MAINE WORKERS’ COMPENSATION BOARD
EDI Training Pop Quizzes & Exercises

Event Table Pop Quiz
Which MTC(s) correspond to the following event triggers:
•	Denial of a claim (full v. partial) 04/PD
•	Initial payment of a claim EP, IP or AP
•	Suspension of benefits (EE RTW) S-1
•	Lump sum settlement PY

Element Requirement Table Pop Quiz
•	Which data element on the A49 record is required on an IP transaction, if available on an AP transaction, and excluded from an EP transaction? DN0075, Agreement to Compensate Code
•	What condition triggers the requirement for the Employee Tax Filing Status Code (DN 158)? DN0031 >=1/1/1993 & <= 12/31/2012

Acknowledgement Report True or False
•	The Edit Matrix Table and Acknowledgement Report are for the “techies”? FALSE, The Edit Matrix Table tells the claim administrators which data elements have edits applied to them and provides the standard error messages used in association with those edits. 
•	As long as a transaction is accepted, that is all I need to care about? FALSE, accepted transactions may require action by the claim administrator based on any business issues found within the transaction.

Exercise 1
Employee sprains his pinkie finger while performing his auto mechanic job. Employee is treated at the local emergency room and returned to work the same day. Costs incurred at the local emergency room for x-rays and treatment are $380.  
Using the Event Table:
•	Is the injury required to be reported to the jurisdiction?  No, medical only, did not lose a day or more of work.  
•	Does your answer change if the claim is denied?  Yes, a FROI 04 would be filed.  This serves the same purpose as filing a FROI and a full denial NOC under present procedures.  
•	Does your answer change if the medicals are being paid voluntarily but the adjuster is denying a request for physical therapy?  Yes, you would file a FROI 00 and a SROI PD.  (The FROI 04 can only be used for a full denial).
  
Exercise 2
Employee pulls a muscle in his back while performing his landscaping job. Costs incurred at the local emergency room for x-rays and treatment are $450.  Employee returns to work after 2 days out.  
Using the Event Table:
•	Is the injury required to be reported to the jurisdiction?  Yes, lost time is a day or more.  File a FROI 00.
•	What additional report may be required?  FROI 02 to report the RTW within the 7 day waiting period, if not already reported on the FROI 00.  
•	What if after a FROI is filed with ME you learn that the employee lives in ME but the injury actually occurred in NH and the employee elects to file a claim in NH? Is there more than one option?  You could file a FROI 01 to cancel the FROI 00, or you could file a SROI 04.    

Exercise 3
Employee is killed as a result of a fall from a roof while removing ice and snow.  The employee was single with no eligible dependents.
Using the Event Table:
•	Which reports must be submitted?  FROI 00 and a SROI CD.
•	How does your answer change if the employee has a dependent eligible for benefits?  FROI 00 and a SROI IP.
•	How does your answer change if the employee died of a heart attack while shoveling the roof rather than a fall?  A death at work is always presumed to be a claim for compensation, regardless of circumstances.  You must file a FROI 00 and either a SROI IP if you are voluntarily paying the claim, or a SROI 04 if you are denying the claim.  

Exercise 4 
Claim administrator reported a lost time injury by sending a FROI 00.  During the investigation, the adjuster discovers that the employee was engaged in horseplay and decides to deny the claim by sending an FROI 04.  The FROI 04 was rejected by the jurisdiction.
Using the Event Table:
•	Why did the FROI 04 reject?  Because a FROI 00 had already been filed.  The FROI 04 is only allowed when filing an original FROI and a full denial at the same time.
•	What needs to be done to deny the claim?  File a SROI 04.  

Exercise 5
Claim administrator denied a claim by sending a FROI 04.  After receiving an updated M-1 report, the adjuster decides to pay the claim voluntarily and sends a SROI IP.  The SROI IP was rejected by the jurisdiction because DN0298 was left blank.  
Using the Element Requirement Table:
•	What is DN0298?  Date CA had knowledge of lost time.
•	When is DN0298 required?  It is MC (mandatory conditional) on the SROI IP.  Looking at the conditional requirements, it is mandatory when DN 0212 (Non-consecutive period code) =W; in other words when the waiting period was comprised of non-consecutive days of disability.  
•	What information should be included in the payment narrative (DN0233)?  Comments should include dates of the waiting period (just like on today’s MOP comments).

Exercise 6 
Claim administrator sent a FROI 00 transaction to report a lost time injury and then filed a SROI IP transaction when indemnity payments began.  After a brief return, the employee went back out of work and the claim administrator sent a SROI RB transaction to report the resumption of indemnity benefits.  The RB transaction was rejected.
Using the Event Table:
•	Why did the RB transaction reject?  There was no full suspension.  A SROI RB is for resumption of benefits following a full suspension.  In today’s procedures, it would be analogous to filing a new MOP before closing the original MOP.  
•	What needs to be done to correct the error?  File a SROI S1 for the return to work, then a SROI RB for resumption of benefits.  

Acquired Claims Processing Pop Quiz
•	If the jurisdiction rejects the AQ transaction because it can’t find a match in its database, what report must the claim administration file on the acquired claim? 00, Original
•	What MTC must the acquiring claim administrator file to report it first indemnity payment on the acquired claim? AP