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EDI and Claims Related Frequently Asked Questions

Printable EDI FAQ's

Why are multiple copies of various notifications being sent from the Commission?
This might occur because a particular party is listed more than once, unless the addresses and name of the party are exactly the same. Identical names and addresses will alert our system to send only one copy of the notice. In addition, an EDI submission accepted by ROES may fail during VWC ingestion;. Re-ingestion can create multiple mailings. We are working with IS to timely re-ingest and stop multiple mailings.
IS recently upgraded the system to identify multiple parties and the system is currently being enhanced to address issues and resolve multiple role mailings.

When multiple mailings are received with different submission dates, such as 20-day orders, which submission date should the carrier follow?
An EDI SROI payment submission generates the 20-day Order Payments Made. If payment submitted does not match an Award, a 20-day Order Payments Made will be generated. There was a glitch in the system in which only the first period of benefits paid is recognized. This has since been fixed to make sure the system recognizes which benefit type does not have a corresponding award. This fix/update included, upon EDI receipt, a 30-day timer and a check for the Award before sending the 20-day Order.

Why are some SROI submissions rejected?
ROES performs technical edits but the VWC system edits for specific information. If a transaction passes ROES’ edits but not VWC’s, then it is flagged for review and we will clarify with the adjuster. If it is determined that the information is correct, we will re- ingest. If it is determined that the information is incorrect, it might require re-submission of the SROI.

Why are we receiving 20-day orders when the IP and QT have gone out and agreement forms have been uploaded?
Until the Award is entered, the process of creating 20 day orders does not stop. The new 30 day timer will facilitate receipt of agreement forms and entry of the award without triggering the 20-day Payments Made orders.

Why does the carrier have to continue to respond to 20-day orders when responses have been sent, agreement form has been issued to the claimant, the claimant is not responding and there is no award?
Our system automatically generates a 20-day Order 30 days after receipt of a SROI transaction if the payment information does not match to an Award. A recent upgrade to our system includes human interaction to trigger whether a subsequent 20-day Payments Made order should be sent. This should help cut down on the volume of duplicate 20-day Orders being generated if a response has already been received.

Is there any way to suppress 20-day orders once QT is sent when reporting payments?
20-day orders only go out on medical payments when the total medical paid exceeds $3500.00 and no award has been entered; and on indemnity benefits paid when no matching award has been entered. If no Award has been entered, a 20 Day Order can be sent up to four times a year (every quarter).

Must we submit QT transactions for medical only files?
Meds under $2,000 with no medical award will not trigger a notice. Medical payment advisory is sent when meds are between $2,000.00 and $3,500.00. Meds over $3,500.00 will trigger a 20-Day Order.
QT transactions are required on medical only claims only if additional medical payments have been made since the last SROI transaction was submitted.

If the claimant is not asking for an award and the carrier continues to make payments without award, how many times does carrier have to respond?
Each SROI transaction may trigger a 20-Day Order that will require a response. If QT then four times a year.

There is an EDI error – waiting on acknowledgement of claim. What does this mean?
ROES sends the acknowledgement record for the VWC. If you have not received your acknowledgement record then you should immediately contact the VWC so they can follow-up with ROES. If the record contains an error then it is because something was submitted incorrectly from the Claim Administrator. They should correct the mistake based on the error text contained in the acknowledgement. VWC is unable to tell you where to correct the mistake because each Claim Administrator may have a different system we are unfamiliar with.

Is there any way the agency can create an imaging e-mail system for carriers and TPA’s to eliminate duplicates?
This is a good suggestion to look at down the road. The Commission would like to conduct as much business as possible electronically.

Why are 20-day orders generated when agreement forms are filed for a closed period and an award is received?
Upon receipt of 20-day orders, a copy of the award order is submitted by carrier as the response to the 20-day order. Our system may have been missing a step in the process. We have since revamped the 20-Day Order process to prevent this from occuring.

When a claim report is filed in some other way than through the carrier, a copy of the claim is not attached to the Notify of Injury requesting the FROI.
At this time a copy is not sent. A pending enhancement will cause a copy to be sent.

Carrier info associated with a claim is being changed; same error occurs with wrong carrier being again identified (This error occurs in multiple claims and the same wrong carrier is identified each time).
Carrier and Claim Administrator information is not claim specific, but is master data that cannot be corrected via EDI; Changes to this information need to be submitted in writing.

Why does the Commission continue to contact claimant multiple times regarding further claim filings for medical only claims when the carrier is making medical payments?
In Casper electronic reporting of payments provides more information than the Legacy system allowed, therefore, more follow-up will occur.

When the carrier agrees to a medical only award, can space be added for body parts covered by agreement?
Currently if carrier wishes to agree to specified body parts (one or a few), an agreement form should be submitted. If agreement comes from a 20-Day Order, the award will be entered for all causally related body parts.

When documentation is submitted, what response is generated via EDI?
Currently no response is generated.

What is required when reporting on claims with dates of accident prior to 10/1/08?
EDI transmissions will be required on all active claims for dates of accident prior to 10/1/08. The Commission will require an initial FROI with 1 catch-up SROI. Normal SROI reports will be required thereafter. Voluntary submissions can be sent beginning January 2012; mandatory submission on migrated files begins July 2012.

What happens if I have multiple JCN’s for the same claim?
When the Commission receives notification of an injury and a FROI has not been filed, we create a JCN for that injury. We then request a FROI and require that it contain the JCN we assigned. If a duplicate JCN is created by FROI, different criteria are used to determine which number is used. All the duplicates will be consolidated into that JCN.

Why are 20-day orders being generated monthly when a 12/09 award was entered for specific body parts for a closed period and termination paper was filed?
Our first 20-day order was issued 1/10, so we have no ready explanation.

Carrier receiving mail they do not really need – going to carrier rather than TPA. TPA filed FROI; mailing still incorrect. PMA was not listed even though they had filed information.
Both get the mailing because the law requires that all parties be notified as a courtesy we also send a copy to the TPA, a non-party.

A claim administrator cannot access both claims when duplicate JCNs are created.
Once a consolidation request is received, the JCN is determined, everything is placed in one JCN, and the parties are notified. The Claim Administrator cannot be identified until a FROI is filed and then they are associated with the claim. Once that happens, they will be able to log on to WebFile and see the JCN we decided to keep. Generally, duplicate JCNs are consolidated under VA00, but can be consolidated under VA02. No JCN should be canceled until the Commission advises which to cancel. Contact Kevin Guild if the file is not viewable in WebFile.

Defense attorney expressed concern over calls from clients indicating FROIs had been filed but could not tell if it had been received. What about a penalty for failing to file FROI in this situation? Recognizing that in the future there will be more enforcement, why should a carrier be penalized if they do not have any indication of non-receipt?
Every EDI transaction (FROI and SROI) is acknowledged by the Commission through our vendor (ROES). Regardless whether the transaction is accepted or rejected, an acknowledgment record is issued back to the submitter. If an adjuster does not see this record, they should check with their IT or EDI team. If for some reason, the acknowledgment record was not received, they should contact the Commission’s EDI Team.
Many states were surveyed on enforcement. Although many suggested the immediate imposition of penalties, the Commission has chosen to emphasize voluntary cooperation as we all work through these new processes. Until things are working more smoothly, penalties are not being issued except in the most egregious cases. The Commission will make future enforcement decisions as necessary.

Who do we contact for future problems?
Claims/Awards – Vivian Guidt, Questions@workcomp.virginia.gov. EDI – Stephanie Brenzovich, for EDI questions, edi.support@workcomp.virginia.gov.

How can a FROI be filed and yet VWC does not have it?
When an EDI transaction is submitted, it is initially sent to our vendor (ROES). The commission receives the EDI transactions from ROES every night. If a customer is completely sure that an EDI transaction was submitted and they are advised by the Commission that there is no record of it, they should ask to speak to someone in the Quality Assurance Department – EDI Unit so we can investigate and reach out to our vendor if needed.

Generation of duplicate documents by VWC.
When a transaction was accepted but not ingested because of ROES differences, some documents were held in the system and not generated until re-ingestion. A decision was made to release all documents once the ingestion could be accepted due to upgrades.

Who should we contact when we have issues?
All calls should be directed to the VWC Call Center at (877) 664-2566 or Questions@workcomp.virginia.gov. Customers can also contact the EDI department via email at edi.support@workcomp.virginia.gov.

What triggers change request for the employer or its address?
If the information came from a written request, VWC sends out the correction required letter. In addition, any address submitted via EDI is scrubbed for accuracy according to the United States Postal Service.
The request is not sent out based on the claimant’s Claim For Benefits. If the claimant’s Claim for Benefits has a different address than the FROI, a letter is sent to the claimant to clarify the address.
Claim Administrators are the owners of the data. If information is incorrect, we send out a letter asking the owner to verify the information and make correction via EDI.

ROES cannot accept two claims for same claimant and same date of accident. This happens frequently with certain professions. How do we resolve this issue?
At this time, the system will not accept two accidents with the same injured worker on the same day. The transaction for the second injury would have to be manually accepted by ROES. VWC is currently working with ROES to resolve this situation.

When VWC makes changes or corrections through USPS, can carriers be notified?
We are reviewing all aspects of address scrubbing, and will consider the need for such notifications.

What has occurred when address changes and scrubbing occurs on an address which is the same as that scrubbed?
FROI02 has been submitted to update VWC’s system.

UR → MO → 00 – lost time.
UR follows up with 00 – changes from minor injury to non-minor (major).

Agreement forms were submitted with PPD medical records, but a notice was generated requesting medical records. Why does this occur?
Mail was originally separated and medical records were not associated with the agreement. Enhancement procedures will keep medical records with agreement forms.

Once PPD has been paid in full, we submit a letter notifying of final payment. Should a suspension be filed?
Yes. The suspension indicates benefits have been paid in full. A SROI payment report should be filed rather than a letter notifying Commission that the PPD Award has been paid.

As a follow-up question, we submitted forms and the rating from a doctor via WebFile, but the carrier received a request for medical records. How could this happen?
If amputation is involved, the Commission needs the actual amputation chart or may require additional medical if the doctor’s rating does not match the agreement form.
If you are using WebFile, upload/file agreement forms and medical documents separately. This process will bypass our manual step to identify documents and place the document(s) directly into the file.

Wage loss award form – return to work modified duty, less wages – use old form?
A Termination of Wage Loss Award form is not required if you are returning the claimant to temporary partial disability due to modified duty at lesser wages. An additional Award Agreement should be filed indicating temporary partial disability information.

Does the Commission still accept Supplemental Varying forms?
These forms should not be used for post 10/1/08 claims. We will accept them if the form is completed correctly. If the form is filled out incorrectly, it will be rejected. The new Award Agreement form does not require the post injury wage information and should be submitted each time the compensation rate and post injury wage changes. Line 2 under the section for temporary partial benefits allows you to average a period of up to 13 weeks.

We are receiving phone calls 2 to 3 weeks later on things, such as 20-day orders, to which carrier has already responded. Why does this happen?
These calls should not be made since mail is up to date. If this is occurring, please contact the VWC’s Claims Services Interim Co-Managers, Angela Lent Truzzie or Renee Marks at 877-664-2566 for further investigation.

Would like webfile capabilities to be more user friendly so all fields do not have to be entered in their entirety each time, i.e., have to go through entire list of states to get to Virginia.
Currently, VWC is researching common fields that can be auto populated which will reduce data entry for users.

COLA – if only claims with an open award and the claimant is not receiving Social Security can they receive COLA, why is it not set up that only those claims receive letters?
Virginia Code Section 65.2-709 requires the claimant to apply each year for COLA with a signed statement from SSA confirming the claimant is not receiving social security disability. Our database is unable to determine if the claimant is receiving social security disability versus social security retirement.

Why are COLA letters are sent in cases where there is no open TTD award?
COLA benefits can be payable on a claim in which there is no open TTD award provided that the date of injury is prior to July 1 and the COLA request is after October 1 of the same year.

Does VWC exchange information with SSA?
No, VWC does not electronically exchange information with the Social Security Administration.

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