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RECONCILIATION REPORT PROCESSING GUIDE

      The Reconciliation Report is a tool for claims professionals to use to analyze their filings and assess their claims processing performance in the State of Maine. It will assist them to identify all current claims filings, address any processing issues, and identify any trends and patterns before they negatively impact compliance. The Reconciliation Report is also a tool that insurers can use to identify those claims or form filings that have been incorrectly assigned. Claims professionals can “reconcile” their claims information with the Board by rebutting any incorrect information identified in the Reconciliation Report. The Report can and should be used as a tool to improve claims processing performance and information quality on the Maine Workers’ Compensation System. The Monitoring Division is more than willing to work with you through the reconciliation process.

      When you receive a quarterly reconciliation report from the State of Maine, the first thing to remember is “don’t panic.”The process is easy if you take some time and address the report one page and one claim at a time. In order to assist you, these notes will do three things, first they will walk you through all three parts of the report, second they will explain what to look for as you reconcile your report, and third they will help you to organize your response to the report.

1. THE REPORT. The report consists of three sections. (You will receive one report for each individual insurance entity or TPA assignment that you have within your insurance group.)

   1. Cover Page. The first page is an overview that assesses the compliance of the insurance entity for the preceding quarter. A sample first page appears below.

      This section gives you the information that will be used to calculate your final compliance percentages if nothing is done during the reconciliation process.

      In the above example six Memorandums of Payment were received, but only three were filed within the first 14 days. The compliance for timely first indemnity payments would be 50% and the timely receipt of memorandum of payment would be 50% as well. The reconciliation process allows an insurance group, self insured or TPA the opportunity to amend any filings or data processing errors to improve their performance prior to publishing information in the quarterly reconciliation report.

2. Detailed Claims Section. The second section is the Detailed Claims Section. This is a record of all the First Reports of Injury (FROIs), Memoranda of Payment (MOPs), and Notices of Controversy (NOCs) that were filed with the Board by the employer directly or by the carrier, TPA or self-insured employer during the quarter. Look at the example below to under-stand the page and what to look for. Due to confidentiality issues, the last names have been removed and the insurance file numbers and claimant’s social security number have been truncated.

Ncci - ?		Detailed Claim Section			04/01/2003 - 06/30/2003
1)	2)	3)	4)	5)	6)	7)
Name Injury Date	SSN Insurer File #	WCBN	First Report Receive Dte/Return to Work	Notice of Controversy Receive Dte:	Initial Check Mailed on Day:	Memorandum of Payment Received on Day:
JANE I DOE 10/29/2002	123-99-9999 678CP146185678	02014247	11/01/2002 10/31/2002		14	06/09/2003 20
JOHN J SMITH 05/24/2003	555-55-9999	03007143	06/26/2003
JOAN DOE 5/10/2003	556-55-9999 678CP152594678	03005372	05/16/2003 05/17/2003
JOHN DOE 04/21/2003	666-55-9999 678CP152354678	03005773	05/20/2003		4	05/23/2003 7
JOHN L SMITH 06/06/2003	777-22-9999 WC204-579109	03006612	06/13/2003 ?
JANE S DOE 06/08/2003	778-44-8888 WC204-579105	03006704	06/13/2003		13	06/26/2003 14

• The first column on the page lists the name of the claimant and the date of his/her injury.
  
• The second column lists the claimant’s social security number and the insurer’s file number if one is on file. This entire section is sorted by social security number in ascending order.
  
• The third column lists the Maine Workers’ Compensation Board’s (MWCB) file number.
  
• The fourth column lists the date that the FROI (WCB1) was received at the MWCB and also, the date that the employee returned to work after lost time if applicable.
  
• The fifth column lists when a Notice of Controversy (NOC) was received at the MWCB.
  
• The sixth column lists the day on which the initial indemnity check was mailed.
  
• The seventh and final column lists when the MOP was received at the MWCB and also calculates on what day it was received relative to the date of employer’s notice or knowledge of first day of incapacity.
3. Missing Required Data Section. The final section is a listing of claims that have been filed with the MWCB that have missing, incomplete or incompatible data. Look at the example below to understand the page and what to look for. Due to confidentiality issues, the last names have been removed and the insurance file numbers and claimant’s social security number have been truncated.

INSURANCE CARRIER NAME
Ncci - ?		Missing Required Data Section			02/05/2002
1)	2)	3)	4)	5)	6)	7)	8)
Name	WCBN	INJURY DATE	SSN	Ins. File #	First Report WCB-1*	MOP WCB-3*	NOC WCB-9*
CATHLEEN E DOE	01018505	10/03/2001	001-54-1299	1c805461	2B
ALTHEA L SMITH	01013373	09/04/2001	002-42-8798	1c804541X2		28 11/29/2001
EUGENE H JONES	01011515	09/22/2001	013-21-9497	1C950744JJ	47b		22 11/19/2001
DAVID N DOE	00009198	12/31/2000	023-62-2396	OCC-19108W			22 07/27/2001
MICHAEL SMITH	01010000	11/01/2001	201-68-0694		2a
CHRISTOS V JONES	01013004	11/16/2001	201-68-0694		52
DONNA DOE	01008253	12/03/2001	301-70-4693		37
MARK L SMITH	98019708	11/08/1998	321-66-6392	011924	45
WALTER C JONES	02000113	01/01/2002	322-54-6291			24 01/18/2002
					48
					45

• Column one lists the claimant’s name.
  
• Column two is the MWCB claim number.
  
• Column three is the injury date.
  
• Column four is the claimant’s social security number.
  
• Column five lists the insurer’s file number if available.

The next three columns indicate the missing data elements. These three columns require your attention.

• Column six lists the box numbers of the FROI that contains incorrect, incompatible, or missing information.
  
• Column seven lists the box number and date of the MOP in question with missing or incorrect information.
  
• Column eight lists the box number and date of the NOC in question with either missing or incorrect information.

 

2. WHAT DO I NEED TO DO?
   
   1. The first thing to do is to review the Detailed Claims Section. Are there any “?”s in the fourth column (First Reports)? If there are, you have an open claim as of the date of the computer run. Don’t panic! A NOC or MOP may have been filed after the date of the computer run or perhaps this employee returned to work within the waiting period. What the MWCB requires is some indication that this claim has been closed or is ongoing. A copy of a NOC or MOP will suffice or a corrected FROI with a return to work date.
      
   2. Question marks in the last or next to last columns will be addressed in the missing required data section of the report.
      
   3. The sixth column automatically computes the day on which the initial indemnity check was mailed. Maine law requires that the first payment of compensation be made within fourteen days after the employer’s notice or knowledge of the first day of incapacity. Carriers, employers or TPAs may submit documentation rebutting non-compliant payments (greater than 14 days.) This determines your compliance for the Initial Indemnity check mailed for this quarter.
      
   4. The final column within the detailed claim section calculates the day when the MOP was received by the MWCB. This number should be less than or equal to 17 in order for it to have been filed timely. Carriers, employers or TPAs may submit documentation rebutting non-compliant filings (greater than 17 days.) This determines your compliance for the Memorandum of Payment received by the Board for this quarter.
      
   5. Missing required data section. First Report Column (WCB-1.) Almost any box can appear under this column, but the following are the most common boxes found and how to correct them.
      
      1. 2a This is the most common error and also the most difficult for insurers or TPAs to understand. Sometimes this simply is a failure to check this box on the FROI. Remember if this “lost time” box is checked it requires:
         
         • an answer in 2b
         • dates in boxes 43 and 45 and,
         • an answer to return to work in box 47.

         Most commonly a “2a” error appears on a medical-only claim. Why? An internal monitoring screen has been run and the computer has determined that either:

         • a MOP has been filed which implies lost time or;
         • a NOC has been filed that disputes lost time.

      The“2a” error prints on the report to indicate an incompatibility between the medical only FROI and a subsequent form being filed that indicates lost time. To reconcile a “2a” error that is the result of a subsequent filing, the insurer/TPA should submit a corrected FROI or NOC whichever is appropriate. 

      2. 2b. A lost time claim is filed, but the filer fails to fill in whether or not the employee was paid for at least half a day on the day of injury. Simply fix by checking yes or no on an amended FROI.
         
      3. 37   This means that we either do not have a legitimate birth date for this employee or we are rechecking the date. Maine has one of the highest injury rates of individuals aged 65 and over. If the employee was 65 orolder when injured, you will get a 37 error so that we can verify that they indeed were older than 65. Other errors occur when a filer enters the birth date as 11/11/03. We know that they probably have a birthday on November 11, but if they are employed, were probably not born in 2003.
         
      4. 45  Date the employer notified the insurer/TPA. Please check your files and enter this date.
         
      5. 47b   In a previous report Box 47a “Has the employee returned to work?” was answered yes, but failed to give a date when that took place. Please correct by adding a date to that box.Sometimes on a medical only claim Box 47 is incorrectly filled in Box 47 is only to be used for lost time claims.
         
      6. 48-52 These errors are specific to the injury or mechanics of injury.Often it is difficult to read the first reports and sometimes the specific injury is not noted when the injury first occurs.
         
   6. Missing required data section. MOP Column (WCB-3). Most common errors appear below. Remember that the date beside the box in question refers to the date the form was sent to the Board.
      
      1. 23 Insert the date of incapacity.
      2. 24 Insert the date the check was mailed. Entities filing a MOP for salary/wage continuation should submit the first payroll date within the initial period of incapacity.
      3. 28 Insert the first date of compensability. For most compensation cases this will be seven days after the first day of incapacity, however in the case of sporadic days or hours out, it will be the date when the seven day waiting period has been exceeded.
      4. 33 Insert the date the MOP was mailed to the board.
         
   7. Missing required data section. NOC Column (WCB-9).
      1. 19a and/or 19bThese errors usually mean that the NOC is not compatible with the FROI. The reconciliation report generates errors when NOCs dispute lost time that is not claimed on the FROI. For NOCs filed for precautionary reasons 19a should check “indemnity not applicable at time of filing.” Note: At least one box per column must be checked. Both columns may not be checked “not applicable at the time of filing”, something must be disputed.
      2. 20 Insert the date of incapacity being disputed/denied and the date the employer was notified. This box should only be completed on a lost time FROI.
      3. 22 Insert a check yes or no as to whether the NOC was filed timely or not.
3. HOW DO I ORGANIZE WHAT I SEND BACK TO THE MWCB? Arrange the corrected forms to include the original three part report. The forms should be arranged in the order in which each claim appears in each report.
   
   1. Do this for each entity within your insurance group.
      
   2. If there are areas of dispute, include a memo or letter with your responses and mail the forms to the MWCB by the date indicated on the cover letter.
      
   3. The insurance groups are divided alphabetically and are handled internally in the following way.A-K =Brad Howard (207-287-7350), M=Jeffery Levesque (207-287-7090), and L and N-Z =Kathy Schulz (207-287-7268).If you have any questions while reviewing your report, call your contact person.
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