a single standard for data transfer make this project a key to controlling expenses in the workers
compensation cost environment.
STATUS OF THE EDI PROJECT

The EDI project grew out of the work of the IAIABC’s Statistic’s Committee initiatives. On April 26, 1916, the
Chair of the IAIABC’s Committee on Statistics and Compensation Insurance Cost introduced a plan to promote
uniform practices in collecting and utilizing administrative information. In 1932, the IAIABC began to consider
the usefulness of standard forms. The IAIABC’s standard version of the Employer’s First Report of Injury was
approved in 1956. The IAIABC began promoting computerized databases with the introduction of the Basic
Administrative Information System (BAIS) in the 1970’s. The IAIABC’s cummulative work in this area is some-
times referred to as the “universal data set” initiative.
The term reflects the ideal of having a single plan for collecting data that will work in every jurisdiction. As in
all previous projects, the EDI Project brings all the stakeholders under one roof to develop an agreed upon and
useful standard. In March of 1991, a group within the IAIABC proceeded with the concept of moving the
national data collection project into a design phase.
At the same time, a technical working group was established and focused on the detail of defining the data
elements and developing the data formats to be used for electronic data transfer. This group, after reviewing all
the various forms presently filed with state agencies, identified distinct phases that the project would follow.
These phases reflect the various generic categories within which the various state reporting forms fall. These
categories include:
1. First Report of Injury (Release I completed 8/95, Release II completed 7/97) The initial report
designed to notify the parties of the occurrence of an injury or illness. Contains basic claim
information regarding the who, what, when and how of an occupational injury or illness.
2. Subsequent Payment Reports (Release I completed 8/95, Release II completed 7/97)

Consists of forms that gather information when benefit payments begin, case progress
information and paid amounts by benefit type when the claim is concluded.
3. Medical Data (Release I completed 3/01) Develops more refined data pertinent to the dates of
service, diagnostic and procedures codes, and costs associated with providing of such care.
4. Proof of Coverage (Release I completed 8/97) Information filed with the majority of state
administrative agencies that verifies the name of the insured employer and the provider
of coverage.
Each of these categories represents a separate project phase for the technical working group.
Variations in the way the state statutes are constructed will present unique problems to the collection of certain
data elements. However, even with recognition for these difficulties, the intent is to utilize EDI to the degree
possible while seeking greater uniformity in order to make comparisons across jurisdictional lines.
Check our website at http://www.IAIABC.org/EDI for up-to-date project status.
SECTION 1
1.
The EDI Project
IAIABC First Report and Subsequent Report of Injury © Release 1 1-1 Revised February 15, 2002
SECTION 1
IAIABC First Report and Subsequent Report of Injury © Release 1 1-2 February 15, 2002
SECTION 1
INTRODUCTION
The term Electronic Data Interchange tends to conjure up visions of added technical com-
plexity. It is difficult, if not impossible, to envision how technology could improve an environ-
ment currently buried in paper and apparently intent on generating more paper and addi-
tional requirements.
Technology will not help that. Technology can only provide us with the capability to exchange
data efficiently. It will not eradicate the necessity for us as business partners to exchange data, or
make simple that which we have made complicated. It does however, provide us with a golden
opportunity to simplify our business processes and exchange data for our mutual benefit.
The first objective of the EDI Development Group is to educate Workers' Compensation System
participants, i.e. employers, claim administrators, jurisdictions, and service providers, of the
business advantages gained from exchanging information efficiently, cost effectively and with
reduced human assistance.
Once this is accomplished, our objective is for the system participants to jointly develop new
business processes that meet today's and tomorrow's requirements in the simplest and most
beneficial way possible.
Together, these objectives will reduce our overhead and focus our attention on our primary busi-
ness: administrating Workers' Compensation claims, providing services and monitoring compli-
ance to insure that our Workers' Compensation Systems function effectively and efficiently.
To accomplish this, IAIABC project participants, with either business or information science
backgrounds, work together to analyze our current processes and develop simpler standard
processes. From this work, data transactions and supporting processes are created.
SECTION 1
SECTION 1
EDI PHILOSPHY
The philosophy of the IAIABC EDI Committee is to simplify and improve the way we do busi-
ness. To meet this objective, the IAIABC EDI Committee maintains several goals:
1. Standardize All Data Elements: Terminology and definitions often differ from juris-
diction to jurisdiction. Our objective is to create common definitions that will allow
cross jurisdictional data comparisons. Such comparisons will be useful in identifying
beneficial legislation and administrative rules.
2. Do Not Re-invent The Wheel: It is not efficient to redesign what already works. Whenever
we find that an existing standard meets our criteria and may be employed by many system
participants, we adopt that standard.
3. Use Codes Where Possible: The Workers' Compensation industry captures more data
than most industries, yet it provides little benefit. Our goal is to use the data we capture to
improve the interaction of the system participants, and to use this data to its best advan-
tage. Although common terminology will improve that, most of the data we capture is
textual, and textual data requires human interpretation. Accordingly, our philosophy is to
use codes wherever possible and minimize textual data. The use of codes also allows imme-
diate analysis of the data.
4. Plan for Change: As our work continues, we will become aware of new business require-
ments that are certain to arise from legislation, administrative rules, customer require-
ments, and our own business needs. Constant change could make EDI costly and difficult
to manage. Our objective is to manage change by designing transactions and processes
and using codes to provide flexibility of use. This approach allows our designs to accommo-
date many enhancements without redesigning the transaction. Transaction revisions will
be scheduled to reduce and regulate their frequency.
5. Simplify The Reporting Requirements: Workers' Compensation data reporting require-

ments appear to be unique to each jurisdiction and customer. After analysis, we found that
all the reporting requirements had basic commonalties. By arranging these common ele-
ments, we developed a menu format that provides unique reporting requirements for any
trading partner in a manner that simplifies the reporting process.
6. A Partnership Approach: Electronic Data Interchange requires that trading partners in-
teract and exchange data so that the business processes of both are improved. It also
implies that data quality is an important joint responsibility. To meet this requirement, a
data edit process and an Acknowledgment Transaction have been designed. The acknowl-
edgment reports acceptance or rejection of the transaction, errors, and business informa-
tion for each report. This process assists Trading Partners by reporting problems promptly
and insuring data quality.
SECTION 1
SECTION 1
IAIABC PROJECT MISSION STATEMENT

To improve the exchange of information between all Workers' Compensation
participants, for the purpose of effecting improvements in all aspects of the Workers'
Compensation System, to benefit those receiving or providing benefits or services, or
monitoring, researching, administrating and legislating our Workers' Compensation
Systems.
ANTITRUST STATEMENT
As an association, the function of the IAIABC is to reflect the interests of participants in
the Workers' Compensation program and state administrative agencies.
In any meeting associated with the IAIABC, insurance companies shall not disclose an
individual company's rates or loss costs. Companies should avoid any discussions
intended to increase or stabilize rates, or raise any complaints about companies that
may be charging low or inadequate rates.
No discussion will be permitted which attempts to pressure companies to raise rates, or

use particular rates, or establish factors as a "benchmark" in setting rates.
There should be no discussion of how changes in state regulation might affect a

company's presence in a particular state or a company's underwriting standards. In
particular, there should be no suggestion that companies withdraw from a particular
market or stop underwriting particular classes of customers in order to induce, deter or
retaliate against government action.
SECTION 1
EDI COMMITTEES
PURPOSE:
To promote the advantages of exchanging data between participant systems.
To promote/recommend business & data interchange objectives.
To assist participants in identifying business data requirements.
To establish data interchange standards.
To provide a structure to accomplish these purposes.
OBJECTIVES:
To unify/motivate participants to improve the Workers' Compensation environment.
To identify Workers' Compensation opportunities:

a. To improve working relationships.
b. To standardize data definitions.
c. To improve the reliability/timeliness of data.
d. To reduce operation expenses.
e. To improve customer service.
f. To improve management of the environment.
To establish a network:
a. To discuss/determine data interchange objectives.
b. To organize activities for efficiency and prioritization of resources by participant interest.
c. To present/request/analyze environment data interchange and process requirements.
d. To develop data interchange solutions.
e. To institute solutions by consensus opinion.
f. To influence environmental change.
To establish standard for:

a. Elements.
b. Transactions.
c. Communication.
d. Edits.
e. Acknowledgment.
f. Management of data interchange.
SCOPE:
Data exchanged between Workers' Compensation environment participants.
Data exchanged via electronic means, or alternate methods that support the exchange of
data electronically, or provide comparable benefit.
SECTION 1
SECTION 2
2.
EDI Contacts
SECTION 2
SECTION 2
Contact List
The list of contacts previously included in the manuals has proven to be of limited
use. The contact persons and phone numbers change too frequently to be
included in the static format of a manual release, which is updated with much
less frequency than needed to maintain a good working list of contacts. Thus, the
material formerly included in the manuals is now available on the International
Association of Industrial Accident Boards and Commissions web page at:
http://www.iaiabc.org/html/edi.htm
Those wishing to suggest updates to the list should contact Faith Howe, EDI
Manager, IAIABC, by e-mail at fhowe@iaiabc.org.
SECTION 2
SECTION 3
3.
Systems Implementation Guide
Including Trading Partner Implementation

Planning, Agreements, and System Tables
SECTION 3
SECTION 3
IAIABC RELEASE 1 SYSTEMS IMPLEMENTATION GUIDE
The System Implementation Guide has been created as an aid to assist you in
developing an EDI reporting systems. This should be used in conjunction with the
EDI Implementation guide published by the IAIABC, and may be complemented
with an addendum describing Jurisdiction specific rules.
The following is a summary of the sections included in this guide:
TRADING PARTNER TABLES
Electronic Data Interchange Partnering Agreement – This form is a set of

expectations, responses, between two entities exchanging data electronically.
Trading Partner Profile - This form will uniquely identify a trading partner and
provide contact information. Members of the partnership will fill out the
information as it pertains to them. The completed forms are then exchanged
between partners.
Transmission Profile - This form is used to communicate all allowable options

the receiver of Workers Compensation data will provide to an originator (or
sender).
Event Table - This table is used to describe the conditions which trigger creation
of EDI transactions.
Element Requirement Table - A matrix the receiver uses to define the level of
reporting (e.g. mandatory, optional, etc.) for each data element within an EDI
transaction.
Payment/Adjustment Element Requirement Table - A separate table has been

included for defining the reporting requirements of the Subsequent Report
Payment Adjustments variable length segments. This table was intended to allow
for differences in reporting requirements based on payment type.
Edit Matrix - Describes the recommended edits the receiver may perform on
each data element. If errors are found the edit matrix provides a standard
numbering methodology to communicate inaccuracies to the sender via the
acknowledgment transaction.
SECTION 3
PROCESS MODELS
These models include all the activities necessary for processing and are intended
to be used only as a guide. Included are process models considering two
perspectives.
Claim Administrator - Describes how a Claim Administrator receives data from

an employer, returns acknowledgments, and creates injury transactions to be
sent to a jurisdiction. It also describes how the Claim Administrator processes
acknowledgment data from the jurisdiction.
Jurisdiction - Describes how the jurisdiction processes injury data from the
claims administrator and creates acknowledgment transactions back to the
Claims Administrator.
SECTION 3
Instructions for Completing Trading Partner Forms
The Trading Partner tables are a set of tables designed to provide information
integral to controlling the extraction and transmission process for successful EDI
of Workers Compensation data. The data contained in these tables are originally
established by the “primary” trading partner (jurisdiction) to reflect their reporting
requirements and environment.
SPECIAL NOTE: Careful consideration of both demonstrated business need as

well as data availability must be given when establishing data element
requirements between trading partners. It is recommended that data requesters
meet with data providers to develop a consensus regarding which data elements
should be collected/reported.
MASTER TRADING PARTNER PROFILE
This form will uniquely identify a trading partner and contact information. Each
member in a partnership will fill out the information as it pertains to them and
then exchange it with their trading partner(s).
TRADING PARTNER TYPE - The business function a given trading

partner performs within a given agreement. If other, please specify.
MASTER TRADING PARTNER INFORMATION:
Name - The name of your business entity corresponding with the Master
FEIN.
Master FEIN - The Federal Employer's Identification Number of your

business entity. This, along with the 9-position postal code (Zip+4) in the
trading partner address field will be used to identify a unique trading
partner.
Address - The street address of the physical location of your business

entity. It will represent where materials may be received regarding this
trading partner agreement if using a delivery service other then the U.S.
Postal Service.
City - The city portion of the street address of your business entity.
State - The 2-character standard state abbreviation of the state portion of

the street address of your business entity.
Postal Code - The 9-position postal code of the street address of your
business entity. This field, along with Trading Partner FEIN will be used to
uniquely identify a trading partner.
SECTION 3
Mailing Address/City/State/Postal Code - The mailing address used to

receive deliveries via the U.S. Postal Service for your business entity. This
should be the mailing address that would be used to receive materials
pertaining to this trading partner agreement. If this address is the same as
the aforementioned street address, indicate “Same as above”.
CONTACT INFORMATION
This section provides the ability to identify individuals within your business entity,
which can be used as contacts for this trading partner agreement. Room has
been provided for two contacts business and technical.
The BUSINESS CONTACT should be the individual most familiar with the
overall extract and transmission process within your business entity.
He/she may be the project manager, business systems analyst, etc. This
individual should be able to track down the answers to any issues, which
may arise from your trading partner that the technical contact cannot
address.
The TECHNICAL CONTACT is the individual that should be contacted if

issues regarding the actual transmission process arise. This individual
may be a telecommunications specialist, computer operator, etc.
BUSINESS/TECHNICAL CONTACT NAME: - The name of the contact.
BUSINESS/TECHNICAL CONTACT TITLE: - The title of the contact or

the role that contact performs within a given trading partner agreement.
BUSINESS/TECHNICAL CONTACT PHONE: - The telephone number at

which that contact can be reached.
BUSINESS/TECHNICAL CONTACT FAX: - If FAX facilities are available,

the telephone number of the FAX machine to use for the contact is
provided in this space.
EMAIL INFORMATION
If the contact can be reached via electronic mail, all Email addresses that may be
used to send messages to this contact are provided in this section.
EMAIL INFORMATION: Network - The name of the Email network or

service through which the contact can be reached.
EMAIL INFORMATION: ID - The Email correspondent identifier of the

contact.
SECTION 3
TRANSMISSION PROFILE - RECEIVER'S SPECIFICATIONS
This form is used to communicate all allowable options the receiver of Workers'
Compensation data will provide to a sender. The receiver is responsible for
providing the information on the first page of this form, indicating all their
requirements, and where applicable, the supported options form, which a sender
can select. The sender will then complete page 2 of this form providing their data
in the allotted spaces, and indicating their selections where the receiver provides
choices. This information is then returned to the receiver.
One profile should be completed for each set of transactions with common
transmission requirements. For example, one form may be used for 148 and A49
transmission because a given receiver can only accept Flat-File format for these
report types and can only accept them via VAN "A", while a second form will
provide requirements and options that will relate to MED reports, which can only
be accepted in ANSI format and via VAN "B" or "C".
Although one profile will satisfy most needs, it should be noted that if
transmission parameters vary by transaction types, you could specify those
difference by providing more then one profile.
Ideally, the receiver will customize the first page of the form, removing those
selections and options that do not apply to their environment.
RECEIVER NAME - The name of your business entity corresponding with

the Master FEIN.
DATE - Date this form completed.
TRADING PARTNER TYPE - Check the appropriate category reflecting

the receiver's business type.
RECEIVER IDENTIFIER - This is unique identifier consisting of the

Receiver’s FEIN and Receiver’s Postal Code.
RECEIVER FEIN - The FEIN of the trading partner, which will receive
Workers' Compensation data. This must match the FEIN supplied on that
entity s Trading Partner Profile. This entity will be the first to fill in this
form.
RECEIVER POSTAL CODE - The 9-position postal code associated with

the receiving trading partner’s street address, which together with the
Receiver FEIN will be used as the identifier of this trading partner.
SECTION 3
PROFILE ID - This profile ID is a Free-Form Field used to uniquely identify

a given profile between any given pair of trading partners. This field
becomes critical when more than one profile exists between a given pair
of trading partners. It is used for reference purposes.
TRANSACTION SETS
This section identifies all the transaction sets/report types described within the
profile along with any options the receiver can provide to the sender for each
transaction set. Both the IAIABC and ANSI designators and Transaction Sets
are provided (e.g. POC/271, where "POC" is the IAIABC designator and "271" is
the ANSI designator).
TRANSACTION SET ID IAIABC/ANSI - Indicates the type of EDI

documents the receiving trading partner will support with parameters.
FLAT FILE RELEASES - If a Flat File can be accepted for a given

transaction set by the receiving trading partner, the release number(s)
supported by the receiver is/are specified here. Note that multiple releases
may be supported per transaction set with a receiver’s environment. The
sender will specify a single release per transaction set on the return form.
ANSI VERSION # - If an ANSI transmission can be accepted for a given

transaction set by the receiving trading partner, the version number(s)
supported by the receiver are specified here. Note that multiple versions
may be supported per transaction set with a receiver’s environment. The
sender will specify a single version per transaction set on the return form.
ACKNOWLEDGMENT INFORMATION
This section provides acknowledgment options the receiver provides.
ACKNOWLEDGMENT INFORMATION: Mode - For any given transaction

set, the receiver will indicate whether they can support electronic, paper or
no acknowledgments. Any unsupported option should be
removed/crossed-off by the receiving trading partner.
ACKNOWLEDGMENT INFORMATION: Resp. Period - The receiving

trading partner will indicate the maximum period of elapsed time within
which an sending trading partner may expect to receive an
acknowledgment for the given transaction set.
SECTION 3
ACKNOWLEDGMENT INFORMATION: Level - For a given transaction

set, the receiving trading partner will specify whether they can support
acknowledgments for all transactions, only transactions with errors, and/or
only transactions that are rejected. It should be noted that providing
multiple options indicates that the receiving Trading Partner is capable of
supporting "Filtered" acknowledgments. Options not supported must be
removed/crossed off.
FREQUENCY - All frequencies the receiving trading partner will accept

transmission for the transaction sets identified within this profile are
specified here. Frequencies that cannot be supported by the receiving
trading partner should be removed/crossed-off the list.
DAY OF WEEK - If the receiving trading partner supports weekly or bi-

weekly options, all days of the week that the receiver will accept
transmission will be specified here. Remove/cross-off any day of the week
that cannot be used to accept transmission data.
DAY OF MONTH - For frequencies other than daily, weekly, and bi-weekly
all calendar days of the month that the receiving trading partner will accept
transmission will be specified here.
MONTH OF YEAR - If frequencies of bi-monthly, quarterly, semi-annually

or annually are supported frequencies by the receiving trading partner, the
month(s) of the year that can be used to receive transmission are
specified here.
TRANSMISSION PAYMENTS - The receiving trading partner will specify

which payment arrangement for transmission costs are acceptable. If each
MEMBER of the trading partner agreement will pay for their own
transmission cost, specify EACH. If all transmission cost will be paid by
the RECEIVING trading partner, for both their transmissions and those of
their trading partner within this agreement, specify ALL. If all transmission
cost will be paid by the ORIGINATING trading partner, for both their
transmissions and those of their trading partner within this agreement,
specify NONE.
TRANSMISSION CUT-OFF TIME - The receiving trading partner will

specify the time up until which the transmission will be accepted for that
processing cycle.
SECTION 3
ELECTRONIC MAILBOX AVAILABLE - If one or more Value Added

Networks (VANS) can be used to exchange data, the receiving trading
partner will specify all available electronic mailboxes to which data can be
transmitted. Separate mailbox information may be provided for
transmitting production versus test data.
NETWORK - The name of the value added network service on which the
mailbox can be accessed.
NETWORK: Mailbox Acct ID - The name of the receiver's mailbox on the

specified VAN.
NETWORK: User ID - This is the identifier of the receiver entity to the

VAN.
NETWORK: Message Class - If this VAN allows for "slots" in their

mailbox (classification of message), this field will contain the message
class to be used when transmitting information to the receiving entity.
SPECIAL NOTE: Message Class is not recommended fo r usage. If the

Receiver allows usage, this information must be coordinated between both
trading partners.
DIRECT CONNECT OR FILE TRANSFER PROTOCOL (FTP)

AVAILABLE - If data can be transmitted directly to the receiving trading
partner's computer, or via File Transfer Protocol (FTP), the receiving
trading partner must provide (or have available upon request) the
technical specifications needed to support these media types. All
pertinent technical information must be available for the sender to develop
the send process if either of these options is selected.
FLAT FILE RECORD DELIMITER - If the receiving trading partner

supports a Flat File format, the character used to physically indicate end of
record is specified here (e.g. carriage return, line feed (CR/LF)).
SECTION 3
COMPLETE IF USING ANSI
This section provides information needed to exchange ANSI formatted

transmission data.
ANSI SEGMENT TERMINATOR – If the receiving trading partner

supports ANSI transmissions, the character used as a segment terminator
is specified here.
ANSI DATA ELEMENT SEPARATOR – If the receiving trading partner

supports ANSI transmissions, the character used as a data element
separator is specified here.
SUB-ELEMENT SEPARATOR – If the receiving trading partner supports

ANSI transmissions, the character used as a sub-element separator is
specified here.
ANSI SENDER/RECEIVER QUALIFIER - If you can accept ANSI

transmissions, this will be your ANSI ID Code Qualifier as specified in an
ISA segment.
Separate Qualifiers are provided to exchange Production and Test data, if

different identifiers are needed.
ANSI SENDER/RECEIVER ID - If you can accept ANSI transmissions,

this will be the ID Code that corresponds with the ANSI Sender/Receiver
Qualifier (ANSI ID Code Qualifier) as specified in an ISA segment.
Separate/Sender/Receiver ID’s are provided to exchange Production and

Test data, if different identifiers are needed.
ACKNOWLEDGMENT INFORMATION: Functional Acknowledgment

for AK-1 - The receiving trading partner can specify if they wish to receive
a functional acknowledgment when an ANSI detailed acknowledgment
has been transmitted back to the sender. This does not apply if the
receiving trading partner cannot support ANSI electronic
acknowledgments.
SECTION 3
SECTION 3
TRANSMISSION PROFILE - SENDER'S RESPONSE
Receiver Name, Receiver Identifier, Profile ID and Description are information

transferred from the Receiver's portion of the Transmission Profile.
SENDER SELECTIONS/INFORMATION
Once the sender has an opportunity to investigate all available options for
transmitting data to the receiving trading partner, their selected media option and
related information is specified in this section.
NAME - The primary trading partner name of the receiver. The trading
partner receiving transmissions should provide this information in pre-
printed form.
FEIN - The primary FEIN of the receiving trading partner. The trading
partner receiving transmissions should provide this information in pre-
printed form.
SENDER NAME - The name of the business entity that will be extracting
and transmitting detailed Workers Compensation information to their
trading partner. This should be the name that appears on the TRADING
PARTNER PROFILE.
TRADING PARTNER TYPE - Check the appropriate category reflecting

the sender’s business type.
SENDER FEIN - the FEIN of the trading partner, which will transmit
Workers' Compensation data. This must match the FEIN supplied on the
entity s Trading Partner Profile.
SENDER POSTAL CODE - The 9 position postal code associated with

the sending trading partner's street address which together with the
Sender FEIN will be used as the identifier of this trading partner.
FOR EACH TRANSACTION SET THE SENDER WILL BE ORIGINATING:
The sender will indicate the format of each transaction set for which an
agreement is being made - Flat File or ANSI. The format and Release/Version
number that the sender wants to receive electronic detailed acknowledgments is
specified on the line indicated by “AKI/824”.
SECTION 3
RELEASE/VERSION - If Flat file was selected, the IAIABC Release

Number this trading partner will use to format the respective report is
specified in this space; if ANSI format was selected, the ANSI Version
Number is specified in this space. It is recommended that the latest
release that can be commonly supported by both sender and receiver be
selected.
PROJECTED # PER TRANSMISSION - The sending trading partner will

specify the projected average number of detail records for a given
Transaction Set Id that will be sent to the receiving trading partner per
transmission. This will be used for planning purposes.
MODE - The sending trading partner will select their preferred mode
(electronic/paper/none) of acknowledgments for that transaction set from
the options provided by the receiving trading partner.
LEVEL - The sending trading partner will select their preferred level
(all/errors/rejected) of acknowledgments for that transaction set from the
options provided by the receiving trading partner.
TRANSMISSION FREQUENCY
The sending trading partner will specify which one frequency they will use to
transmit data from the choices provided by the receiving trading partner.
SELECTED MEDIA - The sender will place an "X" in front of the option,
which they have selected to transmit information. If "DIRECT CONNECT",
the receiver must have provided any technical specifications that the
sending trading partner may need for successful data exchange. If
"ELECTRONIC MAILBOX" is selected, the selected VAN will be specified
by providing network information in the fields provided in this section.
NETWORK - The sender specifies the VAN they will use to transmit data
to the receiving trading partner. Separate mailbox information is provided
for production versus test transmissions.
NETWORK: Mailbox Acct ID - The name of the sender's mailbox on this

VAN where acknowledgments can be routed from the receiver back to the
sender.
NETWORK: User ID - This is the identifier of the sender entity to the VAN.
NETWORK: Message Class - If this VAN allows for slots in their mailbox
(classification of messages), this field will contain the message class to be
used when transmitting information back to the sending entity.
SECTION 3
EVENT TABLE
USAGE INSTRUCTIONS
This table was designed to provide information integral for a sender to

understand the receivers EDI reporting requirements. It relates EDI information to
events and under what circumstances they are initiated. This includes legislative
mandates affecting different reporting requirements based on various criteria
(i.e., dates of injury after a certain period).
It is used and controlled by the receiver of EDI transactions to convey the level of
EDI reporting that they currently accept. It is also used by each trading partner to
record an individual trading partner's production level by MTC, and
implementation dates.
For a sender of EDI information, at least one Event Table must be completed. If
there are any exceptions within clients of a sender, then an Event Table must be
completed for each exception.
TRADING PARTNER ID: A composite Field containing a trading partner's

FEIN and nine position postal code. This is a generic term that can identify
either the sender or receiver.
TRANSACTION SET ID: The code that identifies the transaction being
sent/received (i.e. 148, A49, POC). An entry for each transaction set that a
trading partner is using should be included along with each MTC.
MTC: The Maintenance Type Code defines the specific purpose (event)
for which the transaction is being sent (triggered).
MTC DESCRIPTION: Text describing the Maintenance Type Code.
PRODUCTION LEVEL IND: Reflects an EDI participation status for a

specific transaction. It indicates whether the transaction being sent is
being targeted to a receivers "production" or "test" system. Transactions
performed while under "parallel" status should have the "test" indicator set.
TECHNICAL NOTE: This flag is set at the transmission (batch) header
level in the HD1. Therefore, all transactions with a batch must be at the
same production level.
IMPLEMENTATION DATE FROM/THRU: These are the effective dates of

the production level indicator for a trading partner.
REPORT TRIGGER CRITERIA: This is a list of events that trigger a

specific report and cause it to be submitted. If there are multiple events for
a given MTC, then each event must be listed separately.
REPORT TRIGGER VALUE: A value that is used to modify or define a

Report Trigger Criteria.
SECTION 3
PERIODIC QUALIFIER: These are code values that describe the types of
claims that are required to be reported periodically (e.g. open claims,
closed claims). NOTE: See periodic Qualifier Code Table appendix to
system dictionary.
REPORT LIMIT NUMBER: When present, this value reflects the

maximum number of periodic reports required.
REPORT REQUIREMENT CRITERIA: The criteria that defines the claim

event date. This will be compared to the effective form and thru dates.
This reflects statutory requirements that affect report submission.
EFFECTIVE DATE FROM: The first date that a claim meeting the Report
Requirement Criteria will be reported for a specific report trigger.
EFFECTIVE DATE THRU: The last date that a claim meeting the Report
Requirement Criteria will e reported for a specific report trigger.
REPORT DUE CRITERIA: The criteria that determine the latest date that
a report must be completed and submitted for a specific trigger to be
considered timely.
REPORT DUE VALUE: A value that is used to modify or define a Report

Due Criteria.
FOLLOW UP FORM: The hard copy Form, or Form number, that is

required to be sent out at the time of an EDI transaction is submitted.
RECEIVER: A code (From a valid code list) to identify the receiver of the
Form/Pamphlet being sent.
SECTION 3
ELEMENT REQUIREMENT TABLE

USAGE INSTRUCTIONS
This table was designed to provide a tool to communicate a Receiver's business

data element requirements for each of its trading partners. This allows for
element requirements to be defined to a Transaction Set ID and down to the level
of each Maintenance Type Code. Further, it provides for element requirements to
differ based on Report Requirement Criteria established on the Event Table.
NOTE: This table should be completed after the Event Table as it relates to
events described on that table.
The data element numbers and element descriptions are listed down the left
column while the Maintenance Type Codes are listed across the top of the table.
On each coordinate, the receiver should note the requirement for each element:
M - Element is mandatory
C - Element is mandatory when certain conditions exist (receiver will need to
specify the condition(s))
O - Element is optional
R - Restricted, receiver does not accept this element.
SECTION 3
SECTION 3
EDIT MATRIX
USAGE INSTRUCTIONS
The Edit Matrix is designed to convey which data elements have edits applied to
them and to provide standard error messages to use in association with these
edits. Error messages are communicated in the Acknowledgment records in the
Form of data element number and error message. NOTE: All error messages
and data element numbers must be assigned by the EDI Systems group to
ensure standardization across jurisdictions.
Those elements with ‘X’ on the coordinate are suggested or recommended edits.
Trading Partners should review these recommendations and may want to
include/exclude edits, as they feel appropriate, within the framework of the
matrix.
The Edit Matrix includes all transaction set edits established by the IAIABC EDI
Development committee.
The data element numbers and element descriptions are listed down the left
column while the error message numbers and associated text are listed across
the top of the table.
Some trading partners have found it useful to establish an additional table that
contains more specific, data element-related, and error messages. This can be
useful, especially for error messages that are more generic. Once they are tied to
a data element, they can be made more specific and reduce the need for follow-
up phone calls from receivers.
SECTION 3
SECTION 3
CLAIM ADMINISTRATOR PROCESSING
2.1 RETRIEVE INCOMING DATA
2.1.1 SCHEDULE RECEIVE PROCESS
Using the Transmission Profile - Receiver's Options, the receiver identifies

frequencies to the communications system. This process accommodates
automated scheduling of the receive process.
2.1.2 CONNECT/RECEIVE
All communications processes are executed to receive data from the identified
Electronic Mailboxes and/or the Direct Connect listed on the Receiver's Options.
Both X12 and IAIABC flat files are received during this process. The X12 files
are routed to the Translate (2.1.3) process and the flat file data is either held
pending processing of the X12 files or immediately passed to the next process.
2.1.3 TRANSLATE X12 FILE
This process can be implemented in many different ways depending on whether

the receiver is using commercial translation software or has built a translator
internally.
Processes that may take place during translation are:
Verify trading partner relationship

Convert file from variable to fixed length removing delimiters
Syntactical error checking for X12 compliance
Generation of 997 Functional Acknowledgment
2.1.4 MAP TRANSLATED FILE
The mapping process converts the X12 data to transactions to be processed

(e.g. IAIABC flat file). This process assumes that the X12 transmission is
mapped to the IAIABC flat file. Mapping to a flat file allows the application
interface to process a single file type.
2.2 PROCESS BATCHES
2.2.1 VALIDATE HEADER RECORD (HD1)
Each transmission batch contains a header record (HD1), transaction record(s)

and a trailer record (TR1). Begin the processing of a transmission batch by
validating the header. The header record is used to identify the trading partner
transmitting the transmission batch, the receiver, the interchange version ID, the
date and time the transmission was sent, and the test/production indicator.
SECTION 3
The transmission profile, element requirements table and the edit matrix are used
to edit the data elements in the header record. Any errors in these data elements
would create edit errors that would cause the transmission batch to be rejected at
the header level. The audit file is used to determine a duplicate transmission
batch. Header rejects and duplicate transmissions are acknowledged with one
AK1 transaction containing Record Sequence Number 0000.
The first step in this process is to validate the sender ID. If the sender ID is
invalid, manual verification of trading partner tables and/or communications will
be required. No further processing of this transmission batch will be done.
The next step in this process is to perform edits on the remaining HD1 data
elements and to check for a duplicate transmission batch. A transmission batch
is considered to be a duplicate when the combination of sender ID, date
transmission sent, time transmission sent and interchange version ID already
exist in the audit file.
If a transmission batch is rejected at the header level, a new record is posted to

the audit file with a batch processing status of rejected, an appended AK1-
outbound is written. The individual transactions within the batch are not
processed. The process continues with the next transmission batch.
If a transmission batch is accepted, a new record is posted to the audit file and
the process continues to validate detail records. The audit ID number should be
a unique sequential number assigned by the receiver.
2.2.2 VALIDATE BATCH INTEGRITY
Examine detail transaction records checking to ensure that each contains a

transaction set ID that corresponds to the transmission type code indicated within
the interchange version ID of the HD1. If a transaction within the batch does not
match the HD1 transaction type code, the entire batch will be rejected, the batch
processing status in the audit record will be set to rejected, and an appended
AK1-outbound is written. This will be indicated by a "HD" in the application
acknowledgment code, 'all zeros' in the record sequence number, '0105' in the
element number and '064' in the element error number. Processing of that batch
will cease and will resume with the next HD1 record. The entire transmission
batch will not be processed. The process continues with the next transmission
batch.
As each transaction within a batch is processed, the receiver must assign a

record sequence number to uniquely identify each transaction and maintain the
order in which it was received. The record sequence number, along with the
audit ID number, will be appended to each transaction. The record sequence
number is reset for each batch.
SECTION 3
2.2.3 VALIDATE TRAILER RECORD (TR1)
The trailer record contains the count of the number of detail records within a
transmission batch. The trailer record detail record count for the transmission
batch is edited to make sure the number of transactions is the same as the detail
record count in the trailer. The edit matrix table is read to apply the edits to the
trailer record. If the trailer record is accepted, meaning it passed the edits, the
audit file is updated with the number of records in the transmission. If the trailer
record is rejected, the transmission batch is rejected, the batch processing status
in the audit record will be set to rejected, and an appended AK1-outbound is
written.
2.2.4 BUILD APPENDED TRANSACTIONS
Append the Audit ID number to each incoming injury transaction. This can be
used to associate detail transactions with their corresponding header record
information.
2.3 PROCESS ACKNOWLEDGMENT TRANSACTIONS
2.3.1 RECONCILE EDI ACTIVITY LOG
Each time a transmission is sent to a trading partner, the sender will retain
information about each transaction in the EDI Activity Log. The EDI Activity Log
uniquely identifies each transaction.
As appended acknowledgment transactions are processed, Audit File entries are

reconciled with the EDI Activity Log. The Audit record is created from the injury
batch's HD1 (Header) information in 2.2.1 (Validate Header Record). As the
appended acknowledgment transactions are matched, AK1 data is added to the
EDI Activity Log: EDI status, date acknowledgment transmission sent, processed
and received. The reconciled acknowledgments will then serve as input into
2.3.2 (Interpret Acknowledgment Transactions).
Any acknowledgment transactions not reconciled will be used to create the

Reconciliation Error Report and manual intervention will be required.
2.3.2 INTERPRET ACKNOWLEDGMENT TRANSACTIONS
Reconciled acknowledgment transactions have an Application Acknowledgment

Code (status). The action needed will depend on the code:
Transmission Rejected: This means that every record in the transmission batch
(header record + detail records + trailer record) was rejected. The reason for the
batch rejection will be contained in the error code segment of the
acknowledgment transaction. The sender will determine the cause of the
rejection and respond appropriately.
SECTION 3
Transaction Accepted with no errors (TA): There will be information contained in

the acknowledgment transactions which will need to be conveyed (e.g., Agency
Claim Number).
Transaction Rejected (TR): The reason for the rejection is contained in the Error
Code segment(s) of the AK1. The element number and element error number
will need to be compared to the Edit Matrix in order to determine the reason for
the rejection.
Transaction Accepted with Errors (TE): The element number and element error
number will need to be compared to the Edit Matrix in order to determine the
reasons for the error. Once the error has been fixed, appropriate action should
be taken by the sender (e.g., A correction transaction ("CO") or the next
transaction due will be sent to correct the error).
2.4 PROCESS INJURY TRANSACTIONS
2.4.1 SORT INCOMING TRANSACTIONS
Incoming transactions may be sorted for more efficiency during the edit process
and to run in the MTC sequence required by the receiver.
2.4.2 EDIT INCOMING INJURY TRANSACTIONS
Each data element in a transaction is edited according to the edit matrix and
element requirement table. The element requirement table specifies whether the
element is mandatory, conditional or optional for the corresponding transaction
set ID and maintenance type code. The edit matrix is used to determine which
edits to apply to each data element.
Mandatory data elements with edit errors will cause the transaction to be
rejected. A conditional data element is treated as optional until trading partner
specific conditions are met, at which time it may be treated as mandatory.
Optional data elements with edit errors will allow the transaction to be accepted
with errors and will not be loaded to the database.
Transmission Profile
Access by using Trading Partner ID. Verify that media and format specified in
the profile match with actual media and format.
Event Table
Access using Trading Partner ID, Transaction Set ID and MTC. Verify that
trigger and due date criteria are met.
SECTION 3
Element Requirement Table
Access by using Transaction Set ID and MTC. Retrieve requirement codes for
the transaction, to be used in conjunction with the Edit matrix.
Payment Adjustment Element Requirement Table
This table is used for SROI, to access the Payment Adjustment Code. Retrieve
requirement codes for the transaction, to be used in conjunction with the Edit
Matrix.
Edit Matrix
The cells marked on the edit matrix represent the minimum edits to be applied.
The receiver may perform additional edits to those indicated as long as a
standard element error code is returned to the sender. Any issue with a
mandatory field will cause rejection of the transaction.
All fields must be edited so that all possible errors are returned in the appended
AK1-out. Optional fields with errors are reset to blanks or zeros. Edited
Incoming Transactions will be used to update the Receiver Computer System.
2.4.3 CREATE EDI TRANSACTIONS
2.4.3.1 COMPARE EVENT TABLE
Internal System
Identify updates made since the last transmission. These updates will be
analyzed against the Event Table. Update the Internal Application as needed to
indicate the last update has been EDI processed.
Event Table
Compare updates from the Internal Application to determine whether a new EDI
transaction must be initiated. Compare against the EDI Activity Log to verify
sequence of filing.
EDI Activity Log
Analyze transactions already sent to verify that any potential new transaction is
appropriate.
SECTION 3
2.4.3.2 EXAMINE ELEMENT REQUIREMENT TABLE
Access by using the Trading Partner ID, Transaction Set ID and Maintenance
Type Code. Retrieve Requirement Codes for the transaction, to be used in
conjunction with the Edit Matrix.
Used for SROI, access using the Payment Adjustment Code. Retrieve
Requirement Codes for the transaction, to be used in conjunction with the Edit
Matrix.
2.4.3.3 EDIT TRANSACTIONS
Edit Matrix
Apply edits to each element according to the matrix. Any issue will cause the
transaction to be written to the Application Data Errors file. All elements must be
edited so that all possible errors are communicated to resolution.
Valid Code Table
Used during the edits process. Access by data element number and code value
to verify that a value is valid. Some validation tables will be Trading Partner
specific.
Transactions with no errors are written to the EDI Transaction file.
2.4.4 BUILD EDI BATCH
Obtain detail records from the appended AK1-out and EDI Transaction files. Add
header and trailer records for each batch and write to AK1-out and EDI Injury
Batch. FROI and SROI should be included in separate batches, one batch for
each report type.
Create a new entry in the EDI Activity Log for each transaction included with an
EDI Injury Batch.
2.5 RECONCILE 997-INBOUND
The 997 Functional Acknowledgment can be used to determine several business

issues.
The 997 should be inspected for syntactical errors in the X12 transmission being
functionally acknowledged.
SECTION 3
The 997 can be matched to the appropriate outbound X12 to confirm that the
original transmission was received. This will allow you to identify transmissions
that have not been functionally acknowledged.
2.6 SEND FILES
2.6.1 MAP/TRANSLATE OUTBOUND FILE
The mapping process converts the IAIABC flat file to X12 data.
The translation process can be implemented in many different ways depending

on whether the receiver is using commercial translation software or have built a
translator internally.

2.6.2 CONNECT/SEND
All communications processes are executed to send data to the identified

Both X12 and IAIABC flat files are sent during this process.
SECTION 3
SECTION 3
JURISDICTION PROCESS
3.1 RETRIEVE INCOMING DATA
3.1.1 SCHEDULE RECEIVE PROCESS
Using the Transmission Profile - Receiver's Options, the receiver identifies

frequencies to the communications system. This process accommodates
automated scheduling of the receive process.
3.1.2 CONNECT/RECEIVE
All communications processes are executed to receive data from the identified
Electronic Mailboxes and/or the Direct Connect Listed on the Receiver's Options.
Both X12 and IAIABC flat files are received during this process. The X12 files
are routed to the Translate (3.1.3) process and the flat file data is either held
pending processing of the X12 files or immediately passed to the next process.
3.1.3 TRANSLATE X12 FILE
This process can be implemented in many different ways depending on whether

the receiver is using commercial translation software or has built a translator
internally.

Convert file from variable to fixed length removing delimiters
Generation of 997 Functional Acknowledgment
3.1.4 MAP TRANSLATED FILE
The mapping process converts the X12 data to transactions to be processed

(e.g. IAIABC flat file). This process assumes that the X12 transmission is
mapped to the IAIABC flat file. Mapping to a flat file allows the application
interface to process a single file type.
3.2 PROCESS BATCHES
3.2.1 VALIDATE HEADER RECORD (HD1)
Each transmission batch contains a header record (HD1), transaction record(s)

and a trailer record (TR1). Begin the processing of a transmission batch by
validating the header. The header record is used to identify the trading partner
transmitting the transmission batch, the receiver, the interchange version ID, the
date and time the transmission was sent, and the test/production indicator.
SECTION 3
The transmission profile, element requirements table and the edit matrix are used
to edit the data elements in the header record. Any errors in these data elements
would create edit errors which would cause the transmission batch to be rejected
at the header level. The audit file is used to determine a duplicate transmission
batch. Header rejects and duplicate transmissions are acknowledged with one
AK1 transaction containing Record Sequence Number 0000.
The first step in this process is to validate the sender ID. If the sender ID is
invalid, manual verification of trading partner tables and/or communications will
be required. No further processing of this transmission batch will be done.
The next step in this process is to perform edits on the remaining HD1 data
elements and to check for a duplicate transmission batch. A transmission batch
is considered to be a duplicate when the combination of sender ID, date
transmission sent, time transmission sent and interchange version ID already
exist in the audit file.
If a transmission batch is rejected at the header level, a new record is posted to

the audit file with a batch processing status of rejected, an appended AK1-
outbound is written. The individual transactions within the batch are not
processed. The process continues with the next transmission batch.
If a transmission batch is accepted, a new record is posted to the audit file and
the process continues to validate detail records. The audit ID number should be
a unique sequential number assigned by the receiver.
3.2.2 VALIDATE BATCH INTEGRITY
Examine detail transaction records checking to ensure that each contains a

transaction set ID that corresponds to the transmission type code indicated within
the interchange version ID of the HD1. If a transaction within the batch does not
match the HD1 transaction type code, the entire batch will be rejected, the batch
processing status in the audit record will be set to rejected, and an appended
AK1-outbound is written. This will be indicated by a 'HD' in the application
acknowledgment code, 'all zeros' in the record sequence number, '0105' in the
element number and '064' in the element error number. Processing of that batch
will cease and will resume with the next HD1 records. The entire transmission
batch will not be processed. The process continues with the next transmission
batch.
As each transaction within a batch is processed, the receiver must assign a

record sequence number to uniquely identify each transaction and maintain the
order in which it was received. The record sequence number, along with the
audit ID number, will be appended to each transaction. The record sequence
number is reset for each batch.
SECTION 3
3.2.3 VALIDATE TRAILER RECORDS (TR1)
The trailer record contains the count of the number of detail records within a
transmission batch. The trailer record detail record count for the transmission
batch is edited to make sure the number of transactions is the same as the detail
record count in the trailer. The edit matrix table is read to apply the edits to the
trailer record. If the trailer record is accepted, meaning it passed the edits, the
audit file is updated with the number of records in the transmission. If the trailer
record is rejected, the transmission batch is rejected, the batch processing status
in the audit record will be set to rejected, and an appended AK1-outbound is
written.
3.2.4 BUILD APPENDED TRANSACTIONS
Append the Audit ID number to each incoming injury transaction. This can be
used to associate detail transactions with their corresponding header record
information.
3.3 PROCESS INJURY TRANSACTIONS
3.3.1 SORT APPENDED INCOMING INJURY TRANSACTIONS
Incoming transactions may be sorted for more efficiency during the edit process
and to run in the MTC sequence required by the Receiver.
3.3.2 EDIT INCOMING INJURY TRANSACTIONS
Each data element in a transaction is edited according to the edit matrix and
element requirement table. The element requirement table specifies whether the
element is mandatory, conditional or optional for the corresponding transaction
set ID and maintenance type code. The edit matrix is used to determine which
edits to apply to each data element.
Mandatory data elements with edit errors will cause the transaction to be
rejected. A conditional data element is treated as optional until trading partner
specific conditions are met, at which time it may be treated as mandatory.
Optional data elements with edit errors will allow the transaction to be accepted
with errors and will not be loaded to the database.
Transmission Profile
Access by using Trading Partner ID. Verify that media and format specified in
the profile match with actual media and format.
Event Table
Access using Trading Partner ID, Transaction set ID and MTC. Verify that trigger
and due date criteria are met.
SECTION 3
Access by using Transaction Set ID and MTC. Retrieve requirement codes for
the transaction, to be used in conjunction with the Edit Matrix.
This table is used for SROI, to access the Payment Adjustment Code. Retrieve
requirement codes for the transaction, to be used in conjunction with the Edit
Matrix.
Edit Matrix
The cells marked on the edit matrix represent the minimum edits to be applied.
The receiver may perform additional edits to those indicated as long as a
standard element error code is returned to the sender. Any issue with a
mandatory field will cause rejection of the transaction.
All fields must be edited so that all possible errors are returned in the appended
AK1-out. Optional fields with errors are reset to blanks or zeros. Edited
Incoming Transactions will be used to update the Receiver Computer System.
3.3.3 BUILD EDI BATCH
Obtain detail records from the appended AK1-out and EDI Transaction files. Add
header and trailer records for each batch and write to AK1-out and EDI Injury
Batch. FROI and SROI should be included in separate batches, one batch for
each report type.
3.4 RECONCILE 997-INBOUND
The 997 Functional Acknowledgment can be used to determine several business

issues.
The 997 should be inspected for syntactical errors in the X12 transmission being
functionally acknowledged.
The 997 can be matched to the appropriate outbound X12 to confirm that the
original transmission was received. This will allow you to identify transmissions
that have not been functionally acknowledged.
3.5 SEND FILES
3.5.1 MAP/TRANSLATE OUTBOUND FILE
The mapping process converts the IAIABC flat file to X12 data.
SECTION 3
The translation process can be implemented in many different ways depending

on whether the receiver is using the commercial translation software or have built
a translator internally.

3.5.2 CONNECT/SEND
All communications processes are executed to send data to the identified

Both X12 and IAIABC flat files are sent during this process.
SECTION 3
SECTION 3
Process Model
Record Layouts
AUDIT RECORD
HD1 Received
Audit ID #: Receiver assigned sequential unique number
Batch Received DATE
Batch Received TIME
Batch Processing Status: Accepted/Rejected
Acknowledgment Mode: Electronic/Paper/Both/None
Acknowledgment Format: X12/Flat File
Acknowledgment Media: VAN/Direct Connect/etc.
Acknowledgment DATE
Acknowledgment TIME
Number of Transactions Received
Number of Transactions Accepted (TA)
Number of Transactions Accepted with Errors (TE)
Number of Transactions Rejected (TR)
AK1-IN
AK1
Audit ID #
AK1-OUT
AK1
Audit ID #
EDI ACTIVITY LOG
Claim Administrator Claim Number

MTC
Record Sequence Number
EDI Status
Transaction Set ID
Original Date Sent
Original Time Sent
SECTION 3
SECTION 3
EDI ACTIVITY LOG RECONCILIATION

148 ERROR REPORT
FLAT FILE BATCHES
824
997
FROI TRANSMISSION PROFILE
2.1
ANSI BATCHES SROI
RETRIEVE EDIT MATRIX
AK1 FROI
INCOMING
SROI 2.3
DATA
FLAT FILE BATCHES AKI PROCESS
ACKNOWLEDGEMENT
FROI APPENDED TRANSACTIONS
SROI AK1 TRANSACTION
2.2
AK1 PROCESS
ELEM REQ TABLE
BATCHES
NETWORK FUNCTIONAL
FREQUENCY AK1
997-OUT AUDIT FILE
ERROR MSG
DATA ELEMENT
FUNCTIONAL
TRANSMISSION PROFILE 997-IN
997-OUTBOUND
INJURY TRANSACTION
Internal
System
HD1 ERROR FILE
2.5
RECONCILE
FUNCTIONAL
997-INBOUND HEADER REJECT 2.4
PROCESS
INJURY
TRANSACTIONS
EMPLOYER ACK
BATCH
INJURY BATCH
2.6
SEND
FILES
IAIABC First Report and Subsequent Report of Injury (c) Release 1 3-37 February 15, 2002
SECTION 3
TRANSMISSION PROFILE
NETWORK
FREQUENCY 2.1.3
TRANSLATE FUNCTIONAL
997 FUNCTIONAL
ANSI
OUT 997-OUT
FILE
2.1.1
SCHEDULE ANSI 148
RECEIVE ANSI 824
PROCESS
ANSI FIXED LENGTH ANSI

FILE(S)
ANSI 148
ANSI 824
ANSI 148 2.1.4

ANSI DATA
ANSI 824 2.1.2 MAP
FROM MAILBOX
ANSI 997 CONNECT/RECEIVE TRANSLATED
FILE
ANSI 997 FROI FROI

IN SROI SROI
FROI AK1 AK1
SROI
997-INBOUND AK1
FLAT FILE(S)
FLATFILE DATA
FROM MAILBOX
SECTION 3
XMISSION PROFILE
EDIT MATRIX
SENDER FEIN POSTAL CODE FLATFILE
XMISSION TYPE CODE
REL #
T-P INDICATOR
FLATFILE BATCH
2.2.2
VALIDATE
ELEMENT REQ FLATFILE BATCH
HD1 2.2.1
BATCH INTEGRITY FLATFILE 2.2.3
ELEMENTS VALIDATE
BATCH VALIDATE
HEADER
TRAILER
RECORD
RECORD
BATCH PROCESSING STATUS

HD1 HD1 BATCH PROCESSING STATUS
ELEMENTS AUDIT INFO
RECORD
EDIT MATRIX
AUDIT FILE APPENDED

AK1
FLA FILE BATCH
OUTBOUND
AUDIT ID #
APPENDED AK1 OUTBOUND
HD1
RECEPTION DATE
NBR RECORDS
APPENDED-AK1
2.2.4 INBOUND
APPENDED AK1
BUILD
INBOUND
APPENDED
TRANSACTIONS
APPENDED FROI
APPENDED AK1 OUTBOUND APPENDED SROI
INJ TRANS
SECTION 3
RECONCILIATION EDIT MATRIX

ERROR REPORT
AUDIT FILE
ERROR MSG
ORG TRANS DATE DATA ELEMENT
AK1
ORG TRANS TIME
DATE TRANS SENT
2.3.1 2.3.2
RECONCILE INTERPRET
AK1 RECONCILED ACK AK1
EDI ACKNOWLEDGEMENT
TRANSACTION
ACTIVITY TRANSACTIONS
LOG
APPENDED AK1 APPENDED AK1

TRANSACTION EDI STATUS
DATE ORG TRANSMISSION SENT DATE ACK TRANSMISSION SENT AK1
TIME ORG TRANSMISSION SENT DATE PROCESSED ERROR MSG
RECORD SEQUENCE NBR DATE RECEIVED DATA ELEMENT
AGENCY CLAIM NBR
EDI ACTIVITY LOG
Internal
System
SECTION 3
PAY ADJ ELEM REQ

ELEM REQ TABLE TABLE
EVENT TABLE PAYMENT ADJ CODE
ELEMENTS REQUIRED
MTC RPT REQ BEGIN DATE
T/P MTC
TRANS SET ID RPT REQ END DATE
IND
ELEMENTS REQUIRED
RPT REQ BEGIN DATE EDIT MATRIX
FROI BATCH SROI BATCH RPT REQ END DATE
DATA NBR
ERROR MSG NBR
IA-1
SORTED 2.4.2
2.4.1 EDIT EDITED
FROI
SORT INCOMING INCOMING
INCOMING INJURY TRANSACTIONS
TRANSACTIONS TRANSACTIONS
SORTED
SROI
EXISTING
CLAIMS DATA
TP ID
Claim Admin
Legacy
APPENDED AK1 OUTBOUND TRANSMISSION PROFILE
EDI ACTIVITY LOG System
APPENDED AK1 OUTBOUND ELEM REQ TABLE
AUDIT FILE
CA CLAIM #
MTC
PAY ADJ ELEM REQ INJURY DATA
RECORD SEQUENCE #
2.4.4 TABLE
EDI STATUS AUDIT ID # EDI ACTIVITY LOG
TRANSACTION SET ID BUILD
ORIGINAL DATE SENT
ORIGINAL DATE SENT EDI
ORIGINAL TIME SENT
ORIGINAL TIME SENT BATCH
2.4.3 EDI HISTORY
CREATE
EDI TRANSACTION FROI EDI
SROI TRANSACTIONS
AK1 OUT BATCH INJURY BATCH
AK1 OUT BATCH INJURY BATCH EVENT TABLE EDIT MATRIX
SECTION 3
EDIT MATRIX
EVENT TABLE
ALL ELEMENTS
APPLICATION DATA ERRORS

ALL ELEMENTS
2.4.3.3
EDIT
TRANSACTIONS
CLAIM ADM CLAIM # 2.4.3.1

MAINTENANCE TYPE CODE COMPARE
EDI ACTIVITY LOG EDI STATUS EVENT
DATE TRANSMISSION SENT TABLE
TRANSACTION SET ID
FROI
SROI
TRANSACTION SET ID
MAINTENANCE TYPE CODE
TP ID REPORT DUE CRITERIA
RPT TRIGGER CRITERIA REPORT DUE VALUE
RPT REQMNT CRITERIA TEST/PROD INDICATOR VALID CODE TABLE EDI INJURY TRANSACTION
Internal EXISTING 2.4.3.2

CLAIMS EXAMINE
System DATA ELEMENT REQ
TABLE
ALL ELEMENTS ALL ELEMENTS
ELEMENT REQ TABLE PAYMENT ADJ

ELEMENT REQ TABLE
SECTION 3
997-OUTBOUND
FLATFILES
EMPLOYER ACKNOWLEDGEMENT BATCH

INJURY BATCH Text
2.6.2
Text
CONNECT/SEND
2.6.1
MAP/TRANSLATE
OUTBOUND
FILES
148
824 EMPLOYER ACKNOWLEDGEMENT BATCH
INJURY BATCH
148
824
FLATFILE DATA
X12 FILE(S) TO MAILBOX
SECTION 3
FLATFILE BATCHES
148 FROI EDIT MATRIX
997-IN SROI
3.1 FROI
ANSI BATCHES RETRIEVE SROI
INCOMING
DATA
FLATFILE BATCHES
FROI 3.2
SROI ELEM REQ TABLE PROCESS AUDIT FILE
BATCHES
NETWORK FUNCTIONAL
FREQUENCY 997 OUT
FUNCTIONAL
TRANSMISSION PROFILE 997-IN
997-OUTBOUND
INJURY TRANSACTION
Internal
System
3.4
RECONCILE
FUNCTIONAL
AK1 OUTBOUND 3.3
997-INBOUND APPENDED AK1 PROCESS
OUTBOUND INJURY
TRANSACTIONS
INJURY BATCH
3.5
SEND
FILES
SECTION 3
NETWORK 3.1.3
FREQUENCY TRANSLATE FUNCTIONAL
ANSI 997 FUNCTIONAL
FILE OUT 997-OUT
3.1.1
SCHEDULE
RECEIVE ANSI 148
PROCESS
FIXED LENGTH ANSI
DOWNLOADED
ANSI BATCHES
3.1.4
ANSI 148 MAP
TRANSLATED
FILE
ANSI 148 3.1.2

ANSI BATCHES
ANSI 997 CONNECT/RECEIVE
ANSI 997 FROI

FROI
IN SROI
SROI
FROI
SROI
997-INBOUND
DOWNLOADED
FLATFILE
BATCHES
FLATFILE
BATCHES
SECTION 3
FLATFILE
XMISSION PROFILE EDIT MATRIX
SNDR FEIN & POSTAL CODE

XMISSION TYPE CODE FLATFILE BATCH
REL #
T/P INDICATOR
3.2.2
VALIDATE
BATCH
ELEMENT REQ INTEGRITY
FLATEFILE BATCH
HD1 ELEMENTS
FLATFILE BATCH
3.2.1 3.2.3
VALIDATE VALIDATE
HEADER TRAILER
RECORD RECORD
HD1 INFO
AUDIT
HD1 ELEMENTS RECORD
AUDIT FILE APPENDED
AK1
FLATFILE BATCH OUTBOUND
EDIT MATRIX
AUDIT ID #
HD1
APPENDED AK1 OUTBOUND RECEPTION DATE
NBR RECORDS
3.2.4
BUILD
APPENDED
TRANSACTIONS APPENDED FROI
APPENDED SROI

INJ TRANS
SECTION 3
PAY ADJ ELE REQ

ELEM REQ TABLE TABLE
PAYMENT ADJ CODE Paper

EVENT TABLE ELEMENTS REQUIRED Form
MTC RPT REQ BEGIN DATE
TRANS SET ID RPT REQ END DATE
ELEMENTS REQUIRED EDIT MATRIX
MTC
T/P IND RPT REQ BEGIN DATE
RPT REQ END DATE
DATA NBR
ERROR MSG NBR
EDITED
INCOMING
TRANSACTIONS
3.3.2
FROI BATCH SROI BATCH EDIT
INCOMING EXISTING
INJURY CLAIMS DATA
Internal
SORTED
FROI TRANSACTIONS System
SORTED
SROI TP ID
3.3.1 APPENDED AK1 OUTBOUND
SORT
APPENDED
INCOMING
TRANSMISSION
INJURY
APPENDED AK1 OUTBOUND PROFILE
TRANSACTIONS

AUDIT FILE
3.3.3
BUILD AUDIT ID #
EDI ORIGINAL DATE SENT
BATCH ORIGINAL TIME SENT
AK1 OUT BATCH

EDI TRANSACTION
AK1 OUT BATCH
SECTION 3
FLATFILES 997-OUTBOUND
OUTBOUND ACKNOWLEDGEMENT BATCH

Text
Text3.5.2
CONNECT/SEND
3.5.1
MAP/TRANSLATE
OUTBOUND
FILE
824
OUTBOUND ACKNOWLEDGEMENT BATCH
824
FLATFILE DATA TO
MAILBOX
X12 FILE(S)
SECTION 3
Electronic Data Interchange Partnering Agreement
This is an agreement between the parties named below to use Electronic Data Interchange (EDI)
technologies and techniques for the purpose(s) and objective(s) set out below or as amended from time
to time in writing by mutual agreement and such further purposes and objectives as the parties may agree
in writing from time to time with reference to this Agreement.
1. Parties. The parties to this agreement are: State of ________________________________ (State Name)
Workers' Compensation Commission (hereafter WCC); and ______________________________________
(Partner – Insurer, Third Party Administrator, etc.) and all other Companies within the (Company) authorized
to write WC insurance or provide insurance related services (hereafter Reporter.)
2. Purpose. Reporter is either required to file or may be allowed by law or regulation to file for itself or on
behalf of customers or clients a First Report of Injury or Illness and Subsequent Reports to the (State Name)
Workers' Compensation Commission. The Objective is to initiate, implement and maintain First Reports and
Subsequent Reports through electronic filing.
3. Both agree that the Objective is lawful and performance hereunder shall be deemed complete p erformance
of the parties obligations under any law or regulation governing the Objective. This document shall be
deemed to fulfill any requirement on the part of the Reporter to apply to WCC or any related governmental
entity for permission to file information electronically.
4. Exhibit A which is annexed and incorporated in this Agreement sets forth the following mutually agreed
elements of the arrangement between the parties:
A. The schedule, form, including data element definitions, and format of data transmissions
from the Reporter, including original submissions and corrections or re-submissions as
needed (data transmissions).
B. The test and implementation plan and schedule under which the parties will prepare to
send and receive data from each other.
C. The schedule, form, including data element definitions, and format of data transmissions
from the WCC, including acknowledgments, notices of error or notices of acceptance as
applicable (data transmissions).
D. The Value Added Network (VAN) or other data transmission method that will be used to
transmit and receive data transmissions.
E. The allocation of data transmission costs between the parties.
5. Each party shall retain the content of data transmissions in confidence to the extent required by law.
Agreed this ____ (Write out date) day of _______________(Write out Month), ______(Numerical Year) for the
parties by their duly authorized or lawfully empowered representatives.
(signature) (signature)
(name) (name)
(title) (title)
(REPORTER) (WCC)
SECTION 3
State Of (State Name)

Workers' Compensation Commission
Exhibit A
A.1. Reporter and WCC agree to use the American National Standards Institute X12N Standards
established by the International Association of Industrial Accident Boards and Commissions,
where applicable, or the flat file equivalent.
B.1. The Project will commence upon the transmission of the version of the First Report of Injury
defined per paragraph C3 below on _(Date)____. During the testing phase, the Reporter will be
required to file paper forms in addition to the electronic transmission of records. Once testing
requirements are met, the Reporter will no longer be required to file paper forms. If the Reporter's
customers are required to file a paper copy of the First Report, the WCC agrees to waive the
requirement for all reports made to the WCC by the Reporter on behalf of its customers.
B.2. The parties will perform a test of the reporting system. The test will determine whether the
transmission mechanism is acceptable. Acceptance will occur when the parties agree that 90% of
all electronic first reports (a) meet or pass all technical requirements; and (b) match or are more
accurate than the paper forms filed for a period of 4 consecutive weeks. The term of the test will
not exceed 90 days unless an extension is agreed to between the parties.
C.1. The format of data elements and definitions will conform to the International Association of
Industrial Accident Boards and Commissions (I.A.I.A.B.C.) Release 1 data dictionary as it is today
and as amended from time to time and approved by the I.A.I.A.B.C.'s EDI Working Group, and
EDI Council or as otherwise agreed between the parties in writing.
C.2. The transmission of data will occur on (Day of Week ) of each week from the Reporter or as
otherwise agreed, and will be received by the WCC within the following business week.
C.3. The data elements for the First and Subsequent Reports and their priority are found on the
attached trading partner table. (Attachment 1) Additional tables for other reports and forms can
become part of this agreement by mutual agreement between the parties.
C.4 Any error in transmission will be timely identified by the WCC, but not greater than five (5)
business days.
D.1. Transmissions will be accomplished via a Value Added Network or File Transfer Protocol (FTP)
as agreed between the parties from time to time.
E.1. The Reporter shall pay transmission costs for all reports being sent to the WCC. WCC shall bear
the costs of any transmission to the Reporter.
SECTION 3
MASTER
TRADING PARTNER PROFILE
TRADING PARTNER TYPE:
__ Jurisdiction __ Claims Administrator

__ Service Bureau __ Other (specify):
__ Employer
Name:
Master FEIN:
Phy Address:
City:
State: Postal Code: -
Mail Address:
City:
State: Postal Code: -
CONTACT INFORMATION:
Business Contact: Technical Contact:
Name: Name:
Title: Title:
Phone: Phone:
FAX: FAX:
Email Information: Email Information:
Network: Network:
ID: ID:
Network Network:
ID: ID:
Network: Network:
ID ID:
SECTION 3
SECTION 3
TRANSMISSION PROFILE -- RECEIVER'S SPECIFICATIONS

RECEIVER NAME: DATE:
TRADING PARTNER TYPE: __ Jurisdiction __ Claims Admin __ Employer __ Service Bureau __ Other
RECEIVER IDENTIFIER: Receiver FEIN: Receiver Postal Code
PROFILE ID: DESCRIPTION:
TRANSACTION SETS FOR THIS PROFILE:
TRANSACTION INFORMATION ACKNOWLEDGMENT INFORMATION

Transaction Flat File ANSI Mode Production Level
IAIABC/ANSI Release Version (EDI/Paper/None) Response Period (All/ Err/ Rejects)
148/148
A49/148
POC/271
MED 837
AKI/824
TRANSMISSION FREQUENCIES FOR THIS PROFILE:

Daily __ Weekly __ Bi-Weekly
Semi-Monthly __Monthly __Bi-Monthly
Quarterly __Semi-Annually __Annually __Other
DAY OF WEEK: SUN MON TUE WED THU FRI SAT ALL
DAY OF MONTH: Select Day (1-31): ____
MONTH OF YEAR: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC ALL
TRANSMISSION PAYMENTS: ____Each ____All ____None
Transmission Cut-off Time:
ELECTRONIC MAILBOX(es) FOR THIS PROFILE:
Network: Network:
TEST PROD TEST PROD

Mailbox Acct ID: Mailbox Acct ID:
User ID: User ID:
* Message Class: * Message Class:
* See special note in Trading Partner instructions.
DIRECT CONNECT AVAILABLE:____ NO YES FTP AVAILABLE: ____NO ____YES -- Specifications attached.
FLAT FILE RECORD DELIMITER:
ANSI INFORMATION:
Segment Terminator ISA Information: TEST PROD
Data Elements Separator Sender/Receiver Qualifier
Sub-Element Separator Sender/Receiver ID:
Acknowledge 824 Transmissions? Yes/No
SECTION 3
SECTION 3
TRANSMISSION PROFILE -- SENDER'S RESPONSE

Return this page to:
RECEIVER NAME:
RECEIVER IDENTIFIER: Receiver FEIN: Receiver Postal Code:
PROFILE ID: DESCRIPTION:
SENDER SELECTIONS/INFORMATION:
Name: FEIN:
SENDER NAME:
TRADING PARTNER TYPE: __ Jurisdiction __ Claims Admin __ Employer __ Service Bureau __ Other
SENDER IDENTIFIER: Sender FEIN: Sender Postal Code :
TRANSACTION INFORMATION ACKNOWLEDGMENT INFORMATION

Transaction Release/ Projected Number
IAIABC/ANSI Format Version per Transaction Mode Level
148/148
A49/148
POC/271
MED 837 ANSI
AKI/824
TRANSMISSION FREQUENCY (select only one from Receiver's options):
Daily Weekly -- SUN MON TUE WED THU FRI SAT
Monthly Day (1-31): ____
Quarterly Month(s): JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Day (1-31): ____
Annually Month: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Day (1-31): ____
Other:
SELECTED MEDIA: Electronic Mailbox Direct Connect
ELECTRONIC MAILBOX INFORMATION:
Network:
TEST PROD
Mailbox Acct ID:
User ID:
Message Class:
SECTION 3
SECTION 3
IAIABC Release 1 Systems Event Table

TRANS MTC MTC PROD IMPL. DATE REPORT TRIGGER RPT TRIG PRD REP LMT RPT REQUIREMENT EFFECTIVE DATE REPORT DUE VALUE FOLLOW-UP RECEIVER
SET ID DESCRIPTION LEVEL IND. FROM THRU CRITERIA VALUE QUAL NUM CRITERIA FROM THRU CRITERIA FORM
FROI (148) 00 Original A = New Clm N/A A = Dt of Injury A = Days frm Dt Acc/Inj # Days
B = Cuml Med $ > $$$ B = Dt Disab Began B = Days frm Dt. Disab # Days
C = Lost Time > # days C = Dt Emp. Not. C = Days frm Emp. Not. # Days
D = Cuml Wage Repl > $$$ D = Dt Admin. Not. D = Days from Admin. Not. # Days
E = Days Open # Days E = Dt Juris Not. E = Days frm Juris Not. # Days
F = Formula Fn # F = Date of Initial Payment G = Days frm IP # Days
L = Detrm of Comp Dth L = Detrm of Comp Dth H = Immediate 0 Days
N = Cuml Indemnity $ > $$$ G = Dt of Dth I = Days frm Dt. Of Dth # Days
Q= Employee Death H = Date Report Trigger J = Days frm Rpt Trigger # Days
I = Calendar Date
01 Cancel O = Maintenance Type Event N/A H = Immediate 0 Days

J = Days frm Rpt Trigger # Days
02 Change O = Maintenance Type Event DN = H = Immediate 0 Days

04 Denial O = Maintenance Type Event N/A A = Days frm Dt Acc/Inj # Days

B = Days frm Dt. Disab # Days
C = Days frm Emp. Not. # Days
D = Days from Admin. Not. # Days
E = Days frm Juris Not. # Days
H = Immediate 0 Days
AU Acq/Unallocated O = Maintenance Type Event N/A D = Days from Admin. Not. # Days
CO Correction O = Maintenance Type Event N/A H = Immediate 0 Days

SROI(A49) 02 Change O = Maintenance Type Event DN = H = Immediate 0 Days

04 Denial O = Maintenance Type Event N/A A = Days frm Dt Acc/Inj # Days

4P Partial Denial O = Maintenance Type Event N/A A = Days frm Dt Acc/Inj # Days
AP Acq/Payment O = Maintenance Type Event
SECTION 3

CA Change in Ben Amt O = Maintenance Type Event DN87 H = Immediate 0 Days

CB Change in Ben Type O = Maintenance Type Event DN85 H = Immediate 0 Days

CD Compensable Death- O = Maintenance Type Event C = Days frm Emp. Not. # Days
No Dep/Payees D = Days from Admin. Not. # Days
I = Days frm Dt. Of Dth # Days
CO Correction O = Maintenance Type Event N/A H = Immediate 0 Days

FN Final O = Maintenance Type Event # Days H = Immediate 0 Days

FS Full Salary O = Maintenance Type Event N/A D = Days from Admin. Not. # Days
IP Initial Payment O = Maintenance Type Event > $$$ H = Immediate 0 Days

P1 PSusp-RTRTW O = Maintenance Type Event N/A H = Immediate 0 Days

P2 PSusp-Med Non Cmp O = Maintenance Type Event N/A H = Immediate 0 Days

P3 PSusp-Adm Non Cmp O = Maintenance Type Event N/A H = Immediate 0 Days

P4 PSusp-Dth Non Cmp O = Maintenance Type Event N/A H = Immediate 0 Days

P5 PSusp-Incarceration O = Maintenance Type Event N/A H = Immediate 0 Days

P6 PSusp-Clmt Missing O = Maintenance Type Event N/A H = Immediate 0 Days

P7 PSusp-Bens Exhaust O = Maintenance Type Event N/A H = Immediate 0 Days

P8 PSusp-Juris Change O = Maintenance Type Event N/A H = Immediate 0 Days

P9 PSusp-Setlmnt Aprv O = Maintenance Type Event N/A H = Immediate 0 Days

PJ PSusp-Apl/Jud Rev O = Maintenance Type Event N/A H = Immediate 0 Days

PY Payment Report B = Cuml Med $ > $$$

D = Cuml Wage Repl > $$$
F = Formula Fn #
H = Chg in Elem Value N/A
SECTION 3

N = Cuml Indemnity $ > $$$
RB Reinstmnt of Bens O = Maintenance Type Event N/A H = Immediate 0 Days

RE Reduced Earnings
S1 Susp-RTRTW O = Maintenance Type Event N/A H = Immediate 0 Days

S2 Susp-Med Non Cmp O = Maintenance Type Event N/A H = Immediate 0 Days

S3 Susp-Adm Non Cmp O = Maintenance Type Event N/A H = Immediate 0 Days

S4 Susp-Dth Non Cmp O = Maintenance Type Event N/A H = Immediate 0 Days

S5 Susp-Incarceration O = Maintenance Type Event N/A H = Immediate 0 Days

S6 Susp-Clmt Missing O = Maintenance Type Event N/A H = Immediate 0 Days

S7 Susp-Bens Exhaust O = Maintenance Type Event N/A H = Immediate 0 Days

S8 Susp-Juris Change O = Maintenance Type Event N/A H = Immediate 0 Days

S9 Susp-Setlmnt Aprv O = Maintenance Type Event N/A H = Immediate 0 Days

SJ Susp-Apl/Jud Rev O = Maintenance Type Event N/A H = Immediate 0 Days

UR Upon Request O = Maintenance Type Event N/A
VE Volunteer O = Maintenance Type Event N/A D = Days from Admin. Not. # Days
BM Bi-Monthly O = Maintenance Type Event N/A
BW Bi-Weekly O = Maintenance Type Event N/A
MN Monthly O = Maintenance Type Event N/A
QT Quarterly O = Maintenance Type Event N/A
SA Semi-Annually O = Maintenance Type Event N/A
AN Annual O = Maintenance Type Event MM/DD
SECTION 3
SECTION 3
IAIABC RELEASE I ELEMENT CRITERIA CODES:

ELEMENT REQUIREMENT TABLE C = CONDITIONAL
(Part I) M = MANDATORY
O = OPTIONAL
R = RESTRICTED
IAIABC IAIABC ELEMENT HD1/AK1/TR: 148 MTC's: A49 MTC's:

DN DATA ELEMENT NAME LOCATED ON HD1 AK1 TR1 00 01 02 04 CO AU 02 04 4P AP CA CB CD CO FN FS IP RB RE UR VE AN BM BW MN QT SA
148/ A49/
0001 Transaction Set ID HD1/AK1/TR1 M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M
0002 Maintenance Type Code 148/A49 M M M M M M M M M M M M M M M M M M M M M M M M M M M
0003 Maintenance Type Code Date 148/A49 M M M M M M M M M M M M M M M M M M M M M M M M M M M
0004 Jurisdiction 148/A49 M M M M M M M M M M M M M M M M M M M M M M M M M M M
0005 Agency Claim Number 148/A49
0006 Insurer FEIN 148/A49
0007 Insurer Name 148
0008 Third Party Administrator FEIN 148/A49
0009 Third Party Administrator Name 148
0010 Claim Administrator Address Line 1 148
0011 Claim Administrator Address Line 2 148
0012 Claim Administrator City 148
0013 Claim Administrator State 148
0014 Claim Administrator Postal Code 148/A49
0015 Claim Administrator Claim Number 148/A49
0016 Employer FEIN 148
0017 Insured Name 148
0018 Employer Name 148
0019 Employer Address Line 1 148
0020 Employer Address Line 2 148
0021 Employer City 148
0022 Employer State 148
0023 Employer Postal Code 148
0024 Self Insured Indicator 148
0025 Industry Code 148
0026 Insured Report Number 148/A49
0027 Insured Location Number 148
0028 Policy Number 148
0029 Policy Effective Date 148
0030 Policy Expiration Date 148
SECTION 3

O = OPTIONAL
R = RESTRICTED

0031 Date of Injury 148/A49
0032 Time of Injury 148
0033 Postal Code of Injury Site 148
0034 Employers Premises Indicator 148
0035 Nature of Injury Code 148
0036 Part of Body Injured Code 148
0037 Cause of Injury Code 148
0038 Accident Description/Cause 148
0039 Initial Treatment 148
0040 Date Reported to Employer 148
0041 Date Reported to Claims Administrator 148
0042 Social Security Number 148/A49
0043 Employee Last Name 148
0044 Employee First Name 148
0045 Employee Middle Initial 148
0046 Employee Address Line 1 148
0047 Employee Address Line 2 148
0048 Employee City 148
0049 Employee State 148
0050 Employee Postal Code 148
0051 Employee Phone 148
0052 Employee Date of Birth 148
0053 Gender Code 148
0054 Marital Status Code 148
0055 Number of Dependents 148/A49
0056 Date Disability Began 148/A49
0057 Employee Date of Death 148/A49
0058 Employment Status Code 148
0059 Class Code 148
0060 Occupation Description 148
0061 Date of Hire 148
SECTION 3

O = OPTIONAL
R = RESTRICTED

0062 Wage 148/A49
0063 Wage Period 148/A49
0064 Number of Days Worked 148/A49
0065 Date Last Day Worked 148
0066 Full Wages Paid for Date of Injury Indicator 148
0067 Salary Continued Indicator 148/A49
0068 Date of Return to Work 148
0069 Pre-Existing Disability A49
0070 Dt of Maximum Medical Improvement A49
0071 Return to Work Qualifier A49
0072 Date of Return/Release to Work A49
0073 Claim Status A49
0074 Claim Type A49
0075 Agreement to Compensate Code A49
0076 Date of Representation A49
0077 Late Reason Code A49
0078 Number of Permanent Impairments A49 M M M M M M M M M M M M M M M M M M M M M
0079 Number of Payments/Adjustments A49 M M M M M M M M M M M M M M M M M M M M M
0080 Number of Benefit Adjustments A49 M M M M M M M M M M M M M M M M M M M M M
0081 Number of Paid to Dates/Red.Earnings/Rec. A49 M M M M M M M M M M M M M M M M M M M M M
0082 Number of Death Dep./Payee Relationships A49 M M M M M M M M M M M M M M M M M M M M M
0083 Permanent Impairment Body Part Code A49
0084 Permanent Impairment Percent A49
0085 Payment/Adjustment Code A49 See P/A Requirement Table
0086 Payment/Adjustment Paid to Date A49
0087 Payment/Adjustment Weekly Amount A49
0088 Payment/Adjustment Start Date A49
0089 Payment/Adjustment End Date A49
0090 Payment/Adjustment Weeks Paid A49
0091 Payment/Adjustment Days Paid A49
0092 Benefit Adjustment Code A49
SECTION 3

O = OPTIONAL
R = RESTRICTED

0093 Benefit Adjustment Weekly Amount A49
0094 Benefit Adjustment Start Date A49
0095 Paid to Date/Red.Earnings/Rec.Code A49
0096 Paid to Date/Red. Earnings/Rec. Amt A49
0097 Dependent/Payee Relationship A49
0098 Sender ID HD1 M
0099 Receiver ID HD1 M
0100 Date Transmission Sent HD1 M
0101 Time Transmission Sent HD1 M
0102 Original Transmission Date HD1 *
0103 Original Transmission Time HD1 *
0104 Test/Production Indicator HD1 M
0105 Interchange Version ID HD1 M
0106 Detail Record Count TR1 M
0107 Record Sequence Number AK1 M
0108 Date Processed AK1 M
0109 Time Processed AK1 M
0110 Acknowledgment Transaction Set ID AK1 M
0111 Application Acknowledgement Code AK1 M
0112 Request Code (Purpose) AK1
0113 Free Form Text AK1
0114 Number of Errors AK1 M
0115 Element Number AK1 C
0116 Element Error Number AK1 C
0117 Variable Segment Number AK1 C
* M on HD1 of AK1
SECTION 3

(Part II) M = MANDATORY
O = OPTIONAL
R = RESTRICTED
IAIABC IAIABC ELEMENT A49 MTC's (continued):

DN DATA ELEMENT NAME LOCATED ON S1 S2 S3 S4 S5 S6 S7 S8 S9 SJ P1 P2 P3 P4 P5 P7 P9 PJ PY
148/ A49/
0001 Transaction Set ID HD1/AK1/TR1 M M M M M M M M M M M M M M M M M M M
0002 Maintenance Type Code 148/A49 M M M M M M M M M M M M M M M M M M M
0003 Maintenance Type Code Date 148/A49 M M M M M M M M M M M M M M M M M M M
0004 Jurisdiction 148/A49 M M M M M M M M M M M M M M M M M M M
0005 Agency Claim Number 148/A49
0006 Insurer FEIN 148/A49
0008 Third Party Administrator FEIN 148/A49
0014 Claim Administrator Postal Code 148/A49
0015 Claim Administrator Claim Number 148/A49
0026 Insured Report Number 148/A49
0031 Date of Injury 148/A49
0042 Social Security Number 148/A49
0055 Number of Dependents 148/A49
0056 Date Disability Began 148/A49
0057 Employee Date of Death 148/A49
0062 Wage 148/A49
0063 Wage Period 148/A49
0064 Number of Days Worked 148/A49
0067 Salary Continued Indicator 148/A49
0069 Pre-Existing Disability A49
0070 Dt of Maximum Medical Improvement A49
0071 Return to Work Qualifier A49
0072 Date of Return/Release to Work A49
0073 Claim Status A49
0074 Claim Type A49
0075 Agreement to Compensate Code A49
0076 Date of Representation A49
0077 Late Reason Code A49
0078 Number of Permanent Impairments A49 M M M M M M M M M M M M M M M M M M M
SECTION 3

O = OPTIONAL
R = RESTRICTED

0079 Number of Payments/Adjustments A49 M M M M M M M M M M M M M M M M M M M
0080 Number of Benefit Adjustments A49 M M M M M M M M M M M M M M M M M M M
0081 Number of Paid to Dates/Red.Earnings/Rec. A49 M M M M M M M M M M M M M M M M M M M
0082 Number of Death Dep./Payee Relationships A49 M M M M M M M M M M M M M M M M M M M
0083 Permanent Impairment Body Part Code A49
0084 Permanent Impairment Percent A49
0085 Payment/Adjustment Code A49 SEE P/A ELEMENT REQUIREMENT TABLE
0086 Payment/Adjustment Paid to Date A49
0087 Payment/Adjustment Weekly Amount A49
0088 Payment/Adjustment Start Date A49
0089 Payment/Adjustment End Date A49
0090 Payment/Adjustment Weeks Paid A49
0091 Payment/Adjustment Days Paid A49
0092 Benefit Adjustment Code A49
0093 Benefit Adjustment Weekly Amount A49
0094 Benefit Adjustment Start Date A49
0095 Paid to Date/Red.Earnings/Rec.Code A49
0096 Paid to Date/Red. Earnings/Rec. Amt A49
0097 Dependent/Payee Relationship A49
0098 Sender ID HD1
0099 Receiver ID HD1
0100 Date Transmission Sent HD1
0101 Time Transmission Sent HD1
0102 Original Transmission Date HD1
0103 Original Transmission Time HD1
0104 Test/Production Indicator HD1
0105 Interchange Version ID HD1
0106 Detail Record Count TR1
0107 Record Sequence Number AK1
SECTION 3

O = OPTIONAL
R = RESTRICTED

0108 Date Processed AK1
0109 Time Processed AK1
0110 Acknowledgment Transaction Set ID AK1
0111 Application Acknowledgement Code AK1
0112 Request Code (Purpose) AK1
0113 Free Form Text AK1
0114 Number of Errors AK1
0115 Element Number AK1
0116 Element Error Number AK1
0117 Variable Segment Number AK1
SECTION 3
SECTION 3
ELEMENT CRITERIA CODES:

M = MANDATORY
C = CONDITIONAL- Trading Partner must specify applicable
P/A Codes and required segment conditions
IAIABC RELEASE 1 - PAYMENT/ADJUSTMENT ELEMENT REQUIREMENT TABLE O = OPTIONAL
R = RESTRICTED
* = If Value Changed, Send It
P/A P/A P/A P/A P/A P/A P/A

CRITERIA - Begin or End Dates P/A DESCRIPTION Code PTD AMNT START DATE END DATE WEEKS PAID DAYS PAID
Fatal 010 C C C C C C
PermTotal 020
PermTotal Supplemental 021
Perm Partial/Scheduled 030
Perm Partial/Unscheduled 040
Temporary Total 050
Temp Total Catastrophic 051
Temporary Partial 070
Example: For Dates of Acc < 1-1-94 Perm Partial Disfigurement 090
Employer Paid 240
Vocational Rehab 410
Compromised Unspecified
(lump sum) 500
Compromised Medical 501
Compromised Fatal 510
Compromised Permanent
Total 520
Total Supplemental 521
Compromised Employer Paid 524

Partial Scheduled 530
Partial Unscheduled 540
Compromised Vocational
Rehab 541
Compromised Temporary
Total 550
Total Catastrophic 551
Partial 570
Partial Disfigurement 590
IAIABC First and Subsequent Report of Injury © Release 1 3-69 Revised February 15, 2002
SECTION 3
DN
0030
0029
0028
0027
0026
0025
0024
0023
0022
0021
0020
0019
0018
0017
0016
0015
0014
0013
0012
0011
0010
0009
0008
0007
0006
0005
0004
0003
0002
0001
0000
IAIABC
Jurisdiction
Insurer FEIN
Insurer Name
Industry Code
Insured Name
Employer City
Policy Number
Employer FEIN
Employer State
Employer Name
Entire Transaction
Transaction Set ID
Policy Effective Date

Self Insured Indicator
Policy Expiration Date

Employer Postal Code
Agency Claim Number
Insured Report Number

Claim Administrator City
Maintenance Type Code
Employer Address Line 2
Insured Location Number

Employer Address Line 1
Claim Administrator State
Maintenance Type Code Date
Third Party Administrator FEIN
Claim Administrator Addr Line 2

Third Party Administrator Name
Claim Administrator Addr Line 1
Claim Administrator Postal Code
Claim Administrator Claim Number

IAIABC DATA ELEMENT NAME
ERROR MESSAGE
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
001 Mandatory field not present
X
002 Transaction Set ID Invalid
X
003 MTC invalid for '148'
X
004 MTC invalid for 'A49'
X
005 State Code Invalid
006 NCCI Nature Code Invalid
007 NCCI Part of Body Code Invalid
IAIABC First Report and Subsequent Report of Injury © Release 1

008 NCCI Cause of Injury Code Invalid
009 Gender Code Invalid
010 Marital Status Code Invalid
011 Wage Period Code Invalid
X
012 Indicator Invalid
013 Employment Status Code Invalid
014 Class Code (NCCI or State Spec) Invalid
X
015 Industry Code (SIC or NAICS) Invalid
016 Initial Treatment Code Invalid
017 Claim Status Code Invalid
018 Number of Days worked must be 0-7
019 Days must be 0-6
020 Return to Work Qualifier Code invalid
021 Claim Type Code Invalid
022 Agreement to Compensate Code Invalid
023 Late Reason Code Invalid
024 Payment/Adjustment Code Invalid
025 Benefit/Adjustment Code Invalid
026 PTD/RE/Recovery Code Invalid
027 Dep/Payee Relationship Code invalid
X
X
028 Must be numeric (0-9)
X
X
X
029 Must be a valid date (CCYYMMDD)
X
030 Must be A-Z, 0-9, or spaces
3-71
031 Must be a valid time (HHMMSS)
SECTION 3
X
X
032 Must be valid on Zip Code Table
X
033 Must be <= Date of Injury
X
034 Must be >= Date of Injury
035 Must be >= Date Disability Began
036 Must be <= Date of Death
IAIABC Release 1 Edit Matrix Table
037 Must be <= Maintenance Type Code date

038 Must be >= Start date
X
X
039 No match on database

X
040 All digits cannot be the same

X
041 Must be <= Current date

042 Not statutorily valid
043 Receiver ID Invalid
044 Value is > than required by jurisdiction
045 Value is < than required by jurisdiction
046 Interchange Version ID invalid
X
047 Reinstated but not suspended

X
048 Duplicate First Report (148)

X
049 Duplicate Initial Payment (A49)

X
050 No matching Subsequent report (A49)

X
051 Reduced Earnings prior to Initial Payment

X
052 Suspension prior to Initial Payment

053 No matching FROI (148)
X
054 Must be valid occurence for segment

055 Must be <= Date of Hire
056 Detail Record Count not = # records recv'd
X
X
057 Duplicate transmission/transaction

X
X
X
X
X
X
X
X
X
X
058 Code/ID invalid

X
059 Value not consistent w/ value prev reported

060 Previous supporting docs not received
060 Previous supporting docs not recv'd
061 Event Criteria not met
062 Required segment not present
063 Invalid event sequence/relationship
064 Invalid data sequence/relationship
065 Corresponding report/data not found
066 Invalid record count
067 Must be >= Policy Effective Date
068 Must be <= Policy Expiration Date
X
X
100 No Leading/Embedded Spaces

Revised February 15, 2002
DN
0061
0060
0059
0058
0057
0056
0055
0054
0053
0052
0051
0050
0049
0048
0047
0046
0045
0044
0043
0042
0041
0040
0039
0038
0037
0036
0035
0034
0033
0032
0031
IAIABC
Class Code
Date of Hire
Gender Code
Date of Injury
Time of Injury
Employee City
Employee State
Initial Treatment
Employee Phone
Marital Status Code

Cause of Injury Code
Date Disability Began

Nature of Injury Code
Employee Last Name
Employee First Name
Employee Postal Code

Employee Middle Initial
Occupation Description
Number of Dependents
Employee Date of Birth
Social Security Number
Employee Date of Death

Employee Address Line 2
Employee Address Line 1
Postal Code of Injury Site
Employment Status Code

Part of Body Injured Code
Accident Description/Cause
Date Reported to Employer

Employers Premises Indicator
Date Reported to Claim Admin

ERROR MESSAGE
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

3-72
X

SECTION 3
X
X
X
X
X
X
X
X

X
X
X
X
X
X

X

X

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
058 Code/ID invalid

X
X
X

DN
0092
0091
0090
0089
0088
0087
0086
0085
0084
0083
0082
0081
0080
0079
0078
0077
0076
0075
0074
0073
0072
0071
0070
0069
0068
0067
0066
0065
0064
0063
0062
IAIABC
Wage
Claim Type
Wage Period
Date of MMI
Claim Status
RTW Qualifer
Late Reason Code

Pre-Existing Disability
Number Days Worked
Date Last Day Worked
Date of Representation
Date of Return to Work
Payment/Adj. End Date
Payment/Adj. Days Paid
Benefit/Adjustment Code
Payment/Adj. Start Date
Salary Continued Indicator
Num. Benefit/Adjustments
Payment/Adj. Weeks Paid

Payment/Adjustment Code
Agreement to Comp. Code
Payment/Adj. Paid to Date

Num. Death Dep/Payee Rel
Num. Payment/Adjustments
Perm. Impairment Body Part
Payment/Adjustment Amount
Date Release/Return to Work
Num. PTD/Reduced Earnings
Perm. Impairment Percentage

Num. Permanent Impairments
Full Wages Paid for Date of Inj Ind
ERROR MESSAGE
X
X

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

3-73
SECTION 3

X
X
X
X
X
X
X
X
X
X
X
X
X

X
X
X
X
X
X
X
X
X
X

X
X
X
X
X
X
X
X
X
X
X
X
058 Code/ID invalid

DN
0117
0116
0115
0114
0113
0112
0111
0110
0109
0108
0107
0106
0105
0104
0103
0102
0101
0100
0099
0098
0097
0096
0095
0094
0093
IAIABC
Sender ID
Receiver ID
Date Processed
Free Form Text

Time Processed
Element Number
Number of Errors
Detail Record Count
Element Error Number

Interchange Version ID
Benefit/Adj. Start Date
Time Transmission Sent

PTD/RE/Recovery Amnt
PTD/RE/Recovery Code
Request Code (Purpose)

Date Transmission Sent
Test/Production Indicator
Variable Segment Number

Record Sequence Number
Original Transmission Date
Benefit/Adjustment Amount
Original Transmission Time

Dependent Payee Relationship
Application Acknowledgement Code

Acknowledgment Transaction Set ID

ERROR MESSAGE
X
X
X
X
X
X
X
X
X
X
X
X
X

X

X
X
X
X
X
X
X
028
X
X
Must be numeric (0-9)
X
X
X
X

3-74
X
X
X

SECTION 3

X

X


X

X

X

X

X

X
X
X
X
X
X
X
058
X
X
Code/ID invalid
X

SECTION 4
4.
Transaction Standards
SECTION 4
SECTION 4
Release 1
Hard Copy Form
SECTION 4
WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG NUMBER REPORT PURPOSE CODE
JURISDICTION JURISDICTION CLAIM NUMBER
INSURED REPORT NUMBER
EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT) LOCATION #
INDUSTRY CODE EMPLOYER FEIN PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #) POLICY PERIOD CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
TO
CHECK IF APPROPRIATE
SELF INSURANCE
CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN
EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE
ADDRESS (INCL ZIP) SEX MARITAL STATUS OCCUPATION/JOB TITLE
M MALE U UNMARRIED EMPLOYMENT STATUS

SINGLE/DIVORCED
F FEMALE M MARRIED
U UNKNOWN S SEPARATED
PHONE # OF DEPENDENTS K UNKNOWN NCCI CLASS CODE
RATE DAY MONTH DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? YES NO
PER: WEEK OTHER: DID SALARY CONTINUE? YES NO
OCCURRENCE/TREATMENT
TIME EMPLOYEE AM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE DATE EMPLOYER DATE DISABILITY
BEGAN WORK NOTIFIED BEGAN
PM ( ) CANNOT BE PM
DETERMINED
CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED
DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE
PREMISES?
YES NO
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS
OCCURRED EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE
ILLNESS EXPOSURE OCCURRED OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED
THE EMPLOYEE OR MADE THE EMPLOYEE ILL
CAUSE OF INJURY CODE
DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? YES NO
WERE THEY USED? YES NO

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS) INITIAL TREATMENT
0 NO MEDICAL TREATMENT
1 MINOR: BY EMPLOYER
2 MINOR CLINIC/HOSP
3 EMERGENCY CARE
4 HOSPITALIZED > 24 HOURS
5 FUTURE MAJOR MEDICAL/

LOST TIME ANTICIPATED
OTHER
WITNESSES (NAME & PHONE #)
DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER’S NAME & TITLE PHONE NUMBER
FORM IA-1(r 1-1-02) SEE BACK FOR IMPORTANT INFORMATION IAIABC 2002
EMPLOYER’S INSTRUCTIONS
DO NOT ENTER DATA IN SHADED FIELDS
DATES:
Enter all dates in MM/DD/YY format.
INDUSTRY CODE:
This is the code which represents the nature of the employer’s business, which is contained in the Standard
Industrial Classification Manual or the North American Industry Classification System, published by the Federal
Office of Management and Budget.
CARRIER:
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of
the employer of the claimant.
CLAIMS ADMINISTRATOR:
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering
the claim.
AGENT NAME & CODE NUMBER:

Enter the name of your insurance agent and his/her code number if known. This information can be found on
your insurance policy.
OCCUPATION/JOB TITLE:
This is the primary occupation of the claimant at the time of the accident or exposure.
EMPLOYMENT STATUS:
Indicate the employee’s work status. The valid choices are:
Full-Time On Strike Unknown Volunteer
Part-Time Disabled Apprenticeship Full-Time Seasonal
Not Employed Retired Apprenticeship Part-Time Piece Worker
DATE DISABILITY BEGAN:

The first day on which the claimant originally lost time from work due to the occupation injury or disease
or as otherwise designated by statute.
CONTACT NAME/PHONE NUMBER:

Enter the name of the individual at the employer’s premises to be contacted for additional information.
TYPE OF INJURY/ILLNESS:
Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm).
PART OF BODY AFFECTED:

Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back).
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)
If the accident or illness exposure did not occur on the employer’s premises, enter address or location.
Be specific.
FORM IA-1(r 1-1-02) IAIABC 2002
EMPLOYER’S INSTRUCTIONS – cont’d
ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS
EXPOSURE OCCURRED:
(eg. Acetylene cutting torch, metal plate)
List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating
when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander,
paintbrush, and paint.
Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed
do not have to be directly involved in the employee’s injury or illness.
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE
OCCURRED:
(eg. Cutting metal plate for flooring)
Describe the specific activity the employee was engaged in when the accident or illness exposure occurred,
such as sanding ceiling woodwork in preparation for painting.
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
Describe the work process the employee was engaged in when the accident or illness exposure occurred, such
as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (eg.
walking along a hallway).
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF

EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE
THE EMPLOYEE ILL:
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against
the hot metal.)
Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and
name any objects or substance that directly injured the employee or made the employee ill. For example:
Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The
worker’s right wrist was broken in the fall.
DATE RETURN(ED) TO WORK:

Enter the date following to most recent disability period on which the employee returned to work.
FORM IA-1(r 1-1-02) IAIABC 2002
SECTION 4
SECTION 4
Release 1
Flat File Formats
IAIABC First Report and Subsequent Report of Injury © Release 1 4- 9 February 15, 2002
SECTION 4
SECTION 4
IAIABC RELEASE 1 ACKNOWLEDGMENT RECORD (AK1)
IAIABC IAIABC IAIABC IAIABC POSITIONS

GROUPING DN DATA ELEMENT NAME FORMAT BEG END
TRANSACTION 0001 Transaction Set ID 3 A/N 1 3
0107 Record Sequence Number 9N 4 12
0108 Date Processed Date 13 20
0109 Time Processed Time 21 26
0006 Insurer FEIN 9 A/N 27 35
0014 Claim Administrator Postal Code 9 A/N 36 44
0008 Third Party Administrator Fein 9 A/N 45 53
0110 Acknowledgement Transaction Set ID 3 A/N 54 56
0111 Application Acknowledgment Code 2 A/N 57 58
0026 Insured Report Number 25 A/N 59 83
0015 Claim Administrator Claim Number 25 A/N 84 108
0005 Agency Claim Number 25 A/N 109 133
0002 Maintenance Type Code 2 A/N 134 135
0003 Maintenance Type Date Date 136 143
0112 Request Code (Purpose) 3 A/N 144 146
0113 Free Form Text 60 A/N 147 206
0114 Number of Errors 2N 207 208
VARIABLE SEGMENT
ERROR CODE Error Code Occurs Number of Error Times (maximum number of occurrences = 99)
0115 Element Number 4N 209 212
0116 Element Error Number 3N 213 215
0117 Variable Segment Number 2N 216 217
IAIABC First Report and Subsequent Report of Injury (c) Release 1 4-11 Revised February 15, 2002
SECTION 4
SECTION 4
IAIABC RELEASE 1 FIRST REPORT OF INJURY (148)

0003 Maintenance Type Code Date DATE 6 13
JURISDICTION 0004 Jurisdiction 2 A/N 14 15
CLAIM ADMINISTRATOR 0006 Insurer FEIN 9 A/N 41 49
0007 Insurer Name 30 A/N 50 79
0008 Third Party Administrator FEIN 9 A/N 80 88
0009 Third Party Administrator Name 30 A/N 89 118
0010 Claim Administrator Address Line 1 30 A/N 119 148
0011 Claim Administrator Address Line 2 30 A/N 149 178
0012 Claim Administrator City 15 A/N 179 193
0013 Claim Administrator State 2 A/N 194 195
INSURED 0016 Employer FEIN 9 A/N 230 238
0017 Insured Name 30 A/N 239 268
0018 Employer Name 30 A/N 269 298
0019 Employer Address Line 1 30 A/N 299 328
0020 Employer Address Line 2 30 A/N 329 358
0021 Employer City 15 A/N 359 373
0022 Employer State 2 A/N 374 375
0023 Employer Postal Code 9 A/N 376 384
0024 Self Insured Indicator 1 A/N 385 385
0025 Industry Code 6 A/N 386 391
0027 Insured Location Number 15 A/N 402 416
POLICY 0028 Policy Number 18 A/N 417 434
Filler 12 A/N 435 446
0029 Policy Effective Date DATE 447 454
0030 Policy Expiration Date DATE 455 462
ACCIDENT 0031 Date of Injury DATE 463 470
0032 Time of Injury HHMM 471 474
0033 Postal Code of Injury Site 9 A/N 475 483
0034 Employers Premises Indicator 1 A/N 484 484
0035 Nature of Injury Code 2 A/N 485 486
0036 Part of Body Injured Code 2 A/N 487 488
0037 Cause of Injury Code 2 A/N 489 490
0038 Accident Description/Cause 150 A/N 491 640
0039 Initial Treatment 2 A/N 641 642
0040 Date Reported to Employer DATE 643 650
0041 Date Reported to Claim Administrator DATE 651 658
EMPLOYEE 0042 Social Security Number 9 A/N 659 667
0043 Employee Last Name 30 A/N 668 697
0044 Employee First Name 15 A/N 698 712
0045 Employee Middle Initial 1 A/N 713 713
0046 Employee Address Line 1 30 A/N 714 743
0047 Employee Address Line 2 30 A/N 744 773
0048 Employee City 15 A/N 774 788
IAIABC First Report and Subsequent Report of Injury (c) Release 1 4-13 Revised February 15,2002
SECTION 4
IAIABC RELEASE 1 FIRST REPORT OF INJURY (148)

0049 Employee State 2 A/N 789 790
0050 Employee Postal Code 9 A/N 791 799
0051 Employee Phone 10 A/N 800 809
0052 Employee Date of Birth DATE 810 817
0053 Gender Code 1 A/N 818 818
0054 Marital Status Code 1 A/N 819 819
0055 Number of Dependents 2N 820 821
0056 Date Disability Began DATE 822 829
0057 Employee Date of Death DATE 830 837
EMPLOYMENT 0058 Employment Status Code 2 A/N 838 839
0059 Class Code 4 A/N 840 843
0060 Occupation Description 30 A/N 844 873
0061 Date of Hire DATE 874 881
0062 Wage $9.2 882 892
0063 Wage Period 2 A/N 893 894
0064 Number Days Worked 1N 895 895
0065 Date Last Day Worked DATE 896 903
0066 Full Wages Paid for Date of Injury Indicator 1 A/N 904 904
0067 Salary Continued Indicator 1 A/N 905 905
0068 Date of Return to Work DATE 906 913
IAIABC First Report and Subsequent Report of Injury (c) Release 1 4-14 Revised February 15,2002
SECTION 4
IAIABC RELEASE 1 SUBSEQUENT REPORT OF INJURY (A49) DATA ELEMENTS

0003 Maintenance Type Code Date DATE 6 13
JURISDICTION 0004 Jurisdiction 2 A/N 14 15
CLAIM ADMINISTRATOR 0006 Insurer FEIN 9 A/N 16 24
0008 Third Party Administrator FEIN 9 A/N 25 33
0042 Social Security Number 9 A/N 43 51
0055 Number of Dependents 2N 52 53
0069 Pre-Existing Disability 1 A/N 54 54
0056 Date Disability Began DATE 55 62
0070 Date of Maximum Medical Improvement DATE 63 70
0071 Return to Work Qualifier 1 A/N 71 71
0072 Date of Return/Release to Work DATE 72 79
0057 Employee Date of Death DATE 80 87
WAGE 0062 Wage $9.2 88 98
0063 Wage Period 2 A/N 99 100
0064 Number of Days Worked 1N 101 101
0067 Salary Continued Indicator 1 A/N 102 102
ACCIDENT 0031 Date of Injury DATE 103 110
CLAIM STATUS 0073 Claim Status 1 A/N 186 186
0074 Claim Type 1 A/N 187 187
0075 Agreement to Compensate Code 1 A/N 188 188
0076 Date of Representation DATE 189 196
PAYMENTS 0077 Late Reason Code 2 A/N 197 198
VARIABLE SEGMENT
COUNTERS 0078 Number of Permanent Impairments 2N 199 200
0079 Number of Payments/Adjustments 2N 201 202
0080 Number of Benefit Adjustments 2N 203 204
0081 Number of Paid to Date/Reduced Earnings/Recoveries 2N 205 206
0082 Number of Death Dependent/Payee Relationships 2N 207 208
VARIABLE SEGMENTS
Permanent Impairments Occurs Number of Permanent Impairments times
(maximum number of occurences = 6)
0083 Permanent Impairment Body Part Code 3 A/N 1 3
0084 Permanent Impairment Percentage 3.2 N 4 8
Payment/Adjustments Occurs Number of Payment/Adjustments times
(maximum number of occurences = 10)
0085 Payment/Adjustment Code 3 A/N 1 3
0086 Payment/Adjustment Paid to Date $9.2 4 14
0087 Payment/Adjustment Weekly Amount $9.2 15 25
0088 Payment/Adjustment Start Date DATE 26 33
0089 Payment/Adjustment End Date DATE 34 41
0090 Payment/Adjustment Weeks Paid 4N 42 45
0091 Payment/Adjustment Days Paid 1N 46 46
SECTION 4
IAIABC RELEASE 1 SUBSEQUENT REPORT OF INJURY (A49) DATA ELEMENTS

Benefit Adjustments Occurs Number of Benefit Adjustments times
(maximum number of occurrences = 10)
0092 Benefit Adjustment Code 4 A/N 1 4
0093 Benefit Adjustment Weekly Amount $9.2 5 15
0094 Benefit Adjustment Start Date DATE 16 23
Paid to Date/Reduced Earnings/Recoveries Occurs Number of Paid to Date/Reduced Earning/Recoveries times
0095 Paid To Date/Reduced Earnings/Recoveries Code 3 A/N 1 3
0096 Paid To Date/Reduced Earnings/Recoveries Amount $9.2 4 14
Death Dependent/Payee Relationship Occurs Number of Death Dependent/Payee Relationship times
0097 Dependent/Payee Relationship 2 A/N 1 2
SECTION 4
IAIABC RELEASE 1 TRAILER RECORD (TR1)

0106 Detail Record Count 9N 4 12
SECTION 4
SECTION 4
IAIABC RELEASE 1 HEADER RECORD (HD1)

0098 Sender ID 25 A/N 4 28
Sender FEIN 9 A/N
Filler 7 A/N
Sender Postal Code 9 A/N
0099 Receiver ID 25 A/N 29 53
Receiver FEIN 9 A/N
Filler 7 A/N
Receiver Postal Code 9 A/N
0100 Date Transmission Sent Date 54 61
0101 Time Transmission Sent Time 62 67
0102 Original Transmission Date Date 68 75
0103 Original Transmission Time Time 76 81
0104 Test/Production Indicator 1 A/N 82 82
0105 Interchange Version ID 5 A/N 83 87
Transmission Type Code 3 A/N
Release Number 2 A/N
SECTION 4
SECTION 4
Release 1
ANSI X12N Formats
SECTION 4
SECTION 4
The Release 1 ANSI X12 N Documentation

was not available at the time of publication
and will be placed on the IAIABC website in
the future, as an addendum to the Release 1
manual dated 2-15-02.
SECTION 4
SECTION 5
5.
Electronic Scenarios
SECTION 5
SECTION 5
RELEASE 1 LIMITATIONS
There are limitations in the ability to use Release 1 of the First Report and Subsequent Report record
layouts and coding structures, some of which are listed below. It is recommended that all prospective
Trading Partners discuss the limitations and agree on how they might be overcome PRIOR TO attempting
to implement any particular part of Release 1. The following are some of the documented limitations.
Data Element Limitations:
Reporting usage is limited by the data elements currently on the record layouts. There have been additional
data elements identified that are needed by some, if not all, of the jurisdictions for complete functionality. This
would apply to most of the Maintenance Type Codes.
Benefit Adjustment Code Limitations:
The usefulness of Benefit Adjustment Codes is limited due to the fact that there is a start date but no end
date. Also, quite often a Benefit Adjustment is started on the same transmission as another activity or
change. As there is only one Maintenance Type code Date per transaction, it is difficult or impossible to
determine what happened when the differing activities occurred on different dates but are included in the
same transmission. Thus, Benefit Adjustment Codes should be implemented only after sufficient testing
is done to ensure communication of information will occur as needed.
Maintenance Type Code Limitations:
Some general restrictions for most of the codes are noted as follows:
A. Multiple periods of disability for a specific Payment/Adjustment Code are not reportable on a
single transmission as the layout is limited to one set of start and end dates. This problem comes
into play in two major areas:
1) Single check payments for more than one period of disability.

2) Multiple periods over the life of a claim which causes the dates to be reset each time a
new period occurs.
B. Effective date: There is only one date field for each Maintenance Type Code Date when multiple
date fields are sometimes needed. For instance, the effective date and action date may be
different and both need to be reported.
In addition, some specific limitations were identified for many of the codes. The following is a list of each
code with some of the known limitations that are in addition to data element needs. The (letter) refers to
limits noted above in A or B.
IAIABC First Report and Subsequent Report of Injury  Release 1 5-3 February 15, 2002
SECTION 5
First Report Values:

00 Original
01 Cancel – reason needed
02 Change – (B); changes to jurisdiction, date of injury or SSN (if agency claim number not
being used), date disability began, wage, date last day worked, date of return to work full
salary indicator; reason needed.
04 Denial – (B): reason needed
AU Acquired/Unallocated – data will need to be reviewed carefully by the receiver to ensure
previously received data is not improperly overlaid.
CO Correction
Periodic Values: - (A-2) for all

AN Annual
BM Bi-Monthly
BW Bi-Weekly
MN Month
QT Quarterly
SA Semi-Annual
UR Upon Request
Subsequent Report Values:
02 Change – almost the same as 02 First Report plus Maintenance Type Code dates
04 Denial – same as 04 First Report
4P Partial Denial – same as 04, unknown what specific benefit(s) is being denied
AP Acquired/Unallocated Payment – data will need to be reviewed carefully by the receiver
to ensure previously received data is not improperly overlaid.
CA Change in Benefit Amount – (A-2); (B)
CB Change in Benefit Type – (A-2); (B)
CD Compensable Death
CO Correction
FN Final – (A-2)
FS Full Salary – (A-1)
IP Initial Payment – (A-1)
P1–PJ Partial Suspensions – (A-2); (B); unknown which specific benefit(s) is being suspended
PY Payment Report
RB Reinstatement of Benefit – (A-2)
RE Reduced Earnings – (A-2); unknown usage in R-1.
S1-SJ Full Suspensions – (A-2); (B)
VE Volunteer
SECTION 5
The scenarios in the packet of generic scenarios include some of the limitations noted above in their
narratives.
In addition, it is suggested by the EDI Technical Development Committee that CA and RE are too limited to
be properly used in Release 1. If trading partners agree to attempt to use these codes, they should complete
thorough experimentation and testing prior to any permanent implementation. Some of the reasons for this
recommendation include:
CA: Changes in prior periods for a particular Payment/Adjustment Code are not reportable when a new
period of the same code is currently being paid. Changes are quite often caused by an average weekly wage
change which might have its own Maintenance Type code Date and thus cause the need to have two dates
reported in a single date field. Changes are also quite often associated with the implementation of a Benefit
Adjustment Code which might have its own Maintenance Type Code Date and thus cause the need to have
two dates reported in a single date field. In some cases all three are happening thus possibly needing three
dates in one field.
RE: There is no known jurisdiction definitely requesting usage of this in Release 1. Thus, questions
on how the cumulative dates, rates, and amounts are to be reported have not been documented
sufficiently to create and agree upon a scenario for usage.
SECTION 5
SECTION 5
SCENARIOS
TABLE OF CONTENTS
00 – FROI (Original) ..................................................................................................... Page 5-9

01 – FROI (Cancel) ....................................................................................................... Page 5-10
02 – FROI (Change) ...................................................................................................... Page 5-11
04 – FROI (Denial #1 – Instead of 00) ........................................................................... Page 5-12
04 – FROI (Denial #2 – Subsequent to 00).................................................................... Page 5-13
AU – FROI (Acquired/Unallocated)............................................................................... Page 5-14
CO – FROI (Correction)................................................................................................ Page 5-15
AN – PERIODIC (Annual).............................................................................................. Page 5-16
02 – SROI (Change)...................................................................................................... Page 5-18
04 – SROI (Denial #3) ................................................................................................... Page 5-19
4P – SROI (Partial Denial #1 – Initial Lost Time)........................................................... Page 5-21
4P – SROI (Partial Denial #2 – Reoccurrence) .............................................................. Page 5-22
AP – SROI (Acquired Payment).................................................................................... Page 5-25
CB – SROI (Change in Benefit Type)............................................................................ Page 5-26
CD – SROI (Compensable Death No Dependent/Payees) ............................................. Page 5-29
CO – SROI (Correction) ................................................................................................ Page 5-30
FN –SROI (Final) .......................................................................................................... Page 5-31
FS –SROI (Full Salary) ................................................................................................. Page 5-33
IP –SROI (Initial Payment) ............................................................................................ Page 5-34
IP – SROI (Initial Payment - Fatality #1)........................................................................ Page 5-35
IP – SROI (Initial Payment - Fatality #2)........................................................................ Page 5-37
P7 – SROI (Partial Suspension).................................................................................... Page 5-38
PY – SROI (Payment Report #1 - Medical Payment Reporting) .................................... Page 5-40
PY – SROI (Payment Report #2 - Penalty Payment ...................................................... Page 5-41
RB – SROI (Reinstatement of Benefits - #1 Different Benefit Type............................... Page 5-44
RB – SROI (Reinstatement of Benefits - #2 Same Benefit Type ................................... Page 5-47
S1 – SROI (Suspension)............................................................................................... Page 5-50
VE – SROI (Volunteer) .................................................................................................. Page 5-52
Recoveries................................................................................................................... Page 5-53
Multiple Events – 04/IP (Multiple Payments on IP) ....................................................... Page 5-55
Multiple Events – FS/IP #1 (Employer Reimbursed Full Salary) ................................... Page 5-57
Multiple Events – FS/IP #2 (Employer Not Reimbursed Full Salary)............................. Page 5-59
Acknowledgment Scenario 1:Validate Sender ID of Header (HD1) .............................. Page 5- 62
Acknowledgment Scenario 2:Validate Remaining Header Data Elements ................... Page 5-63
Acknowledgment Scenario 3:Validate Header for Duplicate Batch.............................. Page 5-64
Acknowledgment Scenario 4:Validate Trailer Record .................................................. Page 5-65
Acknowledgment Scenario 5:Validate Batch for Transaction Existence ..................... Page 5-66
Acknowledgment Scenario 6:Validate Batch Integrity ................................................. Page 5-67
SECTION 5
SECTION 5
SCENARIO:
00 – FROI (Original)
Narrative:
Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned. The
employee was not paid by the employer for the day of the injury. The employee’s weekly wage is
$600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible
for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of
injury once seven days of lost time has occurred. The claim administrator transmits the first report of injury
on 1/8/93 as the seven days have elapsed.
Limitations Known To Date:

N/A
Sample of “00”: FROI Data

MTC: 00 Employment Status Code: FT
MTC Date: 1/8/93 Wage: 600.00
Jurisdiction: XX Wage Period: 1
Date Disability Began: 1/1/93 Number of Days Worked: 5
Date of Return to Work: Salary Continued Indicator: N
Date of Death:
SECTION 5
SCENARIO:
01 – FROI (Cancel)
Narrative:
injury once seven days of lost time has occurred. The claim administrator transmitted the first report of
injury on 1/8/93 as the seven days had elapsed. No payments have been made on the claim. On 1/11/93
the claim administrator determines that the claim belongs under a different state jurisdiction and sends a
cancel report to the original jurisdiction.

The reason for the cancel is needed in order for the jurisdictions to properly process the transmission.

MTC Date: 1/8/93 Wage: 600.00
Date of Death:

MTC Date: 1/11/93 Wage: 600.00
Date of Death:
SECTION 5
SCENARIO:
02 – FROI (Change)
Narrative:
the claim administrator is informed that the employment status code was incorrectly reported to them as
FT (full- time) when the correct code is AF (apprenticeship full-time). The claim administrator changes the
data in their system on 1/11/93 and transmits a change report to the jurisdiction to notify them of the
mandatory field that was changed.

Effective date and reason for the change are needed. Changes to jurisdiction, date of injury or SSN (if
agency claim number not used or required by the jurisdiction), date disability began, wage, date last
day worked, date of return to work, and full salary indicator are not fully supported.

MTC Date: 1/8/93 Wage: 600.00
Date of Death:

MTC: 02 Employment Status Code: AF
MTC Date: 1/11/93 Wage: 600.00
Date of Death:
SECTION 5
SCENARIO:
04 – FROI (Denial #1 – Instead of 00)
Narrative:
for temporary total disability wage replacement starting 1/8/93. On 1/8/93 the claim administrator
determines that the claim is not compensable and is therefore denying the entire claim. The claim
administrator transmits an 04 Denial Report (instead of the 00) to the jurisdiction on 1/8/93 to notify them
that the entire claim is denied.

Effective vs. action date and narrative reason for the denial is needed on paper.

MTC Date: 1/8/93 Wage: 600.00
Date of Death:
SECTION 5
SCENARIO:
04 – FROI (Denial #2 – Subsequent to 00)
Narrative:
the claim administrator determines that the claim is not compensable and is therefore denying the entire
claim. The claim administrator transmits an 04 Denial Report to the jurisdiction on 1/13/93 to notify them
that the entire claim is denied.


MTC Date: 1/8/93 Wage: 600.00
Date of Death:

MTC Date: 1/13/93 Wage: 600.00
Date of Death:
SECTION 5
SCENARIO:
AU – FROI (Acquired/Unallocated)
Narrative:
injury once seven days of lost time has occurred. All information has been reported on paper or EDI to the
jurisdiction as required to date. Weekly wage replacement benefits are currently being paid. On 2/1/94 a
new claim administrator takes over administration of the claim. The jurisdiction requires notification of all
reportable claims within 14 days of acquisition. The new claim administrator transmits an
acquired/unallocated report to the jurisdiction on 2/14/94.

Data will need to be edited carefully by the jurisdiction to ensure that previously received data is not
improperly overlaid.
Sample of “00”: FROI Data (from old claim administrator)

MTC Date: 1/8/93 Wage: 600.00
Date of Death: Claim Administrator FEIN 123456789
Sample of “AU”: FROI Data (from new claim administrator)

MTC: AU Employment Status Code: FT
MTC Date: 2/14/94 Wage: 600.00
Date of Death: Claim Administrator FEIN 987654321
SECTION 5
SCENARIO:
CO – FROI (Correction)
Narrative:
injury once seven days of lost time has occurred. The claim administrator transmits the first report of injury
on 01/8/93 as the seven days have elapsed. On 1/9/93, the jurisdiction acknowledged the transmission as
being accepted with a non-critical error of a missing conditional field – employment status code. On
1/12/93 the claim administrator corrects the error and transmits a correction report to the jurisdiction.

Maintenance Type Code Date of the Correction must be the same date as the transaction it is
correcting (see MTC Date Definition, page 6-39).

MTC: 00 Employment Status Code:
MTC Date: 1/8/93 Wage: 600.00
Date of Death:
Sample of “CO”: FROI Data

MTC: CO Employment Status Code: FT
MTC Date: 1/8/93 Wage: 600.00
Date of Death:
SECTION 5
SCENARIO:
AN – PERIODIC (Annual – Page 1 of 2)
Narrative:
Employee was injured on 1/1/92. The jurisdiction requires periodic reporting on an annual basis for all
open cases. The claim administrator transmits a periodic report to the jurisdiction on 1/1/94. Note: For
this scenario, the Sample of Payment Input Fields does not list each check but only the summary for each
Payment Code.

Multiple periods of disability for a specific benefit type are not discernable in a single transmission.
Sample of Payment Input Fields

AWW: 600.00 Days per week: 5 Weekly Rate: 400.00 Daily Rate: 80.00
Payment From Thru Weeks Weekly A/D B/A
Code Date Date Paid Rate Earning Gross Code Paid
350 1/1/92 7/30/93 36500.00 36500.00
360 1/1/92 7/30/93 147000.00 147000.00
370 1/1/92 7/30/93 6000.00 6000.00
300 7/30/93 7/30/93 5000.00 5000.00
050 1/1/92 6/30/92 26 400.00 10400.00 10400.00
030 7/1/92 6/15/93 50 400.00 20000.00 20000.00
020 6/16/93 7/29/93 6.6 400.00 2640.00 2640.00
010 7/30/93 12/31/93 22.2 300.00 6660.00 6660.00
Continued on next page
SECTION 5
SCENARIO:
AN – PERIODIC (Annual – Page 2 of 2)
Sample of “AN” Subsequent Data

MTC: AN Wage: 600.00
MTC Date: 1/1/94 Wage Period: 1
Jurisdiction: XX Number of Days Worked: 5
Date Disability Began: 1/1/92 Salary Continued Ind: N
Date of Return/Release to Work: MMI: 12/31/92
RTW Qualifier: # of Dependents: 1
Date of Death: 7/30/93 Claim Status: 0
# Occurrences 1 # Occurrences 4 # Occurrences 0 # Occurrences 4 # Occurrences 1

Death
Dependent/
Permanent Payment Benefit Paid to Date/Reduced Payee
Impairment Adjustment Adjustment Earnings/Recoveries Relationship
Body Part 99 P/A Code 010 PRR Code 300 Relationship 21
Percent 10.00 P/A Total 6660.00 PRR Amount 5000.00
P/A Amount 300.00
P/A Start 7/30/93 PRR Code 350
P/A End 12/31/93 PRR Amount 36500.00
P/A Weeks 22
P/A Days 1 PRR Code 360
PRR Amount 147000.00
P/A Code 020
P/A Total 2640.00 PRR Code 370
P/A Amount 400.00 PRR Amount 6000.00
P/A Start 6/16/93
P/A End 7/29/93
P/A Weeks 6
P/A Days 3
P/A Code 030

P/A Total 20000.00
P/A Amount 400.00
P/A Start 7/1/92
P/A End 6/15/93
P/A Weeks 50
P/A Days 0
P/A Code 050

P/A Total 10400.00
P/A Amount 400.00
P/A Start 1/1/92
P/A End 6/30/92
P/A Weeks 26
P/A Days 0
SECTION 5
SCENARIO:
02 – SROI (Change)
Narrative:
injury on 1/8/93 as the seven days had elapsed. On 1/20/93, the claim administrator determined that the
claim is compensable and initiated payment to the employee. The claim administrator transmitted an
initial payment report to the jurisdiction on 1/21/93 to notify them of the initial payment. In that
transmission the claim administrator showed a late reason code of L1. On 1/30/93 the claim administrator
determines that the late reason code should have been L7. The claim administrator changes the data in
their system on 1/31/93 and transmits a change report to the jurisdiction to notify them of the mandatory
field that was changed.

Effective date and reason for the change are needed. Changes to jurisdiction, date of injury or SSN (if
agency claim number not used or required by the jurisdiction), date disability began, wage, date of
return to work, full salary indicator, and MTC code or date are not fully supported.
Sample of “IP”: Subsequent Data

MTC: IP Wage: 600.00
Date Disability Began: 1/1/93 Salary Continued Indicator: N
Date of Return/Release to Work: MMI:
RTW Qualifier: Number of Dependents:
Date of Death: Claim Status: 0
Late Reason Code: L1
Sample of “02”: Subsequent Data

MTC: 02 Wage: 600.00
RTW Qualifier: Number of Dependents:
Late Reason Code: L7
SECTION 5
SCENARIO:
04 – SROI (Denial #3 – page 1 of 2)
Narrative:
injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator initially determines
that the claim is compensable and initiates payment to the employee. The claim administrator transmits
an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the
waiting period is not initially paid.

N/A
Sample of Payment Input Fields:
050 1/8/93 1/14/93 1 400.00 400.00 400.00
Sample of “IP” Subsequent Data

RTW Qualifier: # of Dependents:
Date of Death: Claim Status: O

Death
Dependent/
P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
04 – SROI (Denial #3 – page 2 of 2)
Narrative:
On 1/30/93, the claim administrator determines that the claim is not compensable and is therefore denying
the entire claim. The claim administrator transmits a denial report to the jurisdiction on 1/30/93 to notify
them that the entire claim is denied.


050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00
350 1/1/93 1/5/93 200.00 200.00
Sample of “04” Subsequent Data

MTC: 04 Wage: 600.00

Death
Dependent/
P/A Code 050 PRR Code 350
P/A Total 1600.00 PRR Amount 200.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/29/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
4P – SROI (Partial Denial #1 – Initial Lost Time)
Narrative:
injury on 1/8/93 as the seven days had elapsed. On 1/13/93, the claim administrator determines that the
claim is compensable but the lost time from work was not medically authorized. The claim administrator
notifies the employee that they are accepting the claim and will pay reasonable medical expenses but are
denying payment for the lost time. The claim administrator transmits an 04 partial denial report to the
jurisdiction on 1/13/93 to notify them of the partial denial.

Effective vs. action date and narrative reason for the denial is needed on paper. Also, in many
circumstances the jurisdiction will be unable to tell what specific benefit type(s) is being denied.

350 1/1/93 1/5/93 200.00 200.00
Sample of “4P” Subsequent Data

MTC: 4P Wage: 600.00
Jurisdiction: XX NBR Days Worked: 5

Death
Dependent/
PRR Code 350
PRR Amount 200.00
SECTION 5
SCENARIO:
4P – SROI (Partial Denial #2 – Reoccurrence - page 1 of 3)
Narrative:
claim is compensable and initiates payment to the employee. The claim administrator transmits an initial
payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note: the waiting period
is not initially paid.

N/A

050 1/8/93 1/14/93 1 400.00 400.00 400.00

Jurisdiction: XX Number Days Worked: 5

Death
Dependent/
P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
On 1/31/93 the claim administrator is notified that the employee returned to work on 1/29/93 with
restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to notify
them that the indemnity benefits are being suspended effective 1/28/93.

N/A

050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00
Sample of “S1” Subsequent Data

MTC: S1 Wage: 600.00
Date of Return/Release to Work: 1/29/93 MMI:
RTW Qualifier: 2 # of Dependents:

Death
Paid to Dependent/
Permanent Payment Benefit Date/Reduced Payee
P/A Code 050
P/A Total 1600.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
On 3/1/93 the claim administrator is notified that the employee began losing time from work again on
2/28/93. The claim administrator investigates and determines that the lost time is not related to the injury.
On 3/15/93 the claim administrator sends notification to the employee that they are denying only the
additional lost time and reasonable medical payments will continue. The jurisdiction requires a
subsequent report for the partial denial. The claim administrator sends a transmission on 3/15/93 to the
jurisdiction to notify them of the partial denial.

Effective vs. action date and narrative reason for the denial is needed on paper. Also, in many
circumstances the jurisdiction will be unable to tell what specific benefit type(s) is being denied.

050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00
350 1/1/93 1/31/93 500.00 500.00

MTC: 4P Wage: 600.00

Death
Dependent/
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
AP – SROI (Acquired Payment)
Narrative:
injury once seven days of lost time has occurred. The only information reported by the old claim
administrator to the jurisdiction to date was the original first report. Weekly wage replacement benefits are
currently being paid. On 2/1/94 a new claim administrator takes over administration of the claim. The old
administrator can only provide them with a total unallocated indemnity benefits paid to date and a total
unallocated medical expense paid to date. On 2/14/94 the new claim administrator makes their initial
payment to the employee. The claim administrator transmits an acquired payment report to the jurisdiction
on 2/14/94 to notify them of their initial payment.

Data will need to be edited carefully by the jurisdiction to ensure that previously received data is not
improperly overlaid.

050 2/1/94 2/14/94 2 400.00 800.00 800.00
430 1/1/93 1/31/94 10000.00 10000.00
440 1/1/93 1/31/94 12500.00 12500.00
Sample of “AP” Subsequent Data

MTC: AP Wage: 600.00

Permanent Payment Benefit Paid to Date/Reduced Death Dependent/
Impairment Adjustment Adjustment Earnings/Recoveries Payee Relationship
P/A Amount 400.00
P/A End 2/14/94 PRR Amount 12500.00
P/A Weeks 2
P/A Days 0
SECTION 5
SCENARIO:
CB – SROI (Change in Benefit Type – page 1 of 3)
Narrative:
payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note: the waiting period
is not initially paid.

N/A

050 1/8/93 1/14/93 1 400.00 400.00 400.00


Death
Dependent/
P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
restrictions earning $450.00 per week. The employee is due temporary partial wage replacement benefits
starting on 1/29/93 at a weekly rate of 2/3rds of the difference between the pre-injury weekly wage and the
current weekly earnings or 2/3rds of $150.00 = $100.00. On 2/11/93 the claim administrator issues the
initial temporary partial check and sends a transmission to the jurisdiction to notify them of the change in
benefit type. Note: CB is also used when adding concurrent indemnity benefit payments.

Multiple periods of disability for a specific benefit type are not discernable when reported in a single
transmission. Effective vs. action date and reason for the change in benefit are needed. If CA’s or
benefit adjustments happen at the same time as the CB, multiple transmissions may come on the
same day, therefore, jurisdictions should process the transactions in the same sequence as received
to avoid overlaying the most current data.

050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00
070 1/29/93 2/11/93 2 A 450.00 200.00 200.00
SECTION 5
SCENARIO:
Sample of “CB” Subsequent Data:

MTC: CB Wage: 600.00

Death
Dependent/
P/A Amount 400.00
P/A Weeks 4
P/A Days 0
P/A Code 070

P/A Total 200.00
P/A Amount 100.00
P/A Start 1/29/93
P/A End 2/11/93
P/A Weeks 2
P/A Days 0
SECTION 5
SCENARIO:
CD – SROI (Compensable Death No Dependent/Payees)
Narrative:
Employee was fatally injured on 1/1/93. The employee’s weekly wage is $600.00. The jurisdiction
requires a first report of injury within seven days after the death. The claim administrator transmitted the
first report of injury on 1/8/93 as the seven days had elapsed. The claim administrator determines that the
claim is compensable. There are no known dependents and no payment is due to the jurisdiction's fund.
On 1/14/93 the claim administrator issues a check for $5,000.00 to cover the funeral expense and a check
for $1,500.00 for the autopsy expenses. The jurisdiction requires reporting of the compensability
determination within 14 days of the death even where no indemnity benefits are currently payable. The
claim administrator transmits a compensable death report to the jurisdiction on 1/14/93 to notify them of
their determination. Note: When the CD is transmitted, there may not be any paid to dates report.

N/A
370 1/1/93 1/1/93 1500.00 1500.00
300 1/1/93 1/1/93 5000.00 5000.00
Sample of “CD” Subsequent Data

MTC: CD Wage: 600.00
Date of Death: 1/1/93 Claim Status: 0

Death
Dependent/
PRR Code 300
PRR Amount 5000.00
PRR Code 370

PRR Amount 1500.00
SECTION 5
SCENARIO:
CO – SROI (Correction)
Narrative:
payment report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period
is not initially paid. On 1/15/93 the jurisdiction acknowledged the transmission as being accepted with a
non-critical error of a missing conditional field – claim status. On 1/18/93 the claim administrator corrects
the error and transmits a correction report to the jurisdiction.

Maintenance Type Code Date of the Correction must be the same date as the transaction it is
correcting (see MTC Date Definition, page 6-39).
Sample of “IP”: SROI Data

Date of Return to Work: MMI:
Date of Death: Claim Status:
Sample of “CO”: SROI Data

MTC: CO Wage: 600.00
Date of Return to Work: MMI:
SECTION 5
SCENARIO:
FN –SROI (Final - page 1 of 2)
Narrative:
Employee was injured on 1/1/93. All reporting required by the jurisdiction has occurred including
suspension reports. No indemnity benefits are currently being paid nor are there any additional
anticipated to be owed in the future. The last medical treatment by the claimant was more than six months
ago and the health care provider has indicated that there is no future medical care anticipated. On 4/1/94
the claim administrator decides to close the claim due to the fact that all payments owed have been made
and no future payments are anticipated. The jurisdiction requires notification when the claim administrator
closes the claim, therefore the claim administrator transmits a final report on 4/1/94. Note: For this
scenario, the Sample of Payment Input Fields does not list each check but only the summary for each
Payment Code.

Multiple periods of disability for a specific benefit type are not discernable in a single transmission.
350 1/1/93 7/30/93 10000.00 10000.00
370 1/1/93 7/30/93 2000.00 2000.00
050 1/1/93 4/29/93 17 400.00 6800.00 6800.00
SECTION 5
SCENARIO:
FN –SROI (Final – page 2 of 2)
Sample of “FN” Subsequent Data

MTC: FN Wage: 600.00
Date of Return/Release to Work: 4/30/93 MMI: 8/1/93
Date of Death: Claim Status: C

Death
Dependent/
P/A Amount 400.00
P/A Weeks 17
P/A Days 0
SECTION 5
SCENARIO:
FS –SROI (Full Salary)
Narrative:
employee's weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is
satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93. The
jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim
administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93
the claim administrator initially determines that the claim is compensable. The employer is paying salary
in lieu of compensation. The claim administrator transmits a full salary report to the jurisdiction on 1/14/93
to notify them. The date disability began (1/1/93) is used as the start date, since the employer has
continued salary with no break through the disability period to date.

transmission.
240 1/8/93 1/14/93 0 400.00 400.00 0.00
Sample of “FS” Subsequent Data

MTC: FS Wage: 600.00
Date Disability Began: 1/1/93 Salary Continued Ind: Y

Death
Paid to Dependent/
P/A Code 240
P/A Total 0.00
P/A Amount 0.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 0
P/A Days 0
SECTION 5
SCENARIO:
IP –SROI (Initial Payment)
Narrative:
employee was not paid by the employer for the day of the injury. The employee's weekly wage is $600.00.
After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for
temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury
once seven days of lost time has occurred. The claim administrator transmitted the first report of injury of
1/8/93 as the seven days had elapsed. On 1/14/93 the claim administrator determines that the claim is
compensable and initiates payment to the employee. The claim administrator transmits an initial payment
report to the jurisdiction on 1/14/93 to notify them of the initial payment. Note the waiting period is not
initially paid.

transmission.
050 1/8/93 1/14/93 1 400.00 400.00 400.00


Death
Dependent/
P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
IP – SROI (Initial Payment - Fatality #1 – page 1 of 2)
Narrative:
claim is compensable. There are no known dependents and a one time payment is due to the
jurisdiction's fund. On 1/14/93 the claim administrator issues a check for $5,000.00 to cover the funeral
expense, a check for $1,500.00 for the autopsy expenses, and a check for $25,000.00 for a one time
payment to the jurisdiction's fund. The claim administrator transmits an initial payment report to the
jurisdiction on 1/14/93 to notify them of the initial payment.

Multiple periods of disability for a specific benefit type are not reportable in a single transmission.
010 1/1/93 1/1/93 25000.00 25000.00
300 1/1/93 1/1/93 5000.00 5000.00
370 1/1/93 1/1/93 1500.00 1500.00
SECTION 5
SCENARIO:
IP – SROI (Initial Payment - Fatality #1 – page 2 of 2)

Date of Death: 1/1/93 Claim Status: C

Death
Dependent/
P/A Code 010 PRR Code 300 Relationship 81
P/A Amount 400.00
P/A Weeks 0
P/A Days 0
SECTION 5
SCENARIO:
IP – SROI (Initial Payment - Fatality #2)
Narrative:
claim is compensable. There are no known dependents and weekly payments are due to the jurisdiction's
fund for 104 weeks. The claim administrator decides to make all the weekly payments in one lump sum.
On 1/14/93 the claim administrator issues a check for $5,000.00 to cover the funeral expense, a check for
$1,500.00 for the autopsy expenses, and a check for $41,600.00 for a lump sum payment to the
jurisdiction's fund. The claim administrator transmits an initial payment report to the jurisdiction on 1/14/93
to notify them of the initial payment.
010 1/1/93 12/29/94 104 41,600.00 41,600.00
300 1/1/93 1/1/93 5000.00 5000.00
370 1/1/93 1/1/93 1500.00 1500.00

Date of Death: 1/1/93 Claim Status: C

Death
Dependent/
P/A Code 010 PRR Code 300 Relationship 81
P/A Total 41,600.00 PRR Amount 5000.00
P/A Amount 400.00
P/A Weeks 104
P/A Days 0
SECTION 5
SCENARIO:
P7 – SROI (Partial Suspension - Page 1 of 2)
Narrative:
Employee was injured on 1/1/92. All information has been reported to the jurisdiction as required to date.
Weekly permanent total and permanent total supplemental wage replacement benefits are currently being
paid. On 3/1/94 the employee reaches the age of 62, and therefore is not longer eligible for permanent
total supplemental. The claim administrator discontinues payment of the permanent total supplemental
only as of 3/1/94. The claim administrator transmits a partial suspension report to the jurisdiction on
3/6/94 to notify them of the partial suspension. Note: For this scenario, the Sample of Payment Input
Fields does not list each check but only the summary for each Payment Code.

Effective vs. action date and reason for the suspension of the benefit is needed. Also, the
transmission does not specify which benefit types are being suspended.
350 1/1/92 7/30/93 36500.00 36500.00
020 1/1/92 2/28/94 112 400.00 44800.00 44800.00
021 1/1/92 2/28/94 112 400.00 2240.00 2240.00
SECTION 5
SCENARIO:
P7 – SROI (Partial Suspension - Page 2 of 2)
Sample of “P7” Subsequent Data

MTC: P7 Wage: 600.00
Date of Return/Release to Work: MMI: 12/31/92

Death
Dependent/
P/A Amount 400.00
P/A Start 1/1/92
P/A End 2/28/94
P/A Weeks 112
P/A Days 0
P/A Code 021

P/A Total 2240.00
P/A Amount 20.00
P/A Start 1/1/92
P/A End 2/28/94
P/A Weeks 112
P/A Days 0
SECTION 5
SCENARIO:
PY – SROI (Payment Report #1 - Medical Payment Reporting)
Narrative:
Employee was injured on 1/1/93. The employee has not lost any time from work due to the injury. The
jurisdiction requires a first report of injury within seven days after the injury. The claim administrator
transmitted the first report of injury on 1/8/93 as the seven days had elapsed. The claim administrator
determines that the claim is compensable. The jurisdiction requires a subsequent report once payment of
medical bills reaches $500.00 on medical only claims. As of 1/28/93 the payment of medical bills brought
the total paid to date to 500.00. The claim administrator transmits a payment report to the jurisdictions on
1/28/93.

N/A
350 1/1/93 1/21/93 500.00 500.00
Sample of “PY” Subsequent Data

MTC: PY Wage: 600.00
Date Disability Began: Salary Continued Ind: N

Death
Dependent/
PRR Code 350
PRR Amount 500.00
SECTION 5
SCENARIO:
PY – SROI (Payment Report #2 - Penalty Payment - Page 1 of 3)
Narrative:
employee was not paid by the employer for the day of the injury. The employee's weekly wage is $600.00.
After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is eligible for
temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first report of injury
once seven days of lost time has occurred. The claim administrator transmitted the first report of injury on
1/8/93 as the seven days had elapsed. On 1/22/93, the claim administrator determines that the claim is
compensable and initiates payment to the employee. The claim administrator transmits an initial payment
report to the jurisdiction on 1/22/93 to notify them of the initial payment. Note: the initial payment is
required within 14 days but was not made for 21 days and is late.

N/A
050 1/1/93 1/21/93 3 400.00 1200.00 1200.00


Death
Paid to Dependent/
P/A Code 050
P/A Total 1200.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/21/93
P/A Weeks 3
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
On 1/31/93 the claim administrator is notified that the employee returned to work on 1/29/93 with no
restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to notify
them that indemnity benefits are being suspended effective 1/28/93.

N/A
050 1/1/93 1/21/93 3 400.00 1200.00 1200.00
050 1/22/93 1/28/93 1 400.00 400.00 400.00


Death
Paid to Dependent/
P/A Code 050
P/A Total 1600.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
The jurisdiction assessed a penalty for the late first payment on 3/1/93. The amount of the penalty is
10% of the amount owed on the date of the late payment or 10% of $1,200.00 or $120.00 The penalty
is payable to the employee. The claim administrator makes payment to the employee of the $120.00
penalty on 3/31/93. The jurisdiction requires a subsequent report for payment of penalties. The claim
administrator transmits a payment report to the jurisdiction on 3/31/93 to show the penalty payment.

N/A
050 1/1/93 1/21/93 3 400.00 1200.00 1200.00
050 1/22/93 1/28/93 1 400.00 400.00 400.00
310 3/31/93 3/31/93 120.00 120.00
Sample of “PY” Subsequent Data

MTC: PY Wage: 600.00

Death
Dependent/
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
RB – SROI (Reinstatement of Benefits - #1 Different Benefit Type - Page 1 of 3)
Narrative:
Employee was injured on 1/1/93. The employee left work the day of the injury and has not returned.
The employee was not paid by the employer for the day of the injury. The employee's weekly wage is
$600.00. After a seven day waiting period from 1/1/93 through 1/7/93 is satisfied, the employee is
eligible for temporary total disability wage replacement starting 1/8/93. The jurisdiction requires a first
report of injury once seven days of lost time has occurred. The claim administrator transmitted the first
report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator
determines that the claim is compensable and initiates payment to the employee. The claim
administrator transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial
payment. Note the waiting period is not initially paid.
Sample of Payment Input Fields :
050 1/8/93 1/14/93 1 400.00 400.00 400.00


Death
Dependent/
P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
restrictions. The claim administrator transmits a suspension report to the jurisdiction on 1/31/93 to
notify them that indemnity benefits are being suspended effective 1/28/93.
050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00


Death
Dependent/
P/A Code 050
P/A Total 1600.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
On 2/22/93 the claim administrator is notified that the employee could not continue to work full time and
began working part time on 2/8/93 earning a weekly wage of $450.00. Claimant’s weekly wage is
$600.00. The employee is due temporary partial wage replacement benefits starting on 2/8/93 at a
weekly rate of 2/3 of the difference between the pre-injury weekly wage and the current weekly
earnings or 2/3 of $150.00 = $100.00. On 2/22/93 the claim administrator issues the initial temporary
partial check and sends a transmission to the jurisdiction to notify them of reinstatement of benefits.
Limitations Known to Date:
Reason for the reinstatement of benefits is needed.
050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00
070 2/8/93 2/21/93 2 A 450.00 200.00 200.00
Sample of “RB” Subsequent Data

MTC: RB Wage: 600.00

Death
Dependent/
P/A Amount 400.00
P/A Weeks 4
P/A Days 0
P/A Code 070

P/A Total 200.00
P/A Amount 100.00
P/A Start 2/8/93
P/A End 2/21/93
P/A Weeks 2
P/A Days 0
SECTION 5
SCENARIO:
RB – SROI (Reinstatement of Benefits - #2 Same Benefit Type - Page 1 of 3)
Narrative:
The employee was not paid by the employer for the day of the injury. The employee’s weekly wage is
report of injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator
050 1/8/93 1/14/93 1 400.00 400.00 400.00


Death Dependent/
P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00

RTW Qualifier: 2 # of Dependents :

Death Dependent/
P/A Code 050
P/A Total 1600.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
Narrative:
On 2/22/93 the claim administrator is notified that the employee was once again totally off work due to
the injury as of 2/8/93. On 2/22/93 the claim administrator reinstates total wage replacement benefits
and sends a transmission to the jurisdiction to notify them of reinstatement of benefits.
Limitations Known to Date:
Reason for the reinstatement of benefits is needed. There is question concerning whether the return to
work date and qualifier are blanked out or continue to be filled with the previous return to work
information. Note: The payment/adjustment code start date has been reset to the beginning date of
the new period of lost time, yet the payment/adjustment code paid to date total is a cumulative field.
There is a need for careful processing by the jurisdiction.
050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00
050 2/8/93 2/21/93 2 400.00 800.00 200.00
Sample of “RB” Subsequent Data

MTC: RB Wage: 600.00

Death
Dependent/
P/A Code 050
P/A Total 2400.00
P/A Amount 400.00
P/A Start 2/8/93
P/A End 2/21/93
P/A Weeks 6
P/A Days 0
SECTION 5
SCENARIO:
S1 – SROI (Suspension - Page 1 of 2)
Narrative:
report of injury on 1/8/93 as seven days had elapsed. On 1/14/93, the claim administrator determines
that the claim is compensable and initiates payment to the employee. The claim administrator
transmits an initial payment report to the jurisdiction on 1/14/93 to notify them of the initial payment.
Note the waiting period is not initially paid.
050 1/8/93 1/14/93 1 400.00 400.00 400.00


P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
S1 – SROI (Suspension - Page 2 of 2)
Narrative:

Effective vs. action date and narrative reason for the suspension (for some “S” codes) in benefit are
needed.
050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00


Death
Dependent/
P/A Code 050
P/A Total 1600.00
P/A Am ount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
VE – SROI (Volunteer)
Narrative:
The employee is an unpaid volunteer. The jurisdiction requires a first report of injury once seven days
of lost time has occurred. The claim administrator transmitted the first report of injury on 1/8/93 as
seven days had elapsed. The jurisdiction’s statute does not require payment of wage replacement to
unpaid volunteers but does require reporting of the compensability determination within 14 days of the
date disability began. On 1/14/93, the claim administrator determines that the claim is compensable.
The claim administrator transmits a volunteer report to the jurisdiction on 1/14/93 to notify them of the
determination. Note: If the jurisdiction’s statute requires payment of wage replacement benefits then
an initial payment report would be sent when the first check was issued instead of the volunteer report.
350 1/1/93 1/3/93 200.00 200.00
Sample of “VE” Subsequent Data

MTC: VE Wage: 0.00
MTC Date: 1/14/93 Wage Period:

PRR Code 350

PRR Amount 200.00
SECTION 5
SCENARIO:
Recoveries – page 1 of 2
Narrative:
report on injury on 1/8/93 as the seven days had elapsed. On 1/14/93, the claim administrator
300 1/8/93 1/14/93 1 400.00 400.00 400.00


P/A Code 050
P/A Total 400.00
P/A Amount 400.00
P/A Start 1/8/93
P/A End 1/14/93
P/A/ Weeks 1
P/A Days 0
SECTION 5
SCENARIO:
Recoveries - Page 2 of 2)
Narrative:
restrictions. However, payment has already been made to the employee through 2/25/93. The
employee has cashed the check but reimburses the claim administrator $720.00 on 3/1/93 for the
overpayment. The claim administrator transmits a suspension report to the jurisdiction on 3/1/93 to
notify them that indemnity benefits are being suspended effective 2/14/93 and showing the recovered
overpayment. Note: When recovering money due to an overpayment adjust the actual payment
amounts, etc. for the affected payment codes.
050 1/8/93 1/14/93 1 400.00 400.00 400.00
050 1/1/93 1/7/93 1 400.00 400.00 400.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00
050 1/29/93 2/11/93 2 400.00 800.00 800.00
050 2/12/93 2/25/93 2 400.00 800.00 800.00
Sample of Refund Transmittal:

Payment Recovery From Date Thru Date Weeks Weekly Gross Paid
Code Date Rec’d Rate
050 830 2/14/93 2/25/93 1.8 400.00 720.00 720.00


Death
Dependent/
P/A Amount 400.00
P/A Start 1/01/93
P/A End 2/14/93
P/A Weeks 6
P/A Days 1
SECTION 5
SCENARIO:
Multiple Events – 04/IP (Multiple Payments on IP) - page 1 of 2
Narrative:
eligible for temporary total disability wage replacement starting 1/8/93. On 1/8/93, the claim
administrator determines that the claim is not compensable and is therefore denying the entire claim.
The claim administrator transmits an 04 denial report (instead of the 00) to the jurisdiction on 1/8/93 to
notify them that the entire claim is denied.
Sample of “04” Subsequent Data

MTC: 04 Employment Status Code FT
MTC Date: 1/8/93 Wage: 600.00
Date Disability Began: 1/1/93 NBR Days Worked: 5
Date of Return to Work: Salary Continued Ind: N
Date of Death:
Continued
SECTION 5
SCENARIO:
Multiple Events – 04/IP (Multiple Payments on IP) - page 2 of 2
Narrative:
The employee hires an attorney and litigates the issue of compensability. A hearing is held and on
3/19/94 the Judge determines that the claim is compensable and orders the following to be paid:
temporary total wage replacement disability from 1/1/93 through 4/1/93, a scheduled whole body
permanent partial disability of 10% to the body as a whole, $10,000.00 in medical bills accrued to date,
and $3,500.00 in employee attorney fees (to be paid in addition to the indemnity benefits to be paid).
The employer has also incurred $1,800.00 in legal expenses to date. On 4/1/94 the claim
administrator issues a check to cover all the moneys owed per the order. The claim administrator
transmits an initial payment report to the jurisdiction on 4/1/94 to notify them of the initial payment.
Note: None of these payments are compromise payments.
330 1/1/93 3/17/94 1800.00 1800.00
340 1/1/93 3/17/94 3500.00 3500.00
350 1/1/93 3/1/94 10000.00 10000.00
030 4/2/93 3/17/94 50 400.00 20000.00 20000.00
050 1/1/93 4/1/93 13 400.00 5200.00 5200.00

Date of Return/Release to Work: 4/2/93 MMI: 4/2/93
# Occurrences 1 # Occurrences 2 # Occurrences 0 # Occurrences 3 # Occurrences

Death
Dependent/
Body
Part 99 P/A Code 050 PRR Code 330
Percent 10.00 P/A Total 5200.00 PRR Amount 1800.00
P/A Amount 400.00
P/A Weeks 12
P/A Days 0 PRR Code 350
PRR Amount 4000.00
P/A Code 030
P/A Total 20000.00
P/A Amount 400.00
P/A Start 4/2/93
P/A End 3/17/94
P/A Weeks 50
P/A Days 0
SECTION 5
SCENARIO:
Multiple Events – FS/IP #1 (Employer Reimbursed Full Salary) - page 1 of 2
Narrative:
The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93
is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93.
The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim
administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On
1/14/93, the claim administrator initially determines that the claim is compensable. The employer is
paying salary in lieu of compensation. The claim administrator transmits a full salary report to the
jurisdiction on 1/14/93 to notify them. Note: The waiting period is not initially included in the benefits
owed. However, if the payment/adjustment start date is unknown, the date disability began (1/1/93) is
used as the start date.)
240 1/8/93 1/14/93 0 400.00 400.00 .00


Death
Dependent/
P/A Code 240
P/A Total 0.00
P/A Amount 0.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 0
P/A Days 0
SECTION 5
SCENARIO:
Multiple Events – FS/IP #1 (Employer Reimbursed Full Salary) - page 2 of 2
Narrative:
After two weeks, the employer decides not to continue paying salary in lieu of compensation and
wants to be reimbursed for the two weeks already paid. On 1/28/93, claim administrator issues their
initial payment and transmits an initial payment report to the jurisdiction. Note: the initial payment is
probably made in two checks – one sent to the employee and one sent to the employer.
240 1/8/93 1/14/93 1 400.00 400.00 0.00
240 1/1/93 1/7/93 1 400.00 400.00 0.00
050 1/1/93 1/14/93 2 400.00 800.00 800.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00


Death Dependent/
P/A Code 050
P/A Total 1600.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/28/93
P/A Weeks 4
P/A Days 0
SECTION 5
SCENARIO:
Multiple Events – FS/IP #2 (Employer Not Reimbursed Full Salary) - page 1 of 2
Narrative:
The employee’s weekly wage is $600.00. After a seven day waiting period from 1/1/93 through 1/7/93
is satisfied, the employee is eligible for temporary total disability wage replacement starting 1/8/93.
The jurisdiction requires a first report of injury once seven days of lost time has occurred. The claim
administrator transmitted the first report of injury on 1/8/93 as the seven days had elapsed. On
1/14/93, the claim administrator initially determines that the claim is compensable. The employer is
paying salary in lieu of compensation. The claim administrator transmits a full salary report to the
jurisdiction on 1/14/93 to notify them. Note: The waiting period is not initially included in the benefits
owed. However, if the payment/adjustment start date is unknown, the date disability began (1/1/93) is
used as the start date.)
240 1/8/93 1/14/93 0 400.00 400.00 0.00


Death
Dependent/
P/A Code 240
P/A Total 0.00
P/A Amount 0.00
P/A Start 1/8/93
P/A End 1/14/93
P/A Weeks 0
P/A Days 0
SECTION 5
SCENARIO:
Multiple Events – FS/IP #1 (Employer Not Reimbursed Full Salary) - page 2 of 2
Narrative:
After two weeks, the employer decides not to continue paying salary in lieu of compensation and does not
want to be reimbursed for the two weeks already paid. On 1/28/93, claim administrator issues their initial
payment and transmits an initial payment report to the jurisdiction.
240 1/8/93 1/14/93 1 400.00 400.00 0.00
240 1/1/93 1/7/93 1 400.00 400.00 0.00
050 1/15/93 1/28/93 2 400.00 800.00 800.00


P/A Code 050
P/A Total 800.00
P/A Amount 400.00
P/A Start 1/15/93
P/A End 1/28/93
P/A Weeks 2
P/A Days 0
P/A Code 240

P/A Total 800.00
P/A Amount 400.00
P/A Start 1/1/93
P/A End 1/14/93
P/A Weeks 2
P/A Days 0
SECTION 5
TECHNICAL SCENARIOS
BATCH REJECTS: HEADER RECORD, TRANSACTIONS AND TRAILER RECORD
Validate Header Record (Transaction Set ID: HD1)
Each batch contains a header record (HD1), transaction record(s) and a trailer record (TR1). The header
record is used to identify the trading partner transmitting the batch, the receiver, the interchange version
ID, the date and time the transmission was sent, and the test/production indicator.
The transmission profile, element requirements table and the edit matrix are used to edit the data
elements in the header record. Any errors in these data elements would create edit errors that would
cause the batch to be rejected at the header level. The audit file is used to determine a duplicate batch.
If a batch is rejected at the header level, a new record is posted to the audit file with a batch processing
status of rejected. The individual transactions within the batch are not processed. The process continues
with the next batch.
If a batch is accepted, a new record is posted to the audit file and the process continues to validate detail
transactions.
SECTION 5
ACKNOWLEDGMENT SCENARIO 1:
VALIDATE SENDER ID OF HEADER (HD1)
The Sender ID is made up of the Sender FEIN, the FEIN of the sending party, filler and the Sender Postal
Code, the postal code of the sending party. It is used to identify the sending party. If the Sender ID is
invalid, manual verification of trading partner tables and/or communications will be required. No further
processing of the batch will be done. The process continues with the next batch.
SECTION 5
VALIDATE REMAINING HEADER DATA ELEMENTS
A batch with header errors is indicated by an ‘HD’ in the Application Acknowledgment Code of the AK1,
‘all zeros’ in the Record Sequence Number, the element number in error and the element error number
for the error.
ACK SCENARIO 2: ACKNOWLEDGMENT DETAIL

This scenario communicates what the AK1 would contain if a batch is rejected because of header error.
DATA NUMBER DATA ELEMENT NAME VALUES
DN0001 Transaction Set ID AK1
DN0107 Record Sequence Number 000000000
DN0108 Date Processed 19970417
DN0109 Time Processed 020000
DN0006 Insurer FEIN
DN0014 Claim Administrator Mailing Postal Code
DN0008 Third Party Administrator FEIN
DN0110 Acknowledgment Transaction Set ID
DN0111 Application Acknowledgment Code HD
DN0026 Insured Report Number
DN0015 Claim Administrator Claim Number
DN0005 Jurisdiction Claim Number
DN0002 Maintenance Type Code (From Original Trans)
DN0003 Maintenance Type Date (From Original Trans)
DN0112 Request Code
DN0113 Free Form Text
DN0114 Number Of Errors Number of header errors goes here.
DN0115 Element Number Header Data Element Number in error goes here.
DN0116 Element Error Number Header Element Error Number goes here.
DN0117 Variable Segment Number
SECTION 5
ACK SCENARIO 3:
VALIDATE HEADER FOR DUPLICATE BATCH
A batch is considered to be a duplicate when the combination of Sender ID, Date Transmission Sent,
Time Transmission Sent and Interchange Version ID already exist in the audit file. A duplicate batch will
be indicated by an ‘HD’ in the Application Acknowledgment Code of the AK1, ‘all zeros’ in the Record
Sequence Number, ‘0001' in the Element Number and ‘057' in the Element Error Number.

This scenario communicates what the AK1 would contain if a batch is rejected because of duplicate batch.
DN0006 Insurer FEIN
DN0112 Request Code
DN0114 Number Of Errors 01
DN0115 Element Number 0001
DN0116 Element Error Number 057
SECTION 5
ACK SCENARIO 4:
VALIDATE TRAILER RECORD
The trailer record contains the number of transactions within a batch. The trailer record is edited to make
sure the number of transactions is the same as counters in the trailer. If the trailer record is rejected, the
batch is rejected. This will be indicated by an ‘HD’ in the Application Acknowledgment Code of the AK1,
‘all nines’ in the Record Sequence Number, the Element Number for the data element in error and the
Element Error Number referencing the error. Processing of that batch will cease and will resume with the
next HD1 record. The entire batch will not be processed.
ACK SCENARIO4: ACKNOWLEDGMENT DETAIL

This scenario communicates what the AK1 would contain if a batch is rejected because of trailer error.

DN0006 Insurer Fein
DN0112 Request Code
DN0114 Number Of Errors Number of trailer errors goes here.
DN0115 Element Number Trailer Element Number goes here.
DN0116 Element Error Number Trailer Element Error Number goes here.
SECTION 5
VALIDATE BATCH FOR TRANSACTION EXISTENCE
A batch is a set of records containing one header record, one or more transactions and one trailer record.
A batch which contains no transaction(s) is indicated by an ‘HD’ in the Application Acknowledgment Code
of the AK1, ‘all zeros’ in the Record Sequence Number, ‘0000-Entire Batch' Element Number and ‘061-
Event Criteria Not Met' Element Error Number for the error.

This scenario communicates what the AK1 would contain if a batch is rejected because it contains no transactions.
DN0006 Insurer FEIN
DN0112 Request Code
SECTION 5
VALIDATE BATCH INTEGRITY
A batch is a set of records containing one header record, one or more transactions and one trailer record.
The transaction(s) within the batch contain a transaction set ID that corresponds to the transmission type
code indicated within the interchange version ID of the HD1. If a transaction within the batch does not
match the HD1 transaction type code, the entire batch will be rejected. A batch which contains invalid
transactions is indicated by an ‘HD’ in the application acknowledgment code, ‘all zeros’ in the record
sequence number, ‘0105-Interchange Version ID' in the element number and ‘064-Data Sequence
relationship’ in the element error number.

This scenario communicates what the AK1 would contain if a batch is rejected because of invalid transactions within the batch.
DN0006 Insurer FEIN
DN0112 Request Code
SECTION 5
SECTION 6
6.
Definitions, Glossary & Code Lists
SECTION 6
SECTION 6
DICTIONARY
For
TRANSMISSION HEADER
FIRST REPORT
SUBSEQUENT REPORT
ACKNOWLEDGMENT DETAIL
TRANSMISSION TRAILER
SECTION 6
SECTION 6
DATA FORMAT :
Definition: The combination of data length and data type of a specified

data field.
Data Length: The maximum number of characters, expressed as a whole

number, that can be contained in a specific data field.
Data Type: A designation that indicates the intended interpretation, and

processing of data contained in a specific data field.
Computational Fields:
"N" Number Format: Unsigned, right justified, zero fill.
"$9.2" Monetary amount format: Signed, right justified, zero fill, "$" and "."
(decimal) implied, not included.
Non-Computational Fields:
Not used for mathematical calculations.
"DATE" Date format field: left justified, blank fill. CCYYMMDD format.
CC = Century
YY = Year
MM = Month
DD = Day
"HHMM" Time format field: Only a valid time in military format, zero, or spaces are
allowed in time fields. Use 24 hour military time. All zeros in a time field
is valid and equivalent to 240000 or 2400. Spaces indicate absence of
data. May be left blank for occupational disease or injury.
HH = Hours
MM = Minutes
"A/N" Alpha/Numeric format fields: left justified, blank fill.

Data elements that are defined to be alphanumeric (A/N) consist of a
sequence of any characters from common character code schemes of
EBCDIC, ASCII, and CCITT International Alphabet 5. When using an
alphanumeric field the significant characters are always left justified in the
field with any remaining space in the field padded with spaces.
Alphanumeric character set includes those selected from the uppercase
letters, lower case letters, numeric digits, space character, and special
characters as follows:
A...Z a...z 0...9 , < . > / ? ; : ' " [ { ] } \ | ` ~ ! @ # $ % ^ & * ( ) - _ = +(space)
Use of any special characters as record delimiters are subject to the

trading partner agreement identifying delimiters.
Use of any of the alphanumeric characters are permitted in data elements
with the alphanumeric data type unless otherwise indicated in an
Implementation Note.
Revised: 2/15/02
SECTION 6
Element – Data Number:
ACCIDENT DESCRIPTION/CAUSE - DN38

Definition: A free form description of how the accident occurred and the
resulting injuries.
Business Need: To clarify what happen to the injured worker.
Revised: 8/9/95
Source: IAIABC
Format: 150 A/N
Record: First Report
ACKNOWLEDGMENT TRANSACTION SET ID - DN110

Definition: The transaction set identifier that identifies the transaction being
acknowledged.
Business Need: One of the codes needed to uniquely identify the transaction
being acknowledged.
Revised 8/9/95
Source: IAIABC
Format: 3 A/N
Values: 148 - First Report
A49 - Subsequent Report
HD1 - Transmission Header Record
Record: Acknowledgment Detail Record (AK1)
AGENCY CLAIM NUMBER - DN5

Definition: The number assigned by the agency or commission to identify a
specific claim.
Business Need: To identify claim, allow for SSN or date of injury correction.
Revised: 3/11/94
Source: IAIABC
Format: 25 A/N
Subsequent Report
Acknowledgment Detail Record (AK1)
Implementation Note: This number may be changed during the life of the claim by the
jurisdiction.
AGREEMENT TO COMPENSATE CODE - DN75

Definition: A code used to identify the condition under which compensation
benefits are being paid.
Busi ness Need: To indicate whether the payments are being made with/without
determination of liability.
Revised: 8/9/95
Source: IAIABC
Format: 1 A/N
Values: W - Without Liability
L - With Liability
Record: Subsequent Report
SECTION 6
APPLICATION ACKNOWLEDGMENT CODE - DN111

Definition: A code used to identify the accepted/rejected status of the
transaction being acknowledged.
Business Need: To identify to the originator whether a detail transaction was
accepted or rejected by the receiver, and if the receiver
encountered critical and/or non-critical errors in the contents of
the transaction.
Revised: 8/9/95
Source: IAIABC
Format: 2 A/N
Values: HD - Batch Rejected
TA - Transaction Accepted
TE - Transaction Accepted with Errors
TR - Transaction Rejected
BENEFIT ADJUSTMENT CODE - DN92

Definition: A code used to identify an adjustment being applied to a weekly
payment/adjustment amount, still in effect (non suspension).
Business Need: To meet jurisdictional financial reporting requirements.
Revised: 6/7/95 (replaced weekly benefit with payment/adjustment)
Source: IAIABC Ref.: Benefit Offset Codes DCI Table 12 IAIABC
Payment Adjustment Codes
Format: 4 A/N BDDD
B = Benefit Adjustment Type

DDD = IAIABC Payment Adjustment Codes
Example: Overpayment Credit for Permanent Total = C020
B Meaning
A Apportionment/contribution - Weekly payment amount reduced for shared or
partial liability(s).
B Subrogation - Weekly payment amount reduced for recovery from third party tort-
feasor.
C Overpayment credit - Weekly payment amount reduced for benefits paid but not
due.
E Employer provided pension - Weekly payment amount reduced for eligibility or
payments under an employer provided pension program.
H Court ordered lien against workers' compensation benefits - Weekly payment
amount reduced for court ordered liens.
I Intoxication - Weekly payment amount reduced due to employee's intoxication at
the time of the injury.
K Claimant Attorney Fees - Weekly payment amount reduced for withholding or
payment of fees to the claimant's attorney.
L Disability Insurance/Income - Weekly payment amount reduced for disability
insurance/income eligibility or payment other than social security.
M Employer reimbursement (for full salary paid over and above the
compensation rate) - Weekly payment amount reduced for repayment to
employer for full salary paid over and above the compensation rate.
N Non-cooperation: Rehabilitation, training, education, medical - Weekly payment
amount reduced for non-cooperation/failure to comply with jurisdictional
requirements.
P Prepaid Benefit/Advance - Weekly payment amount reduced for reimbursement
of prepaid benefit/advance.
SECTION 6
R Social Security Retirement - Weekly payment amount reduced for eligibility or

payments under the Federal Old Age Survivors Act, 42 USC 402.
S Social Security Disability - Weekly payment amount reduced for eligibility or
payments under the Federal Disability Act, 42 USC 423.
T Acceleration of benefits - Weekly payment amount increased over and above
the compensation rate.
U Unemployment Compensation - Weekly payment amount reduced for eligibility
or payments under unemployment compensation.
V Safety Violations - Weekly payment amount reduced for safety violation(s).
W Partial wage continuation - Weekly payment amount reduced for continuation of
fringe benefits by the employer. (For example; room, board, health insurance,
etc.)
X Death Benefit Reduction - Weekly payment amount reduced for eligibility or
payments to survivors.
Y Partial reimbursement of Claimant attorney fees - Weekly payment amount
increased to the employee for partial reimbursement of claimant attorney fees.
BENEFIT ADJUSTMENT START DATE - DN94

Definition: The first date a benefit adjustment was applied.
Revised: 3/11/94
Source: IAIABC
Format: CCYYMMDD
BENEFIT ADJUSTMENT WEEKLY AMOUNT - DN93

Definition: The weekly amount of benefit adjustment applied per
Payment/Adjustment Code.
Revised: 7/24/95
Source: IAIABC
Format: $9.2
CAUSE OF INJURY CODE - DN37

Definition: The code which corresponds to the cause of injury.
Business Need: Loss Prevention Management
Revised: 3/11/94
Source: DCI Fld 26
Format: 2 A/N
Values: See Appendix (Cause of Injury Codes)
CLAIM ADMINISTRATOR ADDRESS LINE 1 - DN10

Definition: The mailing address of the claim administrator's processing
facility for this claim.
Business Need: Used to identify the Claim Administrator's facility processing the
claim.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
Implementation Note: If claim is being administered by a Third Party Administrator, use
the Third Party Administrator's address.
SECTION 6
CLAIM ADMINISTRATOR ADDRESS LINE 2 - DN11

Definition: The mailing address of the claim administrator's processing
facility for this claim.
claim.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
the Third Party Administrator's address.
CLAIM ADMINISTRATOR CITY - DN12

Definition: The city of the claim administrator's processing facility's mailing
address for this claim.
claim.
Revised: 6/7/95
Source: IAIABC
Format: 15 A/N
the Third Party Administrator's city.
CLAIM ADMINISTRATOR CLAIM NUMBER - DN15

Definition: Identifies a specific claim within a claim administrator's claims
processing system.
Business Need: Business management
Revised: 2/15/02
Source: IAIABC
Format: 25 A/N
Subsequent Report
Implementation Note: This data element shall not contain leading spaces or leading
special characters. The number may contain embedded spaces
and special characters. Montana understands that they may not
be able to implement this in a timely fashion.
CLAIM ADMINISTRATOR POSTAL CODE - DN14

Definition: The postal code of the claim administrator's processing facility's
mailing address for this claim.
claim.
Revised: 8/9/95
Source: IAIABC
Ref.: ANSI A51 for U.S. postal codes plus non-U.S. postal codes.
Format: 9 A/N
Subsequent Report
Implementation Note: If claim is being administered by a Third Part y Administrator, use
the Third Party Administrator's postal code.
SECTION 6
CLAIM ADMINISTRATOR STATE - DN13

Definition: The state of the claim administrator's processing facility's mailing
address.
claim.
Revised: 3/11/94
Source: ANSI A22
Format: 2 A/N
the Third Party Administrator's state.
CLAIM STATUS - DN73

Definition: A code representing the current status of the claim.
Business Need: To report the claim's current status.
Revised: 6/7/95
Source: IAIABC
Format: 1 A/N
Values: O - Open
` C - Closed
R - Re-open
X - Reopened/Closed
CLAIM TYPE - DN74

Definition: A code representing the current benefit classification of the claim
as interpreted by the jurisdiction.
Business Need: To report the claim’s current type.
Revised: 2/15/02
Source: IAIABC
Format: 1 A/N
Values: M - Medical Only
I - Indemnity
N - Notification Only
B - Became Medical Only
L - Became Lost Time
T - Transfer (Claim Juris changed)
Y – Cumulative Injury (MT only; effective 7/1/01)
Z – Occupational Disease (MT only; effective 7/1/01)
Implementation Note: When a jurisdiction code is changed, the Claim type code is
changed to "T", transfer. A transaction with Maintenance Type
Code S8, Jurisdiction Change, is used to submit a Subsequent
Report to the "original" jurisdiction.
Maintenance Type Code "00" is used to submit a 1st Report to

the "New" jurisdiction. Maintenance Type Code "IP" is used to
submit a Subsequent Report to the "New" jurisdiction.
Values of Y and Z can only be sent to those jurisdictions that

receive just "indemnity" claims on subsequent reports. Therefore,
the valid value sets that any one jurisdiction can use are
(M,I,N,B,L or T) or (I, T, Y, Z).
SECTION 6
CLASS CODE - DN59
Definition: A code which corresponds to the primary occupation in which the
employee was engaged at the time of accident/injury, or injurious
exposure.
Business Need: Business management and statistical analysis.
Revised: 6/7/95
Source: DCI Field 23
Format: 4 A/N
Values: NCCI or state specific codes
DATE DISABILITY BEGAN - DN56

Definition: The first day on which the employee originally lost time from work
due to the occupational injury or disease or as otherwise defined
by jurisdiction.
Business Need: Used in determining indemnity benefits.
Revised: 8/9/95
Source: IAIABC
Ref.: DCI Fld 37
Format: CCYYMMDD
Subsequent Report
DATE LAST DAY WORKED - DN65

Definition: The last paid work day prior to the initial date of disability as
defined by jurisdiction.
Business Need: To assist in determining the date benefits should commence.
Revised: 8/9/95
Source: IAIABC
Format: CCYYMMDD
DATE OF HIRE - DN61

Definition: The date the injured worker began his/her employment with the
employer under which the claim is being filed. If there have been
multiple periods of employment, this would be the beginning date
of the current employment period.
Business Need: For statistical analysis.
Revised: 3/11/92
Source: IAIABC
Ref.: DCI Fld 19
Format: CCYYMMDD
Implementation Note: If only the employee's number of years employed is known, an
appropriate date should be calculated using the same month as
the Date of Injury month and 01 for the day.
DATE OF INJURY - DN31

Definition: For traumatic injury, the date on which the accident occurred. For
occupational disease or cumulative injury, the date of injury is the
date of last injurious exposure to the cause or substance creating
the condition, unless otherwise defined by statute.
Business Need: To determine employer responsibility, for determination of
coverage, for claimant benefit entitlement determination, for
jurisdiction compliance review.
Revised: 3/11/94
Source: IAIABC
Format: CCYYMMDD
Subsequent Report
SECTION 6
DATE OF MAXIMUM MEDICAL IMPROVEMENT- DN70

Definition: The date after which further recovery from or lasting
improvements to an injury or disease can no longer be
anticipated based upon reasonable medical probability.
Business Need: To determine benefit eligibility.
Revised: 3/11/94
Source: IAIABC
Format: CCYYMMDD
DATE OF REPRESENTATION - DN76

Definition: The date the claim administrator recognizes the claimant has
secured legal representation.
Business Need: Identifies date to begin communication via counsel.
Revised: 6/7/95
Source: IAIABC
Format: CCYYMMDD
DATE OF RETURN TO WORK - DN68

Definition: The first date on which the employee returned to work following
the injury.
Business Need: To determine the effectiveness of return to work programs. To
evaluate length of injury by disability sustained. To determine
benefit payments.
Revised: 8/9/95
Source: IAIABC
Format: CCYYMMDD
DATE OF RETURN/RELEASE TO WORK - DN72

Definition: The date, following the most recent disability period, on which the
employee actually returned to work, or was released to Return To
Work, as identified by the Return To Work Qualifier.
Business Need: To identify the date the employee’s work status changed. To
determine the employee’s eligibility for benefits. For use in
statistical analysis.
Revised: 6/7/95
Source: IAIABC
Format: CCYYMMDD
Implementation Note: 1. The date of RTW can be one of two dates, either the actual date the
person returned to work or the date the person was released to RTW.
The value in the RTW qualifier will serve to identify whether the date is
the actual or released RTW date. The date has to be present when the
qualifier is coded.
2. The date must be updated to reflect the date associated with the
updated RTW qualifier.
DATE PROCESSED - DN108

Definition: The date that the receiver processed the detail transaction.
Together with time processed and a record sequence number it
will uniquely identify a specific acknowledgment detail record.
Business Need: Needed for reconciliation.
Revised: 8/9/95
Source: IAIABC
Format: CCYYMMDD
SECTION 6
DATE REPORTED TO CLAIM ADMINISTRATOR - DN41
Definition: The date the claim administrator who is processing the claim
received notice of the loss or occurrence.
Business Need: Used to insure compliance with jurisdiction claim processing time
constraints.
Revised: 3/11/94
Source: IAIABC
Ref.: DCI Fld 9
Format: CCYYMMDD
Implementation Note: If the notice of loss or occurrence is passed from one entity to
another; i.e. Carrier to TPA, then the date reported will be the date that
the first entity had knowledge of the occurrence, whether notification was
by phone, fax, mail, or any other means.
DATE REPORTED TO EMPLOYER - DN40

Definition: The date that the injury was reported to a representative of the
employer.
Business Need: To identify the date the employer was aware of the accident.
Revised: 6/7/95
Source: IAIABC
Ref.: DCI Field 32
Format: CCYYMMDD
DATE TRANSMISSION SENT - DN100

Definition: Actual date transmission of data sent.
Business Need: To identify when the transmission was sent.
Revised: 6/7/95
Source: IAIABC
Format: CCYYMMDD
Record: Transmission Header Record HD1
DEPENDENT/PAYEE RELATIONSHIP - DN97

Definition: The relationship of the dependent(s)/Payee(s) to the deceased
employee; to which relationship and benefit entitlement may be
determined by an adjudicator's decision for distribution of the
death benefit.
Business Need: To determine benefit entitlement.
Revised: 9/16/94
Source: IAIABC
Format: 2 A/N RN
Values: R=Relationship
2 - Widow
3 - Widower
4 - Son or Daughter
5 - Brother or Sister
6 - Mother or Father
7 - Handicapped Child
8 - Jurisdiction Fund
(ex: CA - Death without Dependents Fund, TX Subsequent
Injury Fund)
9 – Other
N = Numerical Birth Order
1-9 first to ninth for each Relationship classification.
SECTION 6
DETAIL RECORD COUNT - DN106

Definition: The total number of detail records sent as part of this
transmission. Transmission header and trailer records are not
included in this count.
Business Need: To indicate the number of detail records included in a
transmission for verification purposes.
Revised: 8/18/94
Source: IAIABC
Format: 9N
Record: Transmission Trailer Record (TR1).
ELEMENT ERROR NUMBER DN116

Definition: A number to uniquely identify the edit performed on an element
and is part of the Error Code.
Business Need: Identifies the error that was detected.
Revised: 2/15/02
Source: IAIABC
Format: 3 A/N
Values: 001 Mandatory field not present
002 Transaction Set ID invalid
003 Maintenance Type Code invalid for '148'
004 Maintenance Type Code invalid for 'A49'
005 State Code invalid
006 NCCI Nature Code invalid
007 NCCI Part of Body Code invalid
008 NCCI Cause of Injury Code invalid
009 Gender Code invalid
010 Marital Status Code invalid
011 Wage Period Code invalid
012 Indicator invalid
013 Employment Status Code invalid
014 Class Code (NCCI or State Specific) invalid
015 Industry Code (SIC or NAICS) invalid
016 Initial Treatment Code invalid
017 Claim Status Code invalid
018 Number of Days Worked must be 0-7
021 Claim Type Code invalid
022 Agreement to Compensate Code invalid
023 Late reason Code invalid
024 Payment/Adjustment Code invalid
025 Benefit/Adjustment Code invalid
026 PTD/RE/Recovery Code invalid
027 Dependent/Payee Relationship Code invalid
028 Must be 0-9
029 Must be a valid Date (CCYYMMDD)
031 Must be a valid time
037 Must be <= Maintenance Type Code Date
038 Must be >= Payment/Adjustment Start Date
041 Must be <= Current Date
SECTION 6
043 Receiver ID invalid
044 Value is > required by jurisdiction
045 Value is < required by jurisdiction
050 No matching Subsequent Report (A49)
053 No matching First Report (148)
054 Must be valid occurrence for segment
056 Detail Record Count not equal number records received
057 Duplicate Transmission/Transaction
058 Code/ID invalid
059 Value not consistent with value previously reported
060 Previous supporting documentation not received
Record: Acknowledgment Detail Record (AK1).
ELEMENT NUMBER - DN115

Definition: A unique number assigned to each data element and is part of
the Error Code.
Business Need: Identifies the element for which an error was detected.
Revised: 8/18/94
Source: IAIABC
Format: 4 A/N
EMPLOYEE ADDRESS (LINE 1) - DN46

Definition: The mailing address used by the injured worker.
Business Need: To provide the injured worker’s mailing address.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
EMPLOYEE ADDRESS (LINE 2) - DN47

Definition: The mailing address used by the injured worker.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
SECTION 6
EMPLOYEE CITY - DN48

Definition: The name of the city of the injured worker's mailing address.
Revised: 6/7/95
Source: IAIABC
Format: 15 A/N
EMPLOYEE DATE OF BIRTH - DN52

Definition: The date the injured worker was born.
Business Need: To calculate the injured worker's age.
Revised: 6/7/95
Source: IAIABC
Ref.:DCI Fld 18
Format: CCYYMMDD
Implementation Note: If only the employee's age is known, an appropriate date should
be calculated using the same month as the date of injury month
and 01 for the day.
EMPLOYEE DATE OF DEATH - DN57

Definition: The date the injured worker died.
Business Need: For benefit type determination. For statistical analysis.
Revised: 6/7/95
Source: IAIABC
Format: CCYYMMDD
Subsequent Report
EMPLOYEE FIRST NAME - DN44

Definition: The injured worker's legally recognized first name, which is used
on legal documents, employment, Social Security, banking
records, etc.
Business Need: To identify the injured worker.
Revised: 6/7/95
Source: IAIABC
Format: 15 A/N
EMPLOYEE LAST NAME - DN43

Definition: The injured worker's legally recognized last name, which is used
on legal documents, employment, Social Security, banking
records, etc.
Revised: 6/7/95
Source: IAIABC
Ref.: DCI Fld 15
Format: 30 A/N
Implementation Note: Enter double last names with a hyphen separator, no spaces, to
avoid last name editing errors. For name Suffix Jr, Sr, I, II, III,
etc. enter last name comma and the suffix value, no spaces.
SECTION 6
EMPLOYEE MIDDLE INITIAL - DN45

Definition: The injured worker's legally recognized middle initial.
Revised: 6/7/95
Source: IAIABC
Format: 1 A/N
EMPLOYEE PHONE - DN51

Definition: A telephone number where the injured worker can be reached.
Business Need: To provide the injured worker’s telephone number.
Revised: 6/7/95
Source: IAIABC
Format: 10 A/N
EMPLOYEE POSTAL CODE - DN50

Definition: The postal code of the injured worker’s mailing address.
Revised: 6/7/95
Source: IAIABC
Format: 9 A/N
EMPLOYEE STATE - DN49

Definition: The state of the injured worker’s mailing address.
Revised: 6/7/95
Source: ANSI A22
Format: 2 A/N
EMPLOYER ADDRESS (LINE 1) - DN19

Definition: The address of the employer's facility where the employee was
employed at the time of the injury.
Business Need: To identify the address of the employer's facility.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
EMPLOYER ADDRESS (LINE 2) - DN20

Definition: The address of the employer's facility where the employee was
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
SECTION 6
EMPLOYER CITY - DN21

Definition: The city of the employer's facility where the employee was
Revised: 6/7/95
Source: IAIABC
Format: 15 A/N
EMPLOYER FEIN - DN16

Definition: The FEIN of the employer where the employee was employed at
Business Need: To identify the employer, minimize record data, and reference
employer profile data.
Revised: 8/9/95
Source: IAIABC
Format: 9 A/N
Subsequent Report
EMPLOYER NAME - DN18

Definition: The name of the employer where the employee was employed at
Business Need: To identify the statutorily responsible employer.
Revised: 8/9/95
Format: 30 A/N 148
EMPLOYER POSTAL CODE - DN23

Definition: The postal code of the employer's facility where the employee
was employed at the time of the injury.
Business Need: To identify the address of the employer's facility
Revised: 6/7/95
Source: IAIABC
Format: 9 A/N
Subsequent Report
EMPLOYER STATE - DN22

Definition: The state of the employer's facility where the employee was
Business Need: To identify the address of the employer's facility
Revised: 6/7/95
Source: ANSI A22
Format: 2 A/N
EMPLOYER'S PREMISES INDICATOR - DN34

Definition: An indicator to denote whether the accident occurred at the
employer’s address provided.
Business Need: Loss control management
Revised: 3/11/94
Source: IAIABC
Format: 1 A/N
Values: [Y|N]
SECTION 6
EMPLOYMENT STATUS CODE - DN58
Definition: A code used to indicate the employee's primary work Code status
at the time of the injury with the covered employer.
Business Need: For statistical analysis and benefit computations.
Revised: 3/28/94
Source: IAIABC
Ref.: DCI Fld 21, ANSI 584
Format: 2 A/N
ANSI: Employment Status Codes
(ANSI Codes)(#584)
Hierarchy: In the event that two Employment Status Codes apply to an
employee, the following hierarchy will determine which code, the
topmost, will be reported, i.e. if employee is a part time seasonal
worker, report as seasonal worker.
Hierarchical FLAT/DCI Flat/DCI ANSI ANSI

Order Name Values Name Values
1 Piece Worker C Piece Worker PW
2 Volunteer Worker 9 Volunteer VO
3 Seasonal 8 Seasonal SL
4 Apprenticeship Full-Time A Apprenticeship Full-Time AD
5 Apprenticeship Part-Time B Apprenticeship Part-Time AP
6 Regular Employee 1 Full-Time FT
7 Part-Time Employee 2 Part-Time PT
8 Unemployed 3 Not Employed NE
9 Retired 6 Retired RT
10 On Strike 4 On Strike OS
11 Disabled 5 Disabled DS
12 Other 7 Other ZZ or UK
FREE FORM TEXT - DN113

Definition: An unstructured field used to convey a trading partner's claim
comments.
Business Need: Allows for free form communication.
Revised: 8/18/94
Format: 60 A/N
FULL WAGES PAID FOR DATE OF INJURY INDICATOR - DN66

Definition: Indicates whether full wages for the date of the accident/injury or
illness were paid by the employer.
Revised: 3/11/94
Source: IAIABC
Format: 1 A/N
[Y|N]
GENDER CODE - DN53

Definition: The code which indicates the sex of the employee.
Business Need: For statistical analysis.
Revised: 3/11/94
Source: ANSI Element 1068
Format: 1 A/N
Values: M - Male
F - Female
U - Unknown
SECTION 6
INDUSTRY CODE - DN25
Definition: The code which represents the nature of the employer's business
which is contained in the Standard Industrial Classification
Manual or the North American Industry Classification System
Manual published by the Federal Office of Management and
Budget.
Business Need: Statistical
Revised: 2/15/02
Source: ANSI A113
Ref.: DCI Fld 12
Format: 6 A/N
Implementation Note: The Industry Code selected should represent the primary nature
of the employer's business. If the employer is assigned multiple
Industry Codes, use the code that relates to the specific business
operation for which the employee was employed at the time of
injury. Ths data element may contain an SIC code or NAICS
code. SIC Code will be identified with the characters ‘SC’ in the
last two character positions of the data element. If SC is not
present, the code is NAICS. Claim administrators will not send
NAICS prior to 4/1/2002. Claim administrators will add the SC
suffix to the SIC code beginning 1/1/2002 and no later than
4/1/2002. After 4/1/2002, state jurisdictions could receive either
NAICS or SIC in claim reports.
INITIAL TREATMENT - DN39

Definition: A code used to identify the extent of medical treatment received
by the employee immediately following the accident.
Business Need: To qualify the severity of the injury.
Revised: 3/11/94
Source: IAIABC
Format: 2 A/N
Values: 0 = No medical treatment
1 = Minor on-site remedies by employer medical staff
2 = Minor clinic/hospital medical remedies and diagnostic testing
3 = Emergency evaluation, diagnostic testing, and medical
procedures
4 = Hospitalization > 24 hours
5 = Future Major Medical/Lost Time Anticipated (i.e. hernia case)
INSURED LOCATION NUMBER - DN27

Definition: A code defined by the insured/employer which is used to identify
the employer's location of the accident.
Business Need: For insured loss prevention program management.
Revised: 6/7/95
Source: IAIABC
Format: 15 A/N
SECTION 6
INSURED NAME - DN17

Definition: The named insured of the policy or the financially responsible self
insured approved by the jurisdiction.
Business Need: To identify the insured in a hierarchically structured organization
when the employer is not the parent organization.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N 148
90 A/N POC
Implementation Note: Typically the parent company in a hierarchically structured
organization.
INSURED REPORT NUMBER - DN26

Definition: A number used by the insured to identify a specific claim.
Business Need: Business management
Revised: 3/11/94
Source: IAIABC
Format: 1st - 10 A/N
Sub. - 25 A/N
Subsequent
INSURER FEIN - DN6

Definition: The FEIN of the carrier or self insured assuming the employer's
financial responsibility for Workers' Compensation Claim(s).
Business Need: To identify financial responsibility and to reference claims payer
data.
Revised: 8/9/95
Source: IAIABC
Format: 9 A/N
Subsequent Report
Acknowledgment Detail Record
INSURER NAME - DN7

Definition: The name of the carrier or self insured assuming the employer's
financial responsibility for Workers' Compensation Claim(s).
Business Need: To identify financial responsibility and to reference claims payer
data.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
SECTION 6
INTERCHANGE VERSION IDENTIFIER - DN105

Definition: A composite field comprised of:
Transmission Type Code: The identifier that designates the type
of transmission within a batch.
Release Number field: Identifies the release level of the data
of the record layout contained in the
detail records that follow.
Business Need: To identify the type and release level of the detail records
contained within the batch transmission and to uniquely identify
the version number to anticipate the format of the detail records
that are to follow.
Revised: 8/19/94
Source: IAIABC
Format: Transmission type code 3 A/N
Release Number 2 A/N
Values: Transmission type code/release number:
148/01 - First Report Only
A49/1A - Subsequent Report Only
AK1/01 - Acknowledgment Detail Record
Record: Transmission Header Record (HD1)
JURISDICTION - DN4
Definition: The governing body or territory whose statutes apply.
Business Need: Used to identify the jurisdiction whose statutes apply.
Revised: 6/7/95
Source: IAIABC
REF.: Appendix: ANSI Code List A22 (US Postal State Codes)
plus list of non-state jurisdictions below (OSHA to be developed)
Format: 2 A/N
Values: Non-State Jurisdictions:
UL Long Shore & Harbor Workers' Compensation Act
U1 Defense Base Act
U2 Non Appropriated Fund Instrumentalities Act
U3 Outer Continental Shelf Act
U4 War Hazards Compensation Act
FC Federal Coal Mine Health & Safety Act
FE Federal Employers Liability Act
M1 Admiralty I & II
Subsequent Report
SECTION 6
LATE REASON CODE - DN77

Definition: A code which identifies the reason a payment/report was not
made within a jurisdiction's time requirements.
Business Need: To communicate the reason a jurisdictionally required due date
was not met.
Revised: 6/7/95
Source: IAIABC
Format: 2 A/N
Values:
Delays:
L1 No excuse
L2 Late notification, employer
L3 Late notification, employee
L4 Late notification, state
L5 Late notification, health care provider
L6 Late notification, assigned risk
L7 Late investigation
L8 Tech processing delay/computer failure
L9 Manual processing delay
LA Intermittent lost time prior to first payment
Coverage:
C1 Coverage lack of information
Errors:
E1 Wrongful determination of no coverage
E2 Errors from employer
E3 Errors from employee
E4 Errors from state
E5 Errors from health care provider
E6 Errors from other claim administrator/IA/TPA
Disputes:
D1 Dispute concerning coverage
D2 Dispute concerning compensability in whole
D3 Dispute concerning compensability in part
D4 Dispute concerning disability in whole
D5 Dispute concerning disability in part
D6 Dispute concerning impairment
SECTION 6
MAINTENANCE TYPE CODE - DN2

Definition: Defines the specific purpose of individual records within the transaction being
transmitted.
Business Need: Identifies the purpose of the transaction
Revised: 8/9/95
Source: IAIABC
Format: 2 A/N
Claim Values:
MTC First Report Values
00 Original
01 Cancel
02 Change
04 Denial
AU Acquired/Unallocated
CO Correction
MTC Subsequent Report Values
02 Change
04 Denial
4P Partial Denial
AP Acquired/Payment
CA Change in Benefit Amount
CB Change in Benefit Type
CD Compensable Death No Dependents/Payees
CO Correction
FN Final
FS Full Salary
IP Initial Payment
P1 Partial Suspension, returned to work, or medically determined/qualified to return to
work
P2 Partial Suspension, medical non-compliance
P3 Partial Suspension, administrative non-compliance
P4 Partial Suspension, Employee Death
P5 Partial Suspension, Incarceration
P7 Partial Suspension, Benefits Exhausted
P9 Partially Suspended pending settlement approval
PJ Partially Suspended pending appeal or judicial review
PY Payment Report
RB Reinstatement of Benefit
RE Reduced Earnings
S1 Suspension, returned to work, or medically determined/qualified to return to work.
S2 Suspension, Medical non-compliance
S3 Suspension, Administrative non-compliance
S4 Suspension, Claimant Death
S5 Suspension, Incarceration
S6 Suspension, Claimant’s Whereabouts Unknown
S7 Suspension, Benefits Exhausted
S8 Suspension, Jurisdiction Change
S9 Suspended pending settlement approval
SJ Suspended pending appeal or judicial review
UR Upon Request
VE Volunteer
MTC Periodic Report Values
AN Annual
BM Bi-Monthly
BW Bi-Weekly
MN Monthly
QT Quarterly
SA Semi-Annual
SECTION 6
Definitions for First Report Values:
00 = Original: The original/initial first report transmitted between partners, including the re-transmission of
a first report that was rejected due to a critical error.
01 = Cancel: The original first report was sent in error.

Process: A previous 00 First Report must have been filed.
02 = Change: A change has been made to First Report data elements designated on the trading Partner
Tables for MTC 02.
Process: A first report must have been previously filed.
04 = Denial: The entire claim is being denied.

Process: May or may not be the original (00) First Report.
AU = Acquired/Unallocated: To identify that a claim has been acquired from a prior claim administrator.
CO = Correction: Used in response to an acknowledgment containing non-critical errors.

Process: The first submission of the First Report must use either 00,"Original", 04, "Denial", or AU",
Acquired/Unallocated", Maintenance Type Codes.
Definitions for Subsequent Report Values:

02 = Change: A change has been made to Subsequent Report data elements designated on the trading
Partner Tables for MTC 02.
Implementation Note: For 02 -- Changes in Benefit Amount or Benefit Type are
processed through CA and CB Maintenance Type Codes respectively
04 = Denial: The entire claim is being denied.

Process: Payments have been made or a subsequent report has been filed.
4P = Partial Denial: A specific benefit(s) has been denied.

Process: A previous Subsequent Report may or may or may not have been filed. A previous First Report
must have been filed.
AP = Acquired/Payment: The first payment of indemnity benefits has been made by the acquiring claim
administrator.
CA = Change in Benefit Amount: A change in Payment/Adjustment Weekly Amount has been made for
the same Payment/Adjustment Code.
Process: A previous IP Subsequent Report has been filed.
Implementation Note: The change in Payment/Adjustment amount is not in response to
Reduced Earnings.
CB = Change in Benefit Type: A change in Payment/Adjustment Code has been made or an introduction
of an additional Payment/Adjustment Code has occurred.
Process: A previous IP Subsequent Report has been filed.
Implementation Note: For CB -- The effective date of the change in Payment/Adjustment code is
the start date for that Payment/Adjustment Code.
CD = Compensable Death No Dependents/Payees: The injured worker has died as a result of a covered
injury and no payment(s) of indemnity benefits have been made pending further beneficiary investigation.
Process: A previous Subsequent Report may or may not have been filed.
CO = Correction: Used in response to an acknowledgment containing non-critical errors.

Process: 02 is used when there is a change of an element designated on the trading partner tables for
MTC 02... CO is used in response to an acknowledgment containing non-critical errors. The Original MTC
is used in response to an acknowledgment containing critical errors.
FN = Final: Closed claim, no further payments of any kind anticipated.

Process: An IP or FS Subsequent Report must have previously been filed, and a previous periodic
Subsequent Report may or may not have been filed.
SECTION 6
FS = Full Salary: The employer is paying the injured worker's salary in lieu of compensation, and the claim
administrator is not paying any indemnity benefits at this time.
Process: A previous Subsequent Report may or may not have been filed.
IP = Initial Payment: The first payment of indemnity benefits has been made.
Process: A previous Subsequent Report (other than IP) may or may not have been filed, but no previous
IP reports have been filed for this claim by the same claim administrator/TPA.
P1 = Partial Suspension, returned to work, or medically determined/qualified to return to work: Payment(s)

of one concurrent indemnity benefit has stopped because the injured worker has returned to work, and
payment(s) of other indemnity benefits continue.
P2 = Partial Suspension, Medical Non-Compliance: Payment(s) of one concurrent indemnity benefit has
stopped because of medical non-compliance, and payment(s) of other indemnity benefits continue.
P3 = Partial Suspension, Non compliance with administrative/ jurisdictional requirements not including
medical: Payment(s) of one concurrent indemnity benefit has stopped because of administrative non
compliance, and payment(s) of other indemnity benefits continue.
P4 = Partial Suspension, Non-Compensable Employee Death: Payment(s) of one concurrent indemnity

benefit has stopped because the employee has died not as a result of the compensable injury and
payment(s) of other indemnity benefits continue.
P5 = Partial Suspension Incarceration: Payment(s) of one concurrent indemnity benefit has stopped
because the claimant has been incarcerated, and payment(s) of other indemnity benefits continue.
P7 = Partial Suspension, Benefits/Entitlement Exhausted: Payment(s) of one concurrent indemnity benefit

has stopped because limits of benefit or entitlement have been reached, and payment(s) of other
indemnity benefits continue.
P9 = Partially Suspended pending settlement approval: Payment(s) of one concurrent indemnity benefit
has stopped pending settlement approval, and payment(s) of other indemnity benefits continue.
PJ = Partially Suspended pending appeal or judicial review: Payment(s) of one concurrent indemnity
benefit has stopped pending appeal or judicial review, and payment(s) of other indemnity benefits
continue.
PY = Payment: Identifies payment information for which reporting is required by the jurisdiction.
Values used with a PY code:

080, 310, 320, 330, 340, 350, 360, 370, 380, 390, 400, 420, 440, 501, 580, 800, 810, 820,830, 840.
Implementation Note: Used for reporting payments other than indemnity benefits.
RB = Reinstatement of Benefit: Indemnity payments have resumed.

Process: A previous subsequent report has been filed with a Suspension Maintenance Type Code.
Implementation Note: For RB -- The effective date of reinstatement in the Payment/
Adjustment Code is the start date for that Payment/Adjustment code.
(see also Payment/Adjustment Code Start Date implementation notes.)
Implementation Note: For every RB there must be a corresponding suspension MTC (i.e. a
1 for 1 match). The Payment/Adjustment Code being resumed may or may not have been
previously paid.
RE = Reduced Earnings: The injured worker has returned/been released to return to work and RE codes
600-624 or 650-674 are filed.
Process: An IP or CB report has already been filed.
Implementation Note: This code is similar to the Periodic MaintenanceType codes - the user
must reference the Report Due Submission Due Date Criteria to determine when a
submission is required.
SECTION 6
S1 = Suspension, returned to work, or medically determined/qualified to return to work: All payments of
indemnity benefits have stopped because the employee has returned to work or has been medically
determined qualified to return to work.
S2 = Suspension Medical Non-Compliance: All payments of indemnity benefits have stopped because of
medical non compliance.
Implementation Note: Non-compliance of any party, relating to a medical issue. For
example: Employer, Dr., Employee. This includes vocational rehabilitation for those states
that consider vocational rehabilitation medical.
S3 = Suspension Non compliance with administrative/jurisdictional requirements not including medical: All
payments of indemnity benefits have stopped because of administrative non-compliance.
Implementation Note: Non-compliance of any party, relating to a non-medical issue. For
example: Employer, Dr., Employee. This includes vocational rehabilitation for those states
that do not consider vocational rehabilitation medical.
S4 = Suspension Non-compensable Employee Death: All payments of indemnity benefits have stopped
because the employee has died not as a result of the compensable injury.
S5 = Suspension Incarceration: All payments of indemnity benefits have stopped because the employee
has been incarcerated.
S6 = Suspension Employee’s Whereabouts Unknown: All payments of indemnity benefits have stopped
because the employee's whereabouts are unknown.
S7 = Suspension Benefits/Entitlement Exhausted: All payments of indemnity benefits have stopped

because limits of benefit or entitlement have been reached.
S8 = Suspension Jurisdiction Change: All payments of indemnity benefits have stopped because the
jurisdiction has been changed.
Implementation Note: When a jurisdiction code is changed, the Claim type code is changed
to "T", transfer. A transaction with Maintenance Type Code S8, Jurisdiction Change, is used
to submit a Subsequent Report to the "original" jurisdiction. Maintenance Type Code "00" is
used to submit a First Report to the "New" jurisdiction. Maintenance Type Code "IP" is used to
submit a Subsequent Report to the "New" jurisdiction.
S9 = Suspended pending settlement approval: All payments of indemnity benefits have stopped pending
settlement approval.
SJ = Suspended pending appeal or judicial review: All payments of indemnity benefits have stopped
pending appeal or judicial review.
UR = Upon Request: Submitted in response to a specific request from the Trading Partner.
VE = Volunteer: The employee is a volunteer for the covered employer, and no indemnity payments will
be made by the carrier.
Process: No previous Subsequent Reports have been filed.
Definitions for Periodic Report Values:

Periodic Reports are Subsequent Reports that commence and terminate according to Trading Partner
Table options, and repeat at specified intervals during that period.
AN = Annual: Submitted at yearly intervals based on the report trigger criteria column located on
the event table.
BM = Bi-Monthly: Submitted at two month intervals based on the report trigger criteria column located
on the event table.
BW = Bi-Weekly: Submitted at two week intervals based on the report trigger criteria column located
on the event table.
SECTION 6
MN = Monthly: Submitted at one month intervals based on the report trigger criteria column located
on the event table.
QT = Quarterly: Submitted at three month intervals based on the report trigger criteria column
located on the event table.
SA = Semi-Annual: Submitted at six month intervals based on the report trigger criteria column located
on the event table.
Record: As noted by MTC Code above, plus all apply to Acknowledgment -Detail Record (AK1).
MAINTENANCE TYPE CODE DATE - DN3

MULTI REF. Implementation Note: For P1-PJ: The date the suspension was effective may
be the same or before the end date of the last Payment/Adjustment code paid.
MULTI REF. Implementation Note: For S1-SJ: The date the suspension was effective may
be the same or before the end date of the last Payment/Adjustment code paid.
MULTI REF. Implementation Note: For 04 and 4P: The MTC date and the date of denial on
the supporting paper document may differ.
Definition: Designates the date corresponding to the Maintenance Type Code.

Business Need: To fulfill jurisdictional reporting requirements: i.e. date reported, date of first
payment, etc.
Revised: 3/11/94
Source: IAIABC
Format: CCYYMMDD
Subsequent Report
First Report Values

MTC 00: Date the Maintenance Type Code 00 transaction was moved to the transmission queue or
flagged for transmission.
MTC AU: Date the Maintenance Type Code AU transaction was moved to the transmission queue
or flagged for transmission.
MTC CO: Maintenance Type Code Date of the Original Transaction being corrected that contained
non-critical error(s).
Subsequent Report Values

MTC 4P: Date the Maintenance Type Code 4P transaction was moved to the transmission queue or
MTC AP: Issue date of initial indemnity benefit check after acquiring the file.
MTC CA: Date the change in Payment/Adjustment amount was effective.
MTC CB: Date the Maintenance Type Code CB transaction was moved to the transmission queue
MTC CD: Date the Maintenance Type Code CD transaction was moved to the transmission queue
MTC CO: Maintenance Type Code Date of the Original Transaction being corrected that contained
non-critical error(s).
MTC FN: Date the Maintenance Type Code FN transaction was moved to the transmission queue
SECTION 6
MTC FS: Date the Maintenance Type Code FS transaction was moved to the transmission queue or
MTC IP: Issue date of initial indemnity benefit check.
MTC P1-PJ: The last date through which an indemnity benefit(s) is due.
MTC PY: Issue date of payment.
MTC RB: Issue date of the check reinstating indemnity benefits.
MTC RE: Date the Maintenance Type Code RE transaction was moved to the transmission queue
MTC S1-SJ: The last date through which indemnity benefit(s) are due.
MTC UR: Date the Maintenance Type Code UR transaction was moved to the transmission queue
MTC VE: Date the Maintenance Type Code VE transaction was moved to the transmission queue
Periodic Report Values

AN, BM, BW, MN, QT, SA: Date the Periodic Maintenance Type Code transaction was moved to the
transmission queue or flagged for transmission.
MARITAL STATUS CODE - DN54

Definition: The code which indicates the marital status of the employee.
Business Need: Statistical analysis and benefit calculations.
Revised: 3/11/94
Source: ANSI Element 1067
Ref.: DCI Fld 17
Format: 1 A/N
Values: U = Widowed, Divorced, Single, Unmarried
M = Married
S = Separated
K = Unknown
NATURE OF INJURY CODE - DN35

Definition: The code which corresponds to the nature of the injury sustained
by the employee.
Business Need: Loss prevention management.
Revised: 3/11/94
Format: 2 A/N
Value: See Appendix NCCI Table 8 Codes
NUMBER OF BENEFIT ADJUSTMENTS - DN80

(NBR. BENEFIT ADJUSTMENTS)
Definition: The number of Benefit Adjustment segment occurrences.
Business Need: A technical processing requirement that specifies the number of
variable segments that follow.
Revised: 3/11/94
Source: IAIABC
Format: 2N
Max. Occ: 10
Values: [0 through 10]
SECTION 6
NUMBER OF DAYS WORKED - DN64

(NBR. DAYS WORKED)
Definition: The number of the employee's regularly scheduled work days per
week.
Business Need: To calculate a partial week of disability.
Revised: 3/11/94
Source: IAIABC - ANSI
Format: 1N
Subsequent Report
NUMBER OF DEATH DEPENDENT/PAYEE RELATIONSHIPS - DN82

(NBR. DEATH DEP/PAYEE RELATIONSHIPS)
Definition: The number of Death/Dependent Payee segment occurrences.
Revised: 6/7/95
Source: IAIABC
Format: 2N
Max. Occ: 12
NUMBER OF DEPENDENTS - DN55

(NBR. OF DEPENDENTS)
Definition: The number of dependents as defined by the administering
jurisdiction.
Business Need: May be used to determine benefits.
Revised: 3/11/95
Source: IAIABC
Format: 2N
Subsequent Report
NUMBER OF ERRORS - DN114

(NBR. ERROR CODE)
Definition: The number of error code segment occurrences.
Revised: 8/18/94
Source: IAIABC
Format: 2N
NUMBER OF PAID TO DATE/REDUCED EARNINGS/RECOVERIES - DN81

(NBR. PTD/REDUCED EARNINGS/RECOVERI ES)
Definition: The number of Paid To Date/Reduced Earnings/Recovery
segment occurrences.
Revised: 6/7/95
Source: IAIABC
Format: 2N
Max. Occ: 25
SECTION 6
NUMBER OF PAYMENTS/ADJUSTMENTS - DN79

(NBR. PYMNTS/ADJS)
Definition: The number of Weekly Payments/Adjustments segment
occurrences.
Revised: 3/11/94
Source: IAIABC
Format: 2N
Max. Occ: 10
NUMBER OF PERMANENT IMPAIRMENTS - DN78

(NBR. PERMANENT IMPAIRMENTS)
Definition: The number of Permanent Impairment segment occurrences.
Revised: 6/7/95
Source: IAIABC
Format: 2N
Max. Occ: 6
OCCUPATION DESCRIPTION - DN60

Definition: Identifies the primary occupation of the employee at the time of
the accident or injurious exposure.
Business Need: For claim investigation/loss prevention.
Revised: 6/7/95
Source: IAIABC
Format: 30 A/N
ORIGINAL TRANSMISSION DATE - DN102

Definition: The value obtained from the Date Transmission Sent field of the
Header Record of the originating transmission.
Business Need: To allow a receiving party the ability to match back to the original
batch file for reconciliation purposes. Used in conjunction with the
Original Transmission Time field in the acknowledgment process.
Revised: 8/19/94
Source: IAIABC
Format: CCYYMMDD
Record: Transmission Header Record (HD1).
ORIGINAL TRANSMISSION TIME - DN103

Definition: The value obtained from the Time Transmission Sent field of the
Transmission Header Record of the originating transmission.
Business Need: To allow a receiving party the ability to match back to the original
batch file for reconciliation purposes. Used in conjunction with
the Original Transmission Date field in the acknowledgment
process.
Revised: 2/15/02
Source: IAIABC
Format: HHMMSS
Record: Transmission Header Record (HD1).
Implementation Note: Use 24 hour military time (00:00:00 through 24:00:00). All zeros
in a time field is valid and equivalent to 240000 or 2400. Spaces
indicate absence of data.
SECTION 6
PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT - DN96

(PTD/REDUCED EARNINGS/RECOV. AMOUNT)
Definition: The amount defined by the Paid To Date/Reduced
Earnings/Recoveries Code.
Revised: 6/7/95
Source: IAIABC
Format: $9.2
PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE - DN95

(PTD/REDUCED EARNINGS/RECOVERIES CODE)
Definition: A code that identifies the type of Paid To Date/Reduced
Earnings/Recoveries made.
Business Need: To meet jurisdiction financial reporting requirements.
Revised: 6/7/95
Source: IAIABC
Ref.: DCI Section 4 and others to be developed
Format: 3 A/N
Values:
[300|310|320|330|340|350|360|370|380|390|400|420|430|440
600|650|800|810|820|830|840]
300 Term: Funeral Expenses Paid to Date

Def.: Sum of the funeral expenses paid for this claim.
Source: DCI Fld 67
310 Term: Penalties Paid to Date

Def.: Sum of the penalties paid for this claim.
Source: DCI Fld 79
320 Term: Interest Paid to Date

Def.: Sum of the interest paid for this claim.
Source: IAIABC
330 Term: Employer's Legal Expenses Paid to Date

Def.: Sum of the employer's legal expenses paid for this claim.
Source: DCI Fld 76
340 Term: Claimant's Legal Expenses Paid to Date

Def.: Sum of the claimant’s legal expenses paid for this claim.
Source: DCI Fld 77
350 Term: Total Payments to Physicians to Date

Def.: Sum of services paid to physicians for this claim.
Source: DCI Fld 62
360 Term: Hospital Costs Paid to Date

Def.: Sum of services paid to hospitals for this claim.
Source: DCI Fld 61
370 Term: Other Medical Paid to Date

Def.: Sum of medical services not otherwise reported for this claim.
Source: DCI Fld 63
380 Term: Vocational Rehabilitation Evaluation Paid to Date

Def.: Sum of vocational rehabilitation evaluation services for this claim.
Source: DCI Fld 56
SECTION 6
390 Term: Vocational Rehabilitation Education Paid to Date
Def.: Sum of vocational rehabilitation education payments for this
claim.
Source: DCI Fld 58
400 Term: Other Vocational Rehabilitation Paid to Date

Def.: Sum of vocational rehabilitation services not otherwise reported
for this claim.
Source: DCI Fld 59
420 Term: Expert Witness Fees Paid to Date

Def.: Sum of fees paid to expert witnesses for this claim.
Source: DCI Fld 78
430 Term: Unallocated Prior Indemnity Benefits Paid To Date

Def. Sum of prior Indemnity Benefits paid to date that cannot be
classified by a specific Payment Adjustment Code for this claim.
Source: IAIABC
440 Term: Unallocated Prior Medical Paid To Date

Def.: Sum of prior Medical paid to date that can not be classified by a
specific Paid To Date Code for this claim.
Source: IAIABC
Implementation Note: Does not include Contract Medical
450 Term: Pharmaceutical Paid To Date

Def.: Sum of medication payments for this claim.
Source: IAIABC
460 Term: Physical Therapy Paid To Date

Def.: Sum of physical therapy payments for this claim.
Source: IAIABC
600-624 Term: Actual Reduced Earnings

Def.: The weekly wages of an employee on restricted duty.
Source: IAIABC
Implementation Note: 601-624 represents sequential weekly actual reduced earnings
reported in a single transaction. The 600 represents the first
occurrence.
650-674 Term: Deemed Reduced Earnings

Def.: The estimated weekly wages an employee would have earned
had the employee actually returned to work with physical
restrictions.
Source: IAIABC
Implementation Note: 651-674 represents sequential weekly deemed reduced earnings
reported in a single transaction. The 650 represents the first
occurrence.
800 Term: Special Fund Recovery

Def.: Sum of monies recovered from special funds for this claim.
Source: IAIABC
810 Term: Deductibles Recovery

Def.: Sum of monies recovered through insured reimbursement of
deductible amounts for this claim.
Source: IAIABC
SECTION 6
820 Term: Subrogation Recovery
Def.: Sum of monies recovered through subrogation for this claim.
Source: IAIABC
830 Term: Overpayment Recovery

Def.: Sum of monies recovered due to overpayment of indemnity,
medical or expenses for this claim.
Source: IAIABC
840 Term: Unspecified Recovery

Def.: Sum of monies recovered through salvage, apportionment/
contribution, and all others not otherwise defined for this claim.
Source: IAIABC
Implementation Note: To ensure that a claim reflects costs actually incurred, recoveries
made under code 830 will be backed out of the appropriate
Payment/Adjustment or Paid to Date codes. Recoveries made
under codes 800, 810, 820, and 840 will not be backed out of
their respective Payment/Adjustment or Paid to Date codes.
PART OF BODY INJURED CODE - DN36

Definition: The code which corresponds to the part of the body to which the
employee sustained injury.
Business Need: Loss prevention management.
Revised: 6/7/95
Format: 2 A/N
Values: See appendix NCCI Table 7 codes
PAYMENT/ADJUSTMENT CODE - DN85

(PYMNT/ADJ CODE)
Definition: A code that identifies the payment or adjustment being made.
Business Need: To meet jurisdiction financial reporting requirements.
Revi sed: 9/16/94
Source: IAIABC
Format: 3 A/N
Specific Payment Adjustment Codes:
[010|020|021|030|040|050|051|070|080|090|240|410]
Compromised Payment Adjustment Codes:
[500|501|510|520|524|530|540|550|551|570|580|590]
Comparison Chart:
Specific Compromised Description
---- 500 Unspecified
---- 501 Medical
010 510 Fatal
020 520 Permanent Total
021 521 Permanent Total Supplemental
030 530 Permanent Partial Scheduled
040 540 Permanent Partial Unscheduled
050 550 Temporary Total
051 551 Temporary Total Catastrophic
070 570 Temporary Partial
080 580 Employers Liability
090 590 Permanent Partial Disfigurement
240 524 Employer Paid
410 541 Vocational Rehabilitation Maintenance
SECTION 6
Payment Adjustment Description Definitions:
Unspecified -- Amounts that cannot be assigned to a specific Benefit Type.
Medical -- Compromised settlement amount paid to the employee to conclude past, present,
and/or future medical exposure.
Fatal -- Benefits paid or payable for the death of the claimant resulting from a work -related
accident or occupational injury or disease.
Permanent Total -- Benefits paid or payable for the loss of or the permanent loss of use of any
body part or function which renders the claimant unable to engage in any employment or
occupation.
Permanent Total Supplemental Payments -- Benefits paid to supplement permanent total

benefits.
Permanent Partial/Scheduled -- Benefits paid or payable as established by a statutory list

(schedule) of payments for certain injuries. The benefit amount is determined by the part of body
that was injured subject to limitations set forth in the statute.
Includes:
Wage Loss Without Impairment -- Florida (Accident Dates of 8/1/79 through 12/31/93)
benefits paid or payable for injuries not resulting in permanent disability, but with an
impairment rating of at least 1% and post-injury wages of less than 80% of the pre-injury
wage.
Impairment Income Benefits: -- Paid scheduled Impairment Benefits on Permanent

Partial claims. (Florida Accident Dates 1/1/94 and subsequent.)
Supplemental Earnings Without Permanent Partial -- Louisiana (Accident Dates of

7/1/83 and subsequent) Benefits paid or payable for injuries which are not covered by
permanent partial schedule who suffer wage loss of at least 10%.
Scheduled Disabilities -- (Michigan) Benefits paid or payable for injuries which

specifically appear on the schedule.
Economic Recovery -- Minnesota (Accident Dates of 1/1/84 and subsequent) Benefits

paid or payable for permanent partial injuries not covered in the schedule.
Permanent Partial/Unscheduled -- Benefits paid or payable for injuries to parts of the body not
covered by a schedule. These benefits are payable for the claimant's actual wage loss or
reduction in wage earning ability, subject to limitations set forth in the statute.
Includes:
Supplemental Income Benefits: -- Paid supplemental benefits after the expiration of

Scheduled Impairment benefits on Permanent Partial Claims. (Florida Accident Dates
1/1/94 and subsequent.)
Supplemental Earnings and Permanent Partial --Louisiana (Accident Dates of 7/1/83

and subsequent) Benefits paid or payable for the anatomical loss of use or 25% loss of
physical function of a member in addition to permanent partial benefits.
Other Partial Disability -- (Michigan) Benefits paid or payable for injuries not appearing
on the schedule.
SECTION 6
Temporary Total -- Benefits paid or payable for the period during which the claimant is unable to
perform any work for pay as a result of disability from which that individual can be expected to fully
recover and which period precedes the date of maximum medical improvement.
Temporary Total Catastrophic Loss Benefits -- Benefits paid for catastrophic injuries.
Temporary Partial -- Benefits paid or payable for the period during which the claimant, as a result
of a disability from which he/she is expected to fully recover, is unable to perform work for his/her
regular pay, but is receiving a reduced rate of pay and which period precedes the date of
maximum medical improvement.
Employers Liability -- Reports the indemnity loss portion of Employers Liability, DCI Fields #76-
#79.
Permanent Partial/Disfigurement -- Benefits paid or payable for any scarring or cosmetic defect.
Includes:
Impairment Without Wage Loss -- Florida (Accident Dates of 8/1/79 through 12/31/93)
Benefits paid or payable for amputation, loss of 80% or more of vision of either eye after
correction, or serious facial or head disfigurement resulting from an injury, not resulting in
a Permanent Total award without any wage loss benefits.
Permanent Partial Without Supplemental Earnings -- Louisiana (Accident Dates of

7/1/83 and subsequent) Benefits paid or payable for permanent partial injuries without
supplemental earnings.
Impairment Compensation -- Minnesota (Accident Dates of 1/1/84 and subsequent)

Benefits paid or payable for scheduled permanent partial injuries.
Employer Paid -- Wages paid by the employer to the claimant during their absence from work.
Vocational Rehabilitation Maintenance -- Weekly maintenance benefits paid while the claimant
is participating in a vocational rehabilitation program.
PAYMENT/ADJUSTMENT DAYS PAID - DN91

(PYMNT/ADJ DAYS PAID)
Definition: The number of days paid for a specific Payment/Adjustment
Code.
Revised: 3/11/94
Source: IAIABC
Format: 1N
Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0".
SECTION 6
PAYMENT/ADJUSTMENT END DATE - DN89
(PYMNT/ADJ END DATE)
Definition: For Weekly Benefits: The last date of a benefit period for which
benefits were paid.
For Adjustments: The last date for which the adjustment is
applied.
Revised: 3/28/94
Source: IAIABC
Format: Date
Implementation Note: For Periodic Reports with compromised Payment/Adjustment
Code 500, the end date is the date on which the payment was
mailed. For other Payment/Adjustment Codes, future End Dates
are acceptable.
Implementation Note: For 240 Payment/Adjustment Code, if unknown, use Return To
Work date. If Return To Work date is unknown, use Maintenance
Type Code date.
PAYMENT/ADJUSTMENT PAID TO DATE - DN86

(PYMNT/ADJ PAID TO DATE)
Definition: The cumulative amount paid for the Payment/Adjustment
identified by the associated Payment/Adjustment Code.
Revised: 3/11/94
Source: IAIABC
Format: $9.2
Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0.00".
PAYMENT/ADJUSTMENT START DATE - DN88

(PYMNT/ADJ START DATE)
Definition: For Weekly Benefits: The first Start Date of a benefit period for
which benefits were paid.
For Adjustments: The first date for which the adjustment is
applied.
Revised: 3/11/94
Source: IAIABC
Format: Date
Implementation Note: When there are multiple benefit periods for a Payment/Adjustment
Code, the Start Date will be reset to the first compensated day for
the current benefit period. For periodic reporting, the earliest date
for that Payment/Adjustment code which was paid on the claim.
Implementation Note: For 240 Payment/Adjustment Code, if unknown, use date
disability began.
SECTION 6
PAYMENT/ADJUSTMENT WEEKLY AMOUNT - DN87

(PYMNT/ADJ AMOUNT)
Definition: The net weekly rate for the Payment/Adjustment Code being paid
as modified by any applicable Benefit Adjustment(s).
Revised: 2/3/95
Source: IAIABC
Format: $9.2
Implementation Note: This amount will equal the weekly rate determined by jurisdiction
statute (i.e. Comp Rate) plus or minus any applicable Benefit
Adjustment for the corresponding benefit type. This is equal to
the gross weekly rate when there are no Benefit Adjustments.
Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0.00".
PAYMENT/ADJUSTMENT WEEKS PAID - DN90

(PYMNT/ADJ WEEKS PAID)
Definition: The number of whole weeks paid for a specific
Payment/Adjustment Code.
Revised: 3/11/94
Source: IAIABC
Format: 4N
Implementation Note: For 240 Payment/Adjustment Code, if unknown, use "0".
PERMANENT IMPAIRMENT BODY PART CODE - DN83

Definition: A code referencing the anatomic classification of the injury.
Business Need: To identify the part(s) of body permanently impaired.
Revised: 3/11/94
Source: IAIABC
Ref.: DCI Fld 24
Format: 3 A/N
Values: See appendix NCCI Table 7 codes and whole body “99”.
PERMANENT IMPAIRMENT PERCENT - DN84

Definition: Report the amount of anatomic or functional abnormality or loss
which results from the injury and exists after the date of maximum
medical improvement.
Business Need: To determine benefits.
Revised: 3/11/94
Source: IAIABC
Format: 3.2 N
POLICY EFFECTIVE DATE - DN29

Definition: The date that the contract/policy became effective.
Business Need: To validate coverage compliance.
Revised: 6/6/95
Source: IAIABC
Ref.: DCI Fld 3
Format CCYYMMDD
SECTION 6
POLICY EXPIRATION DATE - DN30
Definition: The date that the contract/policy expired.
Business Need: To validate coverage compliance.
Revised: 6/6/95
Source: IAIABC
Format: CCYYMMDD
POLICY NUMBER - DN28

Definition: The number assigned to the contract/policy for that employer or
association group.
Business Need: Identify contract.
Revised: 2/15/02
Source: DCI Field 2
Format: 18 AN
Implementation Note: Report the alphanumeric characters used for uniquely identifying
the policy. Do NOT report any embedded blanks, marks of
punctuation, or special characters.
POSTAL CODE OF INJURY SITE - DN33

Definition: The postal code that corresponds to the location where the injury
occurred.
Business Need: To determine the location of the accident.
Revised: 3/11/94
Source: IAIABC
Ref.: DCI Fld 14
Format: 9 A/N
Implementation Note: For United States territories, this will be the U.S. Post Office zip
codes.
PRE-EXISTING DISABILITY - DN69

Definition: Identifies the existence of a disability that existed prior to the
injury.
Business Need: To identify injuries pertaining to a claim and identify situations of
recovery.
Revised: 3/11/94
Source: IAIABC
Format: 1 A/N
Values: [Y|N]
RECEIVER IDENTIFIER - DN99

Definition: A composite or group level made up of:
Receiver FEIN - The primary FEIN of the receiving party;
Filler
Receiver Postal Code - Postal code of the receiving party.
Business Need: To uniquely identify the receiver.
Revised: 8/18/94
Source: IAIABC
Format: 25 A/N (Receiver FEIN 9 A/N, Filler 7 spaces, Receiver postal
code 9 A/N.
Implementation Note: Filler is reserved for possible future use in the event FEIN is not
sufficient to uniquely identify the sending party.
SECTION 6
RECORD SEQUENCE NUMBER - DN107
Definition: Identifying control number that must be unique within a
transmission. The number is assigned by the originator of a
transaction.
Business Need: To uniquely identify a transaction in the event trading partners
need to reconcile transactions.
Revised: 8/22/94
Source: IAIABC
Format: 9N
Values: 000000000 = Header Error
000000001 thru 999999998 = Detail Record Identifier
999999999 = Trailer Error
Record: Acknowledgment-Detail Record (AK1).
Implementation Note: Currently assigned by receiver at the time transmission is
received. It is assigned sequentially. It is suggested that the
sender make a corresponding assignment in their file prior to
transmission, although the information cannot be transmitted with
current 148/A49 release levels.
REQUEST CODE - DN112

Definition: A code used to convey additional information such as the need to
follow up or respond manually to a transaction.
Business Need: To have the ability to communicate the need for additional
information associated with a transaction electronically.
Revised: 8/18/94
Source: IAIABC
Format: 3 A/N
Values: 0 = None
1 = Contact Sender
Record: Acknowledgment-Detail Record (AK1)
RETURN TO WORK QUALIFIER - DN71

(RTW QUALIFIER)
Definition: A code identifying the employee's return to work status, with or
without physical restrictions.
Business Need: For determining benefit eligibility. For statistical analysis.
Revised: 6/7/95
Source: IAIABC
Format: 1 A/N
Values: 1 - Actual RTW without physical restrictions
2 - Actual RTW with physical restrictions
5 - Released RTW without physical restrictions
6 - Released to RTW with physical restrictions
Implementation Note: The qualifier code must be updated to reflect: 1) the proper value
associated with an updated Date of Release/Return to Work OR
2) a change occurring in the code values
SECTION 6
SALARY CONTINUED INDICATOR - DN67
Definition: The employer has paid or is paying the employee's salary in lieu
of compensation during an absence caused by a work-related
injury.
Revised: 6/7/94
Source: IAIABC
Format: 1 A/N
Values: [Y|N]
Subsequent Report
Implementation Note: If the employer is reimbursed the full statutory amount for the
benefit period paid by the employer, then the indicator should be
re-set to "N".
SELF INSURED INDICATOR - DN24

Definition: An indicator that identifies the employer as one who retains the
risks arising from their operations and bears the financial
responsibility.
Business Need: To identify employers who are financially responsible for the
claim.
Revised: 3/11/94
Source: IAIABC
Format: 1 A/N
Values: [Y|N]
SENDER IDENTIFIER - DN98

Definition: Composite or group level code made up of:
Sender FEIN - The FEIN of the sending party;
Filler
Sender Postal code - Postal code of the sending party.
Business Need: To identify the sending party.
Revised: 8/18/94
Source: IAIABC
Format: 25 A/N (Sender FEIN 9 A/N, Filler 7 spaces, Sender postal code
9 A/N.
Implementation Note: Filler is reserved for possible future use in the event FEIN is not
sufficient to uniquely identify the sending party.
SOCIAL SECURITY NUMBER - DN42

Definition: A number assigned by the Social Security Administration used to
identify the employee.
Business Need: Used to identify the employee.
Revised: 6/7/95
Format: 9 A/N
Subsequent Report
Implementation Note: If the Social Security Number is not available, the number to be
used will be defined by the jurisdiction.
SECTION 6
TEST/PRODUCTION INDICATOR - DN104
Definition: The Trading Partner's EDI participation status for a specific
transaction.
Business Need: To communicate whether the batch being transmitted is in a test
or production status.
Revised: 8/18/94
Source: IAIABC Trading Partner Table
Format: 6 A/N
Values: T = Test (pilot/parallel or test)
P = Production
THIRD PARTY ADMINISTRATOR FEIN - DN8

Definition: The FEIN of the Third Party Administrator (TPA), Independent
Adjuster, contracted to adjust the claim on behalf of the Carrier or
Self Insured.
Business Need: To provide means of contacting the contracted adjuster.
Revised: 6/7/95
Source: IAIABC
Format: 9 A/N
Subsequent Report
Implementation Note: Used only if the Third Party Administrator is processing payments
to the employee.
THIRD PARTY ADMINISTRATOR NAME - DN9

Definition: The Name of the Third Party Administrator (TPA), Independent
Adjuster, contracted to adjust the claim on behalf of the Carrier or
Self Insured.
Business Need: To provide means of contacting the contracted adjuster.
Revised: 3/11/94
Source: IAIABC
Format: 30 A/N
Implementation Note: Used only if the Third Party Administrator is processing payments
to the employee.
TIME OF INJURY - DN32

Definition: The time at which the accident occurred.
Business Need: To fulfill jurisdictional reporting requirements.
Revised: 2/15/02
Source: IAIABC
Format: HHMM
Implementation Note: Only a valid time in military format, zeros, or spaces are allowed
in time fields. Use 24 hour military time. All zeros in a time field
is valid and equivalent to 240000 or 2400. Spaces indicate
absence of data. May be left blank for occupational disease or
cumulative injury.
SECTION 6
TIME PROCESSED - DN109
Definition: The time that the receiver processed the detail transaction.
Together with date processed and a record sequence number, it
will uniquely identify a specific acknowledgment detail record.
Revised: 8/9/95
Source: IAIABC
Format: HHMMSS
absence of data.
TIME TRANSMISSION SENT - DN101

Definition: The time the sender prepared the batch file for transmission.
Together with the Date Transmission Sent will uniquely identify a
specific transmission batch.
Revised: 8/9/95
Source: IAIABC
Format: HHMMSS
absence of data
TRANSACTION SET ID - DN1

Definition: A code that identifies the transaction being sent/received.
Business Need: Data processing.
Revised: 8/18/94
Source: ANSI 329
Format: 3 A/N
Values: IAIABC ANSI
148 148 First Report of Injury
A49 148 Subsequent/interim/final report
AK1 824 Acknowledgment Detail Record
HD1 NA Transmission Header Record
TR1 NA Transmission Trailer Record
Subsequent Report
Acknowledgment-Detail Record
Transmission Header Record
Transmission Trailer Record
Implementation Note: The prefix A is used to avoid possible conflicts with future ANSI
SECTION 6
VARIABLE SEGMENT NUMBER - DN117

Definition: A number to identify the occurrence of the variable segment in
error and is part of the Error Code.
Business Need: For those fields that are part of the variable segment - to identify
the occurrence of the variable segment on which an error was
detected.
Revised: 8/18/94
Source: IAIABC
Format: 2 A/N
Implementation Note: The variable segment number is used to identify which
occurrence is in error of a multiple occurrence field. This field is
zero for a single occurrence field.
WAGE - DN62
Definition: For First Report: The reported employee's pre-injury wage for
the Wage Period.
For Subsequent Report: The average wage of the employee at
the time of injury as calculated by the Claims Administrator or
jurisdictional authority for the Wage Period.
Business Need: To be used in determining the rate of compensation.
Revised: 3/11/94
Source: IAIABC
Format: $9.2
Subsequent Report
Implementation Note: This amount may include commissions, piecework earnings, and
other forms of income converted to a normal scheduled work
week, plus the estimated value of lodging, food, laundry and other
payments in kind; and concurrent employment earnings, as per
jurisdictional requirements.
WAGE PERIOD - DN63

Definition: A code indicating the time period during which the Wage was
earned.
Business Need: To relate earnings amount to earnings period.
Revised: 3/11/94
Source: IAIABC
Format: 2 A/N
First Report Values Subsequent Report Values
6 = Daily
1 = Weekly 1 = Weekly
2 = Bi-Weekly
4 = Monthly 4 = Monthly
Subsequent Report
SECTION 6
GLOSSARY
RELEASE 1
Revision Date: 2/15/02
SECTION 6
SECTION 6
ACKNOWLEDGMENT LEVEL
Definition: For a given transaction set, the receiving trading partner will specify whether they can
support acknowledgments for all transactions, only transactions with errors, and/or
only transactions that are rejected. It should be noted that providing multiple options
indicates that the receiving trading partner is capable of supporting filtered
acknowledgments. Options not supported must be removed/crossed-off.
Revised: 9/25/96
ACKNOWLEDGMENT MODE
Definition: For any given transaction set, the receiver will indicate whether they can support
electronic, paper or no acknowledgments. Any unsupported option should be
removed/crossed-off by the receiving trading partner.
Revised: 9/25/96
ACKNOWLEDGMENT RECORD (AK1)
Definition: A transaction returned as a result of an original report. It contains enough data

elements to identify the original transaction and any technical and business issues
found with it.
Revised: 9/25/96
ACQUIRED FILE
Definition: A claim previously administered by a different claim administrator.

Revised: 6/7/95
ANSI BATCHES
Definition: A dataset containing transactions formatted according to X12 standards.

Revised: 9/25/96
ANSI DATA ELEMENT SEPARATOR
Definition: The character used as a data element separator when transmitting transactions
formatted according to X12 standards.
Revised: 9/25/96
ANSI ISA QUALIFIER, PROD
Definition: ANSI ID Code Qualifier to be specified in an ISA segment when transmitting

production transactions formatted according to X12 standards.
Revised: 09/25/96
ANSI ISA QUALIFIER, TEST
Definition: ANSI ID Code Qualifier to be specified in an ISA segment when transmitting test
transactions formatted according to X12 standards.
Revised: 9/25/96
ANSI SEGMENT TERMINATOR
Definition: The character used as a segment terminator when transmitting transactions formatted
according to X12 standards.
Revised: 9/25/96
SECTION 6
ANSI SUB-ELEMENT SEPARATOR
Definition: The character used as a sub-element separator when transmitting transactions

formatted according to X12 standards.
Revised: 9/25/96
ANSI VERSION #
Definition: The ANSI version number used when transmitting transactions formatted according to
X12 standards.
Revised: 9/25/96
Definition: An AK1 record appended with the audit ID from the original transaction the AK1 is
responding to.
Revised: 9/25/96
APPENDED FROI
Definition: A First Report of Injury record appended with the audit ID of the batch it came in.
Revised: 9/25/96
APPENDED SROI
Definition: A Subsequent Report of Injury record appended with the audit ID of the batch it came
in.
Revised: 9/25/96
AUDIT FILE
Definition: A file containing a log of each batch received. It includes a unique audit ID and all of
the batch’s data elements.
Revised: 9/25/96
BATCH
Definition: A set of records containing one Header, one or more detail transactions and one-
trailer records. For ANSI this is equivalent to the transaction contained within ST and
SE segments. FROI and SROI cannot be mixed within a batch.
Revised: 9/25/96
BUSINESS CONTACT E-MAIL ID
Definition: The E-mail address where a Business Contact may be reached.

Revised: 9/25/96
BUSINESS CONTACT E-MAIL NETWORK
Definition: The E-mail network where a Business Contact may be reached.

Revised: 9/25/96
BUSINESS CONTACT FAX
Definition: The fax number where a Business Contact may be reached.

Revised: 9/25/96
SECTION 6
BUSINESS CONTACT NAME
Definition: The name of the Business Contact.

Revised: 9/25/96
BUSINESS CONTACT PHONE
Definition: The phone number where a Business Contact may be reached

Revised: 9/25/96
BUSINESS CONTACT TITLE
Definition: The title of the Business Contact or the role the contact performs within a given
trading partner agreement.
Revised: 9/25/96
CARRIER
Definition: The licensed business entity issuing a contract of insurance and assuming financial
responsibility on behalf of the employer.
Revised: 5/26/92
CLAIM ADMINISTRATOR
Definition: Carrier, third party administrator, state fund, self-insured.

Revised: 6/7/95
CLAIMANT
Definition: A person claiming Workers’ Compensation benefits.
Revised: 7/1/97
COMPROMISED PAYMENT
Definition: Payment made to limit or end past, present, and/or future liability.
Revised: 7/1/97
CONCURRENT INDEMNITY BENEFITS

Definition: Weekly indemnity payments are being made for two or more benefity type codes
for a common period of time.
Revised: 7/1/97
CONTRACT MEDICAL
Definition: Contract medical costs are the actual costs incurred by the carrier under medical
contracts with physicians, hospitals, and other which cannot be allocated to a
particular claim.
Revised: 8/9/95
DATA ELEMENT
Definition: A single piece of information e.g. Date of Birth
Revised: 7/1/97
DENIAL
Definition: Benefit entitlement of the entire claim or a portion thereof has been rejected.
Revised: 7/1/97
SECTION 6
DIRECT CONNECT OPTION

Definition: If data can be transmitted directly to the receiving trading partners computer, the
receiving trading partner must provide (or have available upon request) the technical
specifications needed to support this media type. All pertinent data (telephone
numbers, baud rates, communications protocol, transmission window, etc.) must be
available for the sender to develop the send process if the direct connect option is
selected.
Revised: 9/25/96
DOWNLOADED ANSI BATCHES

Definition: A dataset containing transactions formatted according to X12 standards, after it has
been downloaded from an electronic medium into the receiver s system.
Revised: 9/25/96
DOWNLOADED FLAT FILE BATCHES

Definition: A dataset containing transactions formatted according to IAIABC proprietary
standards, after it has been downloaded from an electronic medium into the receivers
system.
Revised: 9/25/96
EDI ACTIVITY LOG

Definition: A file maintained by a sender to keep track of the history of electronic transactions
submitted for a claim. It is used in combination with the Event Table to determine what
transactions need to be submitted.
Revised: 9/25/96
EDIT MATRIX
Definition: Identifies edits to be applied to each data element. Senders will apply them before
submitting a transaction and receivers will confirm at reception time.
Revised: 9/25/96
ELECTRONIC MAILBOX ACCT ID, PROD

Definition: The account ID used by a trading partner to interchange production transactions,
when using a Value Added Network (VAN).
Revised: 9/25/96
ELECTRONIC MAILBOX ACCT ID, TEST

Definition: The account ID used by a trading partner to interchange test transactions, when using
a Value Added Network (VAN).
Revised: 9/25/96
ELECTRONIC MAILBOX MESSAGE CLASS, PROD

Definition: Provides a means to cluster similar production files in different compartments within a
partner’s VAN account ID.
SPECIALNOTE: Message Class is not recommended for usage because it is not a
feature standard to all commercial VANs. If the Receiver allows usage, this
information must be coordinated between both trading partners.
Revised: 9/25/96
ELECTRONIC MAILBOX MESSAGE CLASS, TEST

Definition: Provides a means to cluster similar test files in different compartments within a
partner’s VAN account ID.
SPECIAL NOTE: Message Class is not recommended for usage because it is not a
feature standard to all commercial VANs. If the Receiver allows usage, this
information must be coordinated between both trading partners.
Revised: 9/25/96
SECTION 6
ELECTRONIC MAILBOX NETWORK

Definition: The name of the Value Added Network service through which data will be
electronically interchanged.
Revised: 9/25/96
ELECTRONIC MAILBOX USER ID, PROD

Definition: The user ID specified by a trading partner to interchange production transactions,
when using a Value Added Network (VAN).
Revised: 9/25/96
ELECTRONIC MAILBOX USER ID, TEST

Definition: The user ID specified by a trading partner to interchange test transactions, when
using a Value Added Network (VAN).
Revised: 9/25/96
ELEMENT REQUIREMENT TABLE

Definition: A receiver specific list of requirement codes for each data element depending on the
Maintenance Type Code.
Revised: 9/25/96
EMPLOYEE
Definition: A person receiving remuneration for their services.
Revised: 5/26/92
EMPLOYER
Definition: POC: any entity (e.g. d/b/a, AKA, TA etc.) of the insured. Multiple entities can exist
for an insured.
Revised: 7/3/95
EVENT TABLE
Definition: A receiver specific table, which identifies the conditions which trigger a report and the
timeliness requirements to do it.
Revised: 9/25/96
EXISTING CLAIMS DATA

Definition: Data extracted from the partner s specific application. Data will be used to validate
incoming transactions or to build outgoing transactions.
Revised: 9/25/96
FEIN
Definition: Federal Employers Identification Number. Corporation/Business US Federal Tax ID.
Individual’s US Social Security Number.
Revised: 7/4/92
FIXED LENGTH ANSI

Definition: A translated X12 file. A fixed length ANSI file contains one segment per record and
does not contain separators and delimiters.
Revised: 9/25/96
FLAT FILE BATCHES

Definition: A dataset containing transactions formatted according to IAIABC proprietary
standards.
Revised: 9/25/96
FLAT FILE RECORD DELIMITER

Definition: The character used to physically indicate end of record when submitting transactions
formatted according to IAIABC proprietary standards.
Revised: 9/25/96
SECTION 6
FLAT FILE RELEASE #

Definition: The release number used when transmitting transactions formatted according to the
IAIABC proprietary standards.
Revised: 9/25/96
FOLLOW-UP FORM
Definition: The hard-copy form, pamphlet, or form number, that is required to be sent out at the
time an EDI transaction is submitted.
Revised: 9/25/96
FOLLOW-UP RECEIVER
Definition: A code (from a valid code list) to identify the receiver of a Follow-Up Form.
Revised: 9/25/96
FORMATS
Definition: The technical method used to exchange information, e.g., IAIABC Flat & Hard Copy,
WCPOLS, ANSI X12. The business requirements remain constant. The technology
is different. Refer to the Section 6 Dictionary for format explanations.
Revised: 6/7/95
FROI
Definition: First Report of Injury. A report required by a Jurisdiction to communicate that an on-
the-job incident has occurred.
Revised: 9/25/96
FUNCTIONAL 997-IN
Definition: Functional Response to a sending trading partners receipt of an ANSI transaction.
Revised: 9/25/96
FUNCTIONAL 997-OUT
Definition: A Receiving trading partner’s functional response to receipt of an ANSI transaction.
Revised: 9/25/96
HEADER RECORD (HD1)

Definition: The record that precedes each batch. This and the trailer record are an envelope that
surround a batch of transactions.
Purpose: To uniquely identify a sender, as well as the date/time a batch is prepared and the
transaction set contained within the batch.
Note: For ANSI files, the header record fields are mapped out of the BGN, ISA, GS and ST
segments as described in the ANSI 148-implementation guide.
Revised: 9/25/96
IMPLEMENTATION DATE, “FROM”
Definition: The effective begin date of the production level indicator for a trading partner.
Revised: 9/25/96
IMPLEMENTAT ION DATE, “THRU”

Definition: The effective end date of the production level indicator for a trading partner.
Revised: 9/25/96
IMPLEMENTATION GUIDE
Definition: User friendly specifications issued by an industry organization such as the IAIABC.
Sets the objectives and parameters of Trading Partner Agreements. May also be
exchanged between partners for their unique requirements, e.g. Employer/Carrier.
Revised: 6/7/95
SECTION 6
INDEMNITY BENEFITS
Definition: Benefits paid to the employee, employee's dependent, or jurisdiction Fund, for wage
replacement, permanent partial impairment, vocational rehabilitation maintenance, or
dependency benefits.
Indemnity Benefit Code Table:
010, 020, 021, 030, 040, 050, 051, 070, 090, 240, 410, 500, 510, 520, 521, 524, 530,
540, 541, 550, 551, 570, 590
Revised: 6/7/95
INDEPENDENT ADJUSTER
Definition: Third party administrator (TPA).
Revised: 5/26/92
INJURY BATCH
Definition: A group of like injury transactions. The individual transactions comprise an injury
batch.
Revised: 9/25/96
INJURY TRANSACTION
Definition: An individual injury report.
Revised: 9/25/96
MAINTENANCE TYPE CODE HIERARCHICAL STRUCTURE

Definition: Hierarchy to be used when submitting multiple MTC s on the same claim in one day.
Revised: New Element 11/23/93
MTC HIERARCHICAL STRUCTURE OF USE

First Report
01
04
00
CO
02
Subsequent Report
VE
FS
CD
IP
*Sx - RB*
RE
CB
CA
CO
02
PY
FN
A code higher on the list will take precedence over a lower code. Locate the “MTC’s” on the above
chart. Use the topmost MTC. For example, if a 00 (original) first report and a 01 (cancel) were filed on
the same day, the 01 would take precedence. *Sx and RB can be filed together with the same
transmission set date. MTC 04 for the Subsequent Report can be filed in conjunction with all other
Subsequent MTC’s. The 04 MTC on the Sub will indicate a denial of only part of a claim. If a Sub
report has been transmitted, a 04 MTC on the first report would be filed to deny a claim in its entirety.
SECTION 6
MASTER TRADING PARTNER FEIN
Definition: The Federal Employer’s Identification Number of your business entity. This, along with
the 9-position postal code (Zip+4) in the trading partner address field will be used to
identify a unique trading partner.
Revised: 9/25/96
MASTER TRADING PARTNER MAILING ADDRESS

Definition: The mailing address used to receive deliveries via the U.S. Postal Service for your
business entity. This should be the mailing address that would be used to receive
materials pertaining to this trading partner agreement.
Revised: 9/25/96
MASTER TRADING PARTNER NAME

Definition: The name of the business entity corresponding with the Master FEIN.
Revised: 9/25/96
MASTER TRADING PARTNER PHYSICAL ADDRESS

Definition: The street address of the physical location of your business entity. It will represent
where materials may be received regarding “this” trading partner agreement if using a
delivery service other than the U.S. Postal Service.
Revised: 9/25/96
PAYMENT ADJUSTMENT ELEMENT REQUIREMENT TABLE

Definition: A table that supplements the Element Requirement table. It supports the
documentation of the differences in reporting requirements based on payment type.
Revised: 9/25/96
PERIODIC QUALIFIER
Definition: Code values that describe the types of claims that are required to be reported
periodically (e.g. open claims, closed claims).
Revised: 9/25/96
Value: Q1, Q2
Q1 STATUS
O If Open During Period
C If Closed During Period
E Either Open or Closed During Period
Q2 ACTIVITY
I If Indemnity payments were made
M If Medical payments were made
E If Either Medical or Indemnity payments were made
N No payments/activity has occurred.
PILOT/PARALLEL
Definition: - Dual reporting (current/IAIABC EDI standards)
- Production data (real claims)
- Loaded to test/production system
- IAIABC Data does not yet satisfy receiver’s reporting requirements
- Temporary as defined by trading partners with Production as the goal.
Revised: 9/25/96
PRODUCTION
Definition: - A trading Partner is sending Production Data (real claims).
- The data is loaded to jurisdiction production system
- No dual (paper/EDI) reporting to receiver from sender.
- IAIABC data satisfies receiver’s reporting requirements.
Revised: 9/25/96
SECTION 6
PRODUCTION LEVEL INDICATOR

Definition: Reflects an EDI participation status for a specific transaction. It indicates whether the
transaction being sent is being targeted to a receivers production or test system.
Transactions performed while under parallel status should have the test indicator set.
TECHNICAL NOTE: This flag is set at the batch header level in the HD1. Therefore,
all transactions within a batch must be at the same production level.
Revised: 9/25/96
PROFILE ID
Definition: A free-form field used to uniquely identify a given profile between any given pair of
trading partners. This field becomes critical when more than one profile exists
between a given pair of trading partners. It is used for reference purposes.
Revised: 9/25/96
PTD
Definition: Paid to date
Revised: 6/7/95
RECEIVER NAME
Definition: The name of the business entity corresponding with the Master FEIN.
Revised: 9/25/96
RECONCILED ACK TRANSACTION

Definition: An appended acknowledgment transaction that has been reconciled against the EDI
Activity Log. The EDI Activity Log contains the original transmissions with the
Date/Time original transaction sent and record sequence number.
Revised: 9/25/96
RECONCILIATION ERROR REPORT

Definition: A file containing the acknowledgment transactions that were unable to be reconciled
with the EDI Activity Log.
Revi sed: 9/25/96
RECORDS/TRANSACTIONS
Definition: A group of Data Elements that satisfy a specific business requirement,
e.g. 1st Report, Initial Payment, purchase order, medical bill.
RECOVERIES
Definition: Monies brought into a claim from external sources.
Revised: 7/92
REDUCED EARNINGS
Definition: The actual or deemed weekly earnings of an employee who has returned to work with
employment restrictions that may result in reduced earnings.
Revised: 6/7/95
REGULATORY/REPORTING AGENCY
Definition: Jurisdiction, OSHA, State Agency, etc.
Revised: 7/92
RELEASE/VERSION
Definition: A snapshot of EDI specifications at a given point in time to document development
work and/or referenced by Tutorial or Implementation Guide as prescribed usage.
Revised: 6/7/95
SECTION 6
REPORT DUE CRITERIA

Definition: The criteria that determines the latest date that a report must be completed and
submitted for a specific trigger to be considered timely.
Revised: 9/25/96
REPORT DUE VALUE

Definition: A value that is used to modify or define a Report Due Criteria.
Revised: 9/25/96
REPORT LIMIT NUMBER

Definition: When present, this value reflects the maximum number of periodic reports required.
Revised: 9/25/96
REPORT REQUIREMENT CRITERIA

Definition: Criteria used in conjunction with Report Requirement Effective Date (From and Thru),
to determine whether the corresponding event requirements are applicable for a
particular claim. An example of Report Requirement Criterion is Date of Injury, where
different events may apply depending on its value; this is where the From and Thru
dates come into play to identify the specific event which applies to a claim.
Revised: 9/25/96
REPORT REQUIREMENT EFFECTIVE DATE, FROM

Definition: The first date that a claim meeting the Report Requirement Criteria will be reported for
a specific report trigger.
Revised: 9/25/96
REPORT REQUIREMENT EFFECTIVE DATE, THRU

Definition: The last date that a claim meeting the Report Requirement Criteria will be reported for
a specific report trigger.
Revi sed: 9/25/96
REPORT TRIGGER CRITERIA

Definition: Criteria used in conjunction with Report Trigger Value to determine if an event must
be triggered for a claim covered according to the Report Requirement Criteria, and
Report Requirement Effective Dates. If multiple conditions can independently trigger
an event, then each condition must be listed separately. An example of Report
Requirement Criterion is Indemnity Benefits Paid, and when associated with the
corresponding Report Trigger Value will determine whether a report must be triggered
for a particular claim.
Revised: 9/25/96
REPORT TRIGGER VALUE

Definition: Used in conjunction with report Trigger Criteria, it determines whether a report must
be triggered.
Revised: 9/25/96
SELF INSURED
Definition: A jurisdictional approved or acknowledged employer, group fund, or association
assuming financial risk and responsibility for their employees' Workers' Compensation
claims.
Revised: 9/16/94
SENDER NAME
Definition: The business name of the sending party
Revised: 9/25/96
SECTION 6
SORTED FROI
Definition: A dataset containing First Report of Injury transactions sorted in such a way to
efficiently use the Trading Partner tables. The particular order will depend on the
specific partner system design.
Revised: 9/25/96
SORTED SROI
Definition: A dataset containing Subsequent Report of Injury transactions sorted in such a way to
efficiently use the Trading Partner tables. The particular order will depend on the
specific partner system design.
Revised: 9/25/96
SROI
Definition: Subsequent Report of Injury. A report required by a Jurisdiction to communicate
information related to workers’ compensation payments.
Revised: 9/25/96
SUSPENSION
Definition: Indemnity benefits payments have been interrupted/terminated due to associated
circumstances.
Revised: 7/17/92
TECHNICAL CONTACT E-MAIL ID

Definition: The E-mail address where a Technical Contact may be reached.
Revised: 9/25/96
TECHNICAL CONTACT E-MAIL NETWORK

Definition: The E-mail network where a Technical Contact may be reached.
Revised: 9/25/96
TECHNICAL CONTACT FAX

Definition: The fax number where a Technical contact may be reached
Revised: 9/25/96
TECHNICAL CONTACT NAME

Definition: The name of the Technical Contact
Revised: 9/25/96
TECHNICAL CONTACT PHONE

Definition: The phone number where a Technical Contact may be reached
Revised: 9/25/96
TECHNICAL CONTACT TITLE

Definition: The title of the Technical Contact or the role the contact performs within a given
trading partner agreement.
Revised: 9/25/96
TEST
Definition: - Sending production/test data.
- May not involve others outside of your organization.
- No link between current receiver reporting requirements and IAIABC data.
- Will likely not load to production.
- Trading Partner requirements may not have been established.
- To move to pilot/parallel or production is the goal.
Revised: 8/9/95
SECTION 6
THIRD PART ADMINISTRATOR

Definition: A business entity providing claim services on behalf of the carrier, or self insured.
Revised: 5/26/92
TRADING PARTNER AGREEMENT

Definition: A set of expectations, responses, between two entities exchanging data electronically:
e.g. what transactions to send, what format to use, what data elements to include.
when, where to send it, testing to be performed, etc.
Revised: 6/7/95
TRADING PARTNER PROFILE

Definition: A form to uniquely identify a trading partner and contact information. Each member in
a partnership will fill out the information as it pertains to them and then exchange it
with their trading partner(s).
Revised: 9/25/96
TRADING PARTNER TYPE

Definition: The business function a given trading partner performs within a given agreement.
Most common functions are listed on the form itself. If other, please specify.
Revised: 9/25/96
TRAILER RECORD (TR1)

Definition: A record designed by the IAIABC to designate the end of a batch of transactions and
to provide with a count of records contained within the batch.
Revised: 9/25/96
TRANSACTION SET ID
Definition: A code that identifies the transaction being sent/received.
Revised: 9/25/96
TRANSMISSION
Definition: Consists of one or more batches sent or received during a communication session.
Revised: 9/25/96
TRANSMISSION FREQUENCIES
Definition: All frequencies the receiving trading partner will accept transmission for the
transaction sets identified within a Transmission Profile. Frequencies that cannot be
supported by the receiving trading partner should be removed/crossed-off the list.
Revised: 9/25/96
Definition: A form used to communicate all allowable options the receiver of Workers
Compensation data will provide to a sender. The receiver is responsible for providing
the information on the first page of this form, indicating all their requirements, and,
where applicable, the supported options from which a sender can select. The sender
will then complete page 2 of this form providing their data in the allotted spaces, and
indicating their selections where the receiver provides choices. This information is
then returned to the receiver
Revised: 9/25/96
TRANSLATORS
Definition: An application (Software) that translates information between your system and the
format you send or receive. IAIABC and WCPOLS translators are typically self
developed. ANSI translators are typically off the shelf solutions that are easily
upgradeable and can process several versions.
Revised: 6/7/95
SECTION 6
TUTORIAL
Definition: A broad interpretation of an implementation guide used to express the general
intentions of the developers, e.g., align use for several lines of business.
Revised: 6/7/95
SECTION 6
SECTION 6
APPENDIX
SECTION 6
SECTION 6
285 PART OF BODY CODE

Simple data element/code references:
1270/PB 1460/
Source: ASWG (Advisory Statistical Work Group); code list dated 1/16/98
Available from:
National Council on Compensation Insurance
Products and Services
901 Peninsula Corporate Circle
Boca Raton FL 33487
Abstract
The publication describes parts of body. The part of body affected classification identifies the part of the
injured person's body directly affected by the nature of injury or illness.
TABLE 7: PART OF BODY CODES

I. HEAD
10 Multiple Head Injury – any combination of below parts
11 Skull
12 Brain
13 Ear(s) – includes: hearing, inside eardrum
14 Eye(s) – includes: optic nerves, vision, eyelids
15 Nose – includes: nasal passage, sinus, sense of smell
16 Teeth
17 Mouth – includes: lips, tongue, throat, taste
18 Soft Tissue
19 Facial Bones – includes jaw
II. NECK
20 Multiple Neck Injury – any combination of below parts, excluding hands and wrists combined
21 Vertebrae – includes: spinal column bone, “cervical segment”
22 Disc – includes spinal column cartilage, “cervical segment”
23 Spinal Cord – includes: nerve tissue, “cervical segment”
24 Larynx – includes: cartilage and vocal cords
25 Soft Tissue – other than larynx or trachea
26 Trachea
III. UPPER EXTREMITIES

30 Multiple Upper Extremities – any combination of below parts, excluding hands and wrists combined
31 Upper Arm – Humerus and corresponding muscles, excluding clavicle and scapula
32 Elbow – radial head
33 Lower Arm – forearm – radius, ulna, and corresponding muscles
34 Wrist – carpals and corresponding muscles
35 Hand – metacarpals and corresponding muscles (excluding wrist or fingers)
36 Finger(s) – other than thumb and corresponding muscles
37 Thumb
38 Shoulder(s) – armpit, rotator cuff, trapezius, clavicle, scapula
39 Wrist(s) and Hands(s)
SECTION 6
IV. TRUNK
40 Multiple Trunk – any combination of below parts
41 Upper Back Area (Thoracic Area) – upper back muscles, excluding vertebrae, disc, spinal cord
42 Low Back Area (Lumbar Area and Lumbo-Sacral) – lower back muscles, excluding sacrum, coccyx,
pelvis, vertebrae, disc, spinal cord
43 Disc – spinal column cartilage other than cervical segment
44 Chest – including Ribs, Sternum and soft tissue
45 Sacrum and Coccyx – final nine vertebrae - fused
46 Pelvis
47 Spinal Cord – nerve tissue other than cervical segment
48 Internal Organs – other than heart and lungs
49 Heart
60 Lungs
61 Abdomen Including Groin – excluding injury to internal organs
62 Buttocks – soft tissue
63 Lumbar and/or Sacral Vertebrae (Vertebrae NOC Trunk) – bone portion of the spinal column
V. LOWER EXTREMITIES
50 Multiple Lower Extremities – any combination of below parts
51 Hip
52 Upper Leg – femur and corresponding muscles
53 Knee - patella
54 Lower Leg – tibia, fibula, and corresponding muscles
55 Ankle - tarsals
56 Foot – metatarsals, heel, Achilles tendon and corresponding muscles (excluding ankle or toes)
57 Toe(s)
58 Great Toe
VI. MULTIPLE BODY PARTS

64 Artificial Appliance – braces, etc.
65 Insufficient Info to Properly Identify – Unclassified – insufficient information to identify part affected
66 No Physical Injury – mental disorder
90 Multiple Body Parts (including body systems and body parts) – applies when more than one major
body part has been affected such as an arm and a leg and multiple internal organs
91 Body Systems and Multiple Body Systems – applies to the functioning of an entire body system that
has been affected without spedific injury to any other part, as in the case of poisoning, corrosive
action, inflammation affecting internal organs, damage to nerve centers, etc. Does NOT apply when
the systemic damage results from an external injury affecting an external part, such as a back injury
which includes damage to the nerves of the spinal cord.
SECTION 6
284 NATURE OF INJURY CODE
1270/NI 1463/-
Available from:
Boca Raton FL 33487
Abstract
The publication describes nature of injury. The nature of injury or illness classification identifies the injury or
illness in terms of its principal characteristics. Reprinted with permission.
TABLE 8: NATURE OF INJURY CODES

I. SPECIFIC INJURY
01 No Physical Injury – i.e. glasses, contact lenses, artificial appliance, replacement of artificial appliance
02 Amputation – cut off extremity, digit, protruding part of body, usually by surgery, i.e. leg, arm
03 Angina Pectoris – chest pain
04 Burn – (heat) burns or scald: the effect of contact with hot substances (chemical) burns: tissue
damage resulting from the corrosive action of chemicals, fumes, etc. (acids, alkalis)
07 Concussion – brain, cerebral
10 Contusion – bruise – intact skin surface; hematoma
13 Crushing – to grind, pound, or break into small bits
16 Dislocation – pinched nerve, slipped/ruptured disc, herniated disc, sciatica, complete tear,
H.P.subluxation, MD dislocation
19 Electric Shock - electrocution
22 Enucleation – removal of organ or tumor
25 Foreign Body
28 Fracture – breaking of bone or cartilage
30 Freezing – frostbite and other effects of exposure to low temperature
31 Hearing Loss or Impairment – traumatic only: a separate injury, not the sequella of another injury
32 Heat Prostration – heat stroke, sun stroke, heat exhaustion, heat cramps and other effects of
environmental heat; does not include sunburn
34 Hernia – the abnormal protrusion of an organ or part through the containing wall of its cavity
36 Infection – the invasion of a host by organisms such as baceria, fungi, viruses, protozoa or insects,
with or without manifest disease
37 Inflammation – the reaction of tissue to injury characterized clinically by heat, swelling, redness, and
pain
40 Laceration – cuts, scratches, abrasions, superficial wounds, calluses, wound by tearing
41 Myocardial Infarction - heart attack, heart conditions, hypertension; the inadequate blood flow to the
muscular tissue of the heart
42 Poisoning – General (Not OD or Cumulative Injury) – a systemic morbid condition resulting from the
inhalation, ingestion or skin absorption of a toxic substance affecting the metabolic system, the
nervous system, the circulatory system, the digestive system, the respiratory system, the excretory
system, the musculoskeletal system, etc.; includes chemical or drug poisoning, metal poisoning,
organic diseases and venomous reptile and insect bites; does NOT include effects of radiation,
pneumoconiosis, corrosive effects of chemicals, skin surface irritations, septicemia, or infected
wounds
43 Puncture – a hole made by the piercing or a pointed instrument
46 Rupture
47 Severance – to separate, divide, or take off
49 Sprain – internal derangement; a trauma or wrenching of a joint, producing pain and disability
depending on degree of injury to ligaments
SECTION 6
52 Strain – internal derangement; the trauma to the muscle or musculotendinous unit from violent
contraction or excessive forcible stretch
53 Syncope – swooning, fainting, passing out; no other injury
54 Asphyxiation – strangulation, drowning
55 Vascular - cerebrovascular and other conditions of circulatory systems NOC, excludes heart and
hemorrhoids; includes strokes, varicose veins – non-toxic
58 Vision Loss
59 All Other Specific Injuries, NOC
II. OCCUPATIONAL DISEASE OR CUMULATIVE INJURY

60 Dust Disease NOC (All other Pneumoconiosis)
61 Asbestosis – lung disease; a form of pneumoconiosis, resulting from protracted inhalation of asbestos
particles
62 Black Lung – the chronic lung disease or pneumoconiosis found in coal miners
63 Byssinosis – the pneumoconiosis of cotton, flax, and hemp workers
64 Silicosis – pneumoconiosis resulting from inhalation of silica (quartz) dust
65 Respiratory Disorders (Gases, Fumes, Chemicals, etc.)
66 Poisoning – Chemical (Other than Metals)
67 Poisoning – Metal – man-made
68 Dermatitis – rash, skin, or tissue inflammation including boils, etc.: generally resulting from direct
contact with irritants or sensitizing chemicals such as drugs, oils, biologic agents, plants, woods, or
metals which may be in the form of solids, pastes, liquids or vapors and which may be contacted in the
pure state or in compounds or in combination with other materials; do NOT include skin tissue damage
resulting from corrosive action of chemicals, burns from contact with hot substances, effects of
exposure to radiation, effects of exposure to low temperatures or inflammation or irritation resulting
from friction or impact
69 Mental Disorder – a clinically significant behavioral or psychological syndrome or pattern typically
associated with either a distressing symptom or impairment of function, i.e. acute anxiety, neurosis,
stress, non-toxic depression
70 Radiation – all forms of damage to tissue, bones or body fluids produced by exposure to radiation
71 All Other Occupational Disease Injury NOC
72 Loss of Hearing
73 Contagious Disease
74 Cancer
75 AIDS
76 VDT-Related Disease – video display terminal disease other than carpal tunnel syndrome
77 Mental Stress
78 Carpal Tunnel Syndrome – soreness, tenderness and weakness of the muscles of the thumb caused
by pressure on the median nerve at the point where it goes through the carpal tunnel of the wrist. May
involve damage to the hands, wrists, forearms, elbow and shoulders. May also include ganglion cysts
in the wrist area.
80 All Other Cumulative Injuries, NOC
III. MULTIPLE INJURIES

90 Multiple Physical Injuries Only
91 Multiple Injuries Including Both Physical and Psychological
SECTION 6
281 CAUSE OF INJURY CODE
1270/CN 1461/-
Available from:
Boca Raton FL 33487
Abstract
The publication describes cause of injury. The code categorizes the object or activity from which the injury
was inflicted, e.g. chemical, hand tool, lifting. Reprinted with permission.
TABLE 9: CAUSE OF INJURY CODES
I. BURN OR SCALD-HEAT OR COLD EXPOSURE

01 Chemicals
02 Hot Object or Substances
03 Temperature Extremes
04 Fire or Flame
05 Steam or Hot Fluids
06 Dust, Gases, Fumes or Vapors
07 Welding Operations
08 Radiation
09 Contact With, NOC
11 Cold Objects or Substances
14 Abnormal Air Pressure
84 Electrical Current
II. CAUGHT IN, UNDER, OR BETWEEN

10 Machine or Machinery
12 Object Handled
13 Caught In, Under, or Between, NOC
20 Collapsing Materials (Slides of Earth) – either man made or natural
III. CUT, PUNCTURE, SCRAPE, INJURED BY

15 Broken Glass
16 Hand Tool, Utensil; Not Powered
17 Object Being Lifted or Handled
18 Powered Hand Tool, Appliance
19 Cut, Puncture, Scrape, NOC
IV. FALL, SLIP OR TRIP INJURY

25 From Different Level (Elevation) – off wall, catwalk, bridge, etc.
26 From Ladder or Scaffolding
27 From Liquid or Grease Spills
28 Into Openings – shafts, excavations, floor openings, etc.
29 On Same Level
30 Slipped, Did Not Fall
31 Fall, Slip, Trip, NOC
32 On Ice or Snow
33 On Stairs
SECTION 6
V. MOTOR VEHICLE
40 Crash of Water Vehicle
41 Crash of Rail Vehicle
45 Collision or Sideswipe with Another Vehicle – both vehicles in motion
46 Collision with a Fixed Object – standing vehicle or stationary object
47 Crash of Airplane
48 Vehicle Upset – overturned or jackknifed
50 Motor Vehicle, NOC
VI. STRAIN OR INJURY BY

52 Continual Noise
53 Twisting
54 Jumping
55 Holding or Carrying
56 Lifting
57 Pushing or Pulling
58 Reaching
59 Using Tool or Machinery
60 Strain or Injury By, NOC
61 Wielding or Throwing
97 Repetitive Motion – carpal tunnel syndrome
VII. STRIKING AGAINST OR STEPPING ON

65 Moving Parts of Machine
67 Sanding, Scraping, Cleaning Operation
68 Stationary Object
69 Stepping on Sharp Object
70 Striking Against or Stepping On, NOC
VIII. STRUCK OR INJURED BY – INCLUDES KICKED, STABBED, BIT, ETC.

74 Fellow Worker, Patient
75 Falling or Flying Object
76 Hand Tool or Machine in Use
77 Motor Vehicle
78 Moving Parts of Machine
80 Object Handled by Others
81 Struck or Injured, NOC – includes kicked, stabbed, bit, etc.
85 Animal or Insect
86 Explosion or Flare Back
IX. RUBBED OR ABRADED BY

94 Repetitive Motion – callous, blister, etc.
95 Rubbed or Abraded, NOC
X. MISCELLANEOUS CAUSES
82 Absorption, Ingestion or Inhalation, NOC
87 Foreign Matter (Body) in Eye(s)
89 Person in Act of a Crime – robbery or criminal assault
90 Other Than Physical Cause of Injury
98 Cumulative, NOC – all other
99 Other – Miscellaneous, NOC
SECTION 6
FIPS Codes
SECTION 6
SECTION 6
TABLE 1
FIPS Alpha State Codes for the States and the District of Columbia
FIPS State Name Code FIPS State Name Code

Alabama AL Missouri MO
Alaska AK Montana MT
Arizona AZ Nebraska NE
Arkansas AR Nevada NV
California CA New Hampshire NH
Colorado CO New Jersey NJ
Connecticut CT New Mexico NM
Delaware DE New York NY
District of Colombia DC North Carolina NC
Florida FL North Dakota ND
Georgia GA Ohio OH
Hawaii HI Oklahoma OK
Idaho ID Oregon OR
Illinois IL Pennsylvania PA
Indiana IN Rhode Island RI
Iowa IA South Carolina SC
Kansas KS South Dakota SD
Kentucky KY Tennessee TN
Louisiana LA Texas TX
Maine ME Utah UT
Maryland MD Vermont VT
Massachusetts MA Virginia VA
Michigan MI Washington WA
Minnesota MN West Virginia WV
Mississippi MS Wisconsin WI
Wyoming WY
SECTION 6
TABLE 2
FIPS Alpha State Codes for Outlying Areas of the United States, the Freely
Associated States, and Trust Territory
FIPS Area Name Code Status

American Samoa AS 1
Federated States of Micronesia FM 3
Guam GU 1
Marshall Islands MH 3
Northern Mariana Islands MP 1
Palau PW 4
Puerto Rico PR 1
U.S. Minor Outlying Islands UM 2
Virgin Islands of the U.S. VI 2
Status:
1. Under U.S. sovereignty
2. An aggregation of nine UB territories: Bakers Island, Howland Isla nd,
Jarvis, Island, Johnston Atoll, Kingman Reef, Midway Island, Palmyra
and Wake Island. Each territory is assigned a FIPS County Code in
FIPS PUB 6–3, and may be individually identified through a
combination of the FIPS State Code (UM) and the appropriate FIPS
County Code.
3. A compact of Free Association with the United States of America is
now in full force. It was announced by Presidential proclamation on
November 3, 1986.
4. Remains a trust Territory.
TABLE 3
FIPS numeric State codes for the individual minor Outlying Island Territories
FIPS Area Name Code

Baker Island 81
Howland Island 84
Jarvis Island 86
Johnston Atoll 67
Kingman Reef 89
Midway Islands 71
Navassa Island 76
Palmyra Atoll 95
Wake Island 79

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IAIABC

International Association of Industrial Accident Boards and Commissions

SECTION 1: THE EDI PROJECT

SECTION 2: EDI CONTACTS

SECTION 3: SYSTEMS IMPLEMENTATION GUIDE (Including Forms and Tables)

SECTION 4: TRANSACTION STANDARDS

SECTION 5: ELECTRONIC SCENARIOS

SECTION 6: DEFINITIONS, GLOSSARY, AND CODE LISTS

The Foreword provides an in-depth background on Workers’ Compensation

Section 1, the EDI Project, provides project philosophy, and organizational

Section 2, EDI Contacts, provides jurisdiction and EDI committee participant

Section 3, Systems Implementation Guide, will assist you through the

Section 4, Transaction Standards, includes IAIABC Release 1 data

Section 5, Electronic Scenarios, contains scenarios that define the approved

Section 6, Definitions, Glossary & Codes Lists, provides definitions and

Together these documents should provide the initiative and information

• Measure aggregate system costs,

• RATE-SETTING DATA — This data is collected by rating organizations and insurance

• MANAGEMENT DATA — Management data is comprised of those data elements which

A. OCCUPATIONAL SAFETY AND HEALTH (FEDERAL AND STATE)

B. WORKERS’ COMPENSATION INSURANCE ORGANIZATIONS (WCIO)

C. STATE WORKERS’ COMPENSATION ADMINISTRATIVE AGENCIES

D. OTHER SOURCES OF WORKPLACE DATA

A. THE INTERNATIONAL ASSOCIATION

B. WORKGROUP FOR ELECTRONIC DATA INTERCHANGE (WEDI)

C. WORKERS’ COMPENSATION INSURANCE ORGANIZATIONS (WCIO)

D. NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS (NAIC)

E. INSURANCE DATA MANAGEMENT ASSOCIATION WORKGROUP (IDMA)

AMERICAN NATIONAL STANDARDS INSTITUTE

Working with ANSI ASC X12 provides the following benefits:

POINTS FAVORING EDI

STATUS OF THE EDI PROJECT

2. Subsequent Payment Reports (Release I completed 8/95, Release II completed 7/97)

Check our website at http://www.IAIABC.org/EDI for up-to-date project status.

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5. Simplify The Reporting Requirements: Workers' Compensation data reporting require-

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IAIABC PROJECT MISSION STATEMENT

No discussion will be permitted which attempts to pressure companies to raise rates, or

There should be no discussion of how changes in state regulation might affect a

To promote/recommend business & data interchange objectives.

To assist participants in identifying business data requirements.

To establish data interchange standards.

To provide a structure to accomplish these purposes.

To identify Workers' Compensation opportunities:

To establish standard for:

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Including Trading Partner Implementation

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IAIABC RELEASE 1 SYSTEMS IMPLEMENTATION GUIDE

The following is a summary of the sections included in this guide:

TRADING PARTNER TABLES

Electronic Data Interchange Partnering Agreement – This form is a set of

Transmission Profile - This form is used to communicate all allowable options

Payment/Adjustment Element Requirement Table - A separate table has been

Claim Administrator - Describes how a Claim Administrator receives data from

Instructions for Completing Trading Partner Forms

SPECIAL NOTE: Careful consideration of both demonstrated business need as

MASTER TRADING PARTNER PROFILE

TRADING PARTNER TYPE - The business function a given trading