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SROI - AK EDI

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									                                                                                       Alaska Department of Labor and Workforce Development (DOL)
                                                                                                Claims Release 3 First Report of Injury Event Table
The First Report of Injury (FROI) Event Table is designed to provide information integral for a sender to understand the receiver’s EDI reporting requirements. It relates EDI information to the circumstances under which they are
initiated as well as the timeframes for sending the information. These circumstances and timeframes reflect legislative mandates and specifications relative to reporting requirements based on various criteria.

Interpreting the jurisdiction's requirements: For a (Report Type) (Maintenance Type-Code) meeting (Event Rule Criteria) within (Event Rule Date range - FROM/THRU) where the (Trigger Criteria-Trigger Value), the Report is due
(Report Due Value-Type) from the (Report Due-From). If the Event Rule Thru date is blank, reporting requirements apply until further notice. When a Paper Form(s) is indicated, this implies that in addition to the EDI transaction,
this form(s) must be sent to the Receiver indicated.
Report    Maintenance Type                      Event Rule                                                         Report Trigger                                          When is the Report Due?                 Paper
                                                                                                                                                                                                                            Receiver
 Type     Code Description           Criteria        From        Thru       Criteria                                      Trigger Value                                 Value Due Type        From                Form(s)
                                                                                         Any new claim, Including indemnity or medical where Date Claim Administrator
                                 2 - EDI Mandate                            A - New                                                                                                C-     C - Employer
 FROI      00        Original                       2-12-12                               Had Knowledge of Injury (DN0041) is >= Event Rule Criteria and From/Thru (if 10 Days                                     N/A        N/A
                                       Date                                  Claim                                                                                             Calendar Notification
                                                                                                                        applicable) Date
                                 2 - EDI Mandate                           M - MTC                                                                                                             H-
 FROI      01        Cancel                         2-12-12                                                        Cancel of an accepted claim                           N/A      N/A                              N/A        N/A
                                       Date                                Defined                                                                                                         Immediate
                                 2 - EDI Mandate                           M - MTC       Claim admin changes the value of a FROI element with FY, YC, Y on AK Element                          H-
 FROI      02        Change                         2-12-12                                                                                                              N/A      N/A                              N/A        N/A
                                       Date                                Defined                                     Requirement table                                                   Immediate
                                 2 - EDI Mandate                           M - MTC                                                                                                       C-    C - Employer
 FROI      04         Denial                        2-12-12                                 Claim is being denied before indemnity or medical benefits have been paid       21 Days                                6105        EE
                                       Date                                Defined                                                                                                    Calendar Notification
                    Acquired 2 - EDI Mandate                               M - MTC                                                                                                                   H-
 FROI      AQ                                       2-12-12                                    Any newly acquired claim unless AU is filed to report the acquisition          N/A       N/A                        N/A        N/A
                      Claim          Date                                  Defined                                                                                                                Immediate
                    Acquired/ 2 - EDI Mandate                              M - MTC                                                                                                                   H-
 FROI      AU                                       2-12-12                                            Any newly acquired claim or previously rejected AQ                     N/A       N/A                        N/A        N/A
                   Unallocated       Date                                  Defined                                                                                                                Immediate
                               2 - EDI Mandate                             M - MTC                                                                                                                   H-            6101
 FROI      CO      Correction                       2-12-12                                       Correction of errors in response to a FROI TE acknowledgment                N/A       N/A                                   N/A
                                     Date                                  Defined                                                                                                                Immediate        6105


                                                                                         Open Claims: All open claims, Including indemnity and medical where Date Claim
                                                                               J-
                      Upon       2 - EDI Mandate                                            Administrator Had Knowledge of Injury (DN0041) is Event Rule Criteria and                                H-
 FROI      UR                                       2-12-12               Jurisdiction                                                                                        N/A       N/A                        N/A        N/A
                     Request           Date                                               From/Thru (if applicable) Date which includes claims where a paper report was                           Immediate
                                                                            Defined
                                                                                                      sent that received a Jurisdiction Claim Number (JCN).


                                                                                         Re-Open Claims: All re-open claims, Including indemnity and medical where Date
                                                                               J-         Claim Administrator Had Knowledge of Injury (DN0041) is < Event Rule Criteria
                      Upon       2 - EDI Mandate                                                                                                                                                     H-
 FROI      UR                                       2-12-12               Jurisdiction    and From/Thru (if applicable) Date where the claim is re-opened on or after the     N/A       N/A                        N/A        N/A
                     Request           Date                                                                                                                                                       Immediate
                                                                            Defined        EDI Mandate Date which includes claims where a paper report was sent that
                                                                                                           received a Jurisdiction Claim Number (JCN).

                                Event Rule Criteria                 Report Trigger Criteria Codes                                                                           Report Due Type                   Receiver Codes
                                1=Date of Injury                    A = New Claim                                                                                           B = Business Days                 EE = Employee
                                2=EDI Mandate Date                  B = Cumulative Medical $ Paid                                                                           C = Calendar Days                 ER = Employer
                                3=Jurisdiction defined              C = Lost Time                                                                                                                             PR = Provider
                                                                    D = Cumulative Wage Replacement                                                                         Report Due From Code              Others as defined
                                                                    E = Days Open                                                                                           A = From Date of Accident/Injury  by jurisdiction
                                                                    F = Formula                                                                                             B = From Date of Disability
                                                                    J = Jurisdiction Defined                                                                                C = From Employer Notification
                                                                    L = Determination of Compensable Death                                                                  D = From Administrator Notification
                                                                    M = MTC Defined                                                                                         E = From Jurisdiction Notification
                                                                    N = Cumulative Indemnity $ Paid                                                                         F = From Carrier Notification
                                                                    Q = Employee Death                                                                                      H = Immediate
                                                                                                                                                                            I = From Date of Death
                                                                                                                                                                            J = From Report Trigger
                                                                                                                                                                            K = Prior to Final Report (FN)




           FROI                                                                                                             1                                                                        9a8c644e-bb5e-49c2-83fe-7be96d0a02f9.xls
                                                                                  Alaska Department of Labor and Workforce Development (DOL)
                                                                                    Claims Release 3 Subsequent Report of Injury Event Table


       The Subsequent Report of Injury (SROI) Event Table is designed to provide information integral for a sender to understand the receiver’s EDI reporting requirements. It relates EDI information to the circumstances under which
       they are initiated as well as the timeframes for sending the information. These circumstances and timeframes reflect legislative mandates and specifications relative to reporting requirements based on various criteria.

       Interpreting the jurisdiction's requirements: For a (Report Type) (Maintenance Type-Code) meeting (Event Rule Criteria) within (Event Rule Date range - FROM/THRU) where the (Trigger Criteria-Trigger Value), the Report is
       due (Report Due Value-Type) from the (Report Due-From) If the Event Rule Thru date is blank, reporting requirements apply until further notice. When a Paper Form(s) is indicated, this implies that in addition to the EDI
       transaction, this form(s) must be sent to the Receiver indicated.

       Report           Maintenance Type                            Event Rule                                                  Report Trigger                                      When is the Report Due?            Paper
                                                                                                                                                                                                                                Receiver
        Type     Code         Description                Criteria        From        Thru            Criteria                               Trigger Value                       Value   Due Type        From          Form(s)
                                                    2 - EDI Mandate                                                       Claim admin changes the value of a SROI element
        SROI      02              Change                                2-12-12                  M - MTC Defined                                                                 N/A        N/A      H - Immediate     N/A        N/A
                                                          Date                                                             with FY or Y on AK Element Requirement table
                                                 2 - EDI Mandate                                                                                                                             C-      C - Employer
        SROI      04              Denial                                2-12-12                  M - MTC Defined         Claim is denied after a previous SROI has been filed   28 Days                                N/A        N/A
                                                       Date                                                                                                                               Calendar   Notification
                                                 2 - EDI Mandate                                                       First payment of indemnity benefits is issued by the
        SROI      AP        Acquired/Payment                            2-12-12               J - Jurisdiction Defined                                                           N/A        N/A      H - Immediate     N/A        N/A
                                                       Date                                                                       acquiring claim administrator
                                                 2 - EDI Mandate                                                           Net Weekly Amount (DN0087) changes from
        SROI      CA    Change in Benefit Amount                        2-12-12               J - Jurisdiction Defined                                                           N/A        N/A      H - Immediate     N/A        N/A
                                                       Date                                                                previous reported for the Benefit Type Code
                                                 2 - EDI Mandate                                                         Benefit Type Code is changed without a break in
        SROI      CB      Change in Benefit Type                        2-12-12               J - Jurisdiction Defined                                                           N/A        N/A      H - Immediate     N/A        N/A
                                                       Date                                                                      continuity of indemnity benefits
                         Compensable Death-No
                                                 2 - EDI Mandate                               L = Determination of
        SROI      CD       Known Dependents /                           2-12-12                                                                Fatality                          N/A        N/A      H - Immediate    6104b       N/A
                                                       Date                                    Compensable Death
                                 Payees
                                                 2 - EDI Mandate                                                             Correction of errors in response to a SROI TE
        SROI      CO           Correction                               2-12-12                  M - MTC Defined                                                                 N/A        N/A      H - Immediate    6104b       N/A
                                                       Date                                                                                acknowledgment
                                                 2 - EDI Mandate
        SROI      EP          Employer Paid                             2-12-12               J - Jurisdiction Defined     1st Employer payment or continuation of wages         N/A        N/A      H - Immediate     N/A        N/A
                                                       Date
                                                 2 - EDI Mandate                                                       Resumption of Employer payment or continuation of
        SROI      ER     Employer Reinstatement                         2-12-12               J - Jurisdiction Defined                                                           N/A        N/A      H - Immediate                N/A
                                                       Date                                                                                wages
                                                                                                                                                                                                       D - From
                                                    2 - EDI Mandate                                                      No further indemnity or other benefits are expected                 C-
        SROI      FN               Final                                2-12-12               J - Jurisdiction Defined                                                          28 Days              Administrator     N/A        N/A
                                                          Date                                                                               to be paid                                   Calendar
                                                                                                                                                                                                      Notification
                                                    2 - EDI Mandate                                                      1st payment of indemnity benefit other than a lump                  C-         J - From
        SROI      IP          Initial Payment                           2-12-12               J - Jurisdiction Defined                                                          28 Days                                N/A        N/A
                                                          Date                                                                           sum or settlement                                Calendar   Report Trigger
                                                                                                                          Denial ofr some indemnity benefits and/or some
                                                    2 - EDI Mandate
        SROI      PD           Partial Denial                           2-12-12               J - Jurisdiction Defined    medical benefits and/or all of either indemnity or     N/A        N/A      H - Immediate     N/A        N/A
                                                          Date
                                                                                                                                     medical (but not all of both)
                                                                                                                                  Payment of a lump sum settlement
                                                    2 - EDI Mandate
        SROI      PY         Payment Report                             2-12-12                  M - MTC Defined          and first payment of Other Benefit Type Codes for      N/A        N/A      H - Immediate     N/A        N/A
                                                          Date
                                                                                                                           medical, funeral, penalty and attorney fees, etc.
                                                    2 - EDI Mandate
        SROI      RB    Reinstatement of Benefits                       2-12-12               J - Jurisdiction Defined           Reinstatement by indemnity benefits             N/A        N/A      H - Immediate     N/A        N/A
                                                          Date
                                                    2 - EDI Mandate
        SROI      RE        Reduced Earnings                            2-12-12               J - Jurisdiction Defined               Any change in TPD earnings                  N/A        N/A      H - Immediate    6104b       N/A
                                                          Date
                           Suspension, RTW, or
                                                                                                                             Suspension by insurance company for RTW, or
        SROI      S1            Medically        2 - EDI Mandate        2-12-12               J - Jurisdiction Defined                                                           N/A        N/A      H - Immediate     N/A        N/A
                                                                                                                                 Medically Determined/Qualified RTW
                        Determined/Qualified RTW       Date
                        Suspension, Medical Non- 2 - EDI Mandate                                                         Suspension by insurance company for Medical Non-
        SROI      S2                                                    2-12-12               J - Jurisdiction Defined                                                           N/A        N/A      H - Immediate     N/A        N/A
                              compliance               Date                                                                                 compliance




SROI                                                                                                                     2                                                                                 9a8c644e-bb5e-49c2-83fe-7be96d0a02f9.xls
                                                                              Alaska Department of Labor and Workforce Development (DOL)
                                                                                Claims Release 3 Subsequent Report of Injury Event Table


       Report          Maintenance Type                         Event Rule                                               Report Trigger                                     When is the Report Due?            Paper
                                                                                                                                                                                                                         Receiver
        Type    Code         Description             Criteria        From      Thru          Criteria                                Trigger Value                      Value   Due Type        From          Form(s)
                       Suspension, Administrative 2 - EDI Mandate                                                Suspension by insurance company for Administrative
       SROI      S3                                                 2-12-12           J - Jurisdiction Defined                                                           N/A         N/A      H - Immediate     N/A        N/A
                            Non-compliance              Date                                                                      Non-compliance
                         Suspension, Claimant    2 - EDI Mandate
       SROI      S4                                                 2-12-12           J - Jurisdiction Defined        Suspension by insurance company for Fatality       N/A         N/A      H - Immediate     N/A        N/A
                               Death                   Date
                                                 2 - EDI Mandate
       SROI      S5    Suspension, Incarceration                    2-12-12           J - Jurisdiction Defined Suspension by insurance company for Incarceration         N/A         N/A      H - Immediate     N/A        N/A
                                                       Date
                         Suspension, Claimant's 2 - EDI Mandate                                                   Suspension by insurance company for Claimant's
       SROI      S6                                                 2-12-12           J - Jurisdiction Defined                                                           N/A         N/A      H - Immediate     N/A        N/A
                        Whereabouts Unknown            Date                                                                   Whereabouts Unknown
                        Suspension, Jurisdiction 2 - EDI Mandate                                                  Suspension by insurance company for Jurisdiction
       SROI      S8                                                 2-12-12           J - Jurisdiction Defined                                                           N/A         N/A      H - Immediate     N/A        N/A
                                Change                 Date                                                                           Change
                        Suspension, Directed by 2 - EDI Mandate                                                    Suspension by insurance company Directed by
       SROI     SD                                                  2-12-12           J - Jurisdiction Defined                                                           N/A         N/A      H - Immediate     N/A        N/A
                              Jurisdiction             Date                                                                         Jurisdiction
                       Suspended Pending Appeal 2 - EDI Mandate                                                  Suspension by insurance company Pending Appeal or
       SROI      SJ                                                 2-12-12           J - Jurisdiction Defined                                                           N/A         N/A      H - Immediate     N/A        N/A
                           or Judicial Review         Date                                                                         Judicial Review
                                                 2 - EDI Mandate
       SROI     VE             Volunteer                            2-12-12             M - MTC Defined                    Determination of volunteer status             N/A         N/A      H - Immediate    6104b       N/A
                                                       Date

                                                 Rule Date Criteria                   Report Trigger Criteria Codes                                                   Report Due Type                         Receiver Codes
                                                 1=Date of Injury                     A = New Claim                                                                   B = Business Days                       EE = Employee
                                                 2=EDI Mandate Date                   B = Cumulative Medical $ Paid                                                   C = Calendar Days                       ER = Employer
                                                 3=Jurisdiction defined               C = Lost Time                                                                   Report Due From Codes                   PR = Provider
                                                                                      D = Cumulative Wage Replacement Paid                                            A = From Date of Accident/Injury        Others as defined by
                                                                                      E = Days Open                                                                   B = From Date of Disability             jurisdiction
                                                                                      F = Formula                                                                     C = From Employer Notification
                                                                                      J = Jurisdiction Defined                                                        D = From Claim Administrator Notification
                                                                                      L = Determination of Compensable Death                                          E = From Jurisdiction Notification
                                                                                      M = MTC Defined                                                                 F = From Carrier Notification
                                                                                      N = Cumulative Indemnity $ Paid                                                 G = From Initial Payment (IP)
                                                                                      Q = Employee Death                                                              H = Immediate
                                                                                                                                                                      I = From Date of Death
                                                                                                                                                                      J = From Report Trigger
                                                                                                                                                                      K = Prior to Final Report (FN)




SROI                                                                                                              3                                                                                  9a8c644e-bb5e-49c2-83fe-7be96d0a02f9.xls
                                                                                 Alaska Department of Labor and Workforce Development (DOL)
                                                                                     Claims Release 3 Periodic Report of Injury Event Table


The Periodic Subsequent Report of Injury (SROI) Event Table is designed to provide information integral for a sender to understand the receiver’s EDI reporting requirements. It relates EDI information to the
circumstances under which they are initiated as well as the timeframes for sending the information. These circumstances and timeframes reflect legislative mandates and specifications relative to reporting requirements
based on various criteria.
Interpreting the jurisdiction's requirements: A (Report Type) (Maintenance Type-Code) must be filed based on the (Event Rule Criteria) within (Event Rule Date range) on Claims that meet the Report Trigger (Criteria and
Trigger Value), meets the Periodic Qualifier (Status and Activity) and must be filed by the Periodic Report Due indicated (Value, Due Type, From).
* If the Event Rule Thru date is blank, reporting requirements apply until further notice.
* Periodic Report Due indicated (Value, Due Type, From) is the last day a claim administrator has to receive a “Transaction Accepted” or “Transaction Accepted with Errors” for that MTC, and not just the date on which
that transaction must be triggered regardless of errors. It was suggested that the Claim Administrator trigger the reports prior to this date in order to allow time for correcting errors.

Report Maintenance Type                    Event Rule                                        Report Trigger                                         Periodic Qualifiers                          Periodic Report Due
 Type Code   Description        Criteria     From        Thru        Criteria                          Trigger Value                      Status               Activity                 Value    Due Type          From
                                                                                     Date of Injury (DOI) plus 3 months and every 3
                                                                                     months thereafter until a MTC FN is accepted.
                                                                                  If a FN has been filed and the claim is reopened to
                                 2 - EDI
                                                                 J - Jurisdiction pay ongoing indemnity benefits, an MTC QT is due                  E - Either (either IL - Indemnity
 SROI      QT     Quarterly     Mandate    2-12-12                                 no later than the next 3-month interval based on      1 - Open                                       N/A         N/A         H - Immediate
                                                                      Defined                                                                             or MB - Medical Only)
                                  Date                                            the DOI unless the MTC FN is filed prior to the due
                                                                                                     date for MTC QT.
                                                                                    This report will replace the Alaska annual report
                                                                                             and SIF report by March 2013.
                                Event Rule Criteria              Report Trigger Criteria Codes                                          Status Qualifier                                        Due Type
                                1=Date of Injury                 A = New Claim                                                          1 = Open (If claim is open at time of Report
                                                                                                                                                                                                B = Business Days
                                                                                                                                        Trigger)
                                2=EDI Mandate Date               B = Cumulative Medical $ Paid                                          2 = Closed (If claim has closed since the               C =Calendar Days
                                                                                                                                        last periodic report)
                                3=Jurisdiction defined           C = Lost Time                                                          3 = Either (if claim is open or has closed
                                                                                                                                        since the last periodic report)
                                                                 D = Cumulative Wage Replacement Paid                                                                                           Report Due From Codes
                                                                 E = Days Open                                                          Activity Qualifier                                      A = From Date of Accident/Injury
                                                                 F = Formula                                                            E = Either (either IL or MB)                            B = From Date of Disability
                                                                 J = Jurisdiction Defined                                               IL = Indemnity (If Claim Type Code =
                                                                                                                                                                                                C = From Employer Notification
                                                                                                                                        Indemnity or Became Lost Time)
                                                                 L = Determination of Compensable Death                                 J = Jurisdiction defined (define details in
                                                                                                                                                                                                D = From Claim Admin Notification
                                                                                                                                        column)
                                                                 M = MTC Defined                                                        MB = Medical Only (If Claim Type Code =                 E = From Jurisdiction Notification
                                                                                                                                        Medical Only or Became Medical Only)
                                                                 N = Cumulative Indemnity $ Paid                                                                                                F = From Carrier Notification
                                                                 Q = Employee Death                                                                                                             G = From Initial Payment (IP)
                                                                                                                                                                                                H = Immediate
                                                                                                                                                                                                I = From Date of Death
                                                                                                                                                                                                J = From Report Trigger
                                                                                                                                                                                                K = Prior to Final Report (FN)




Periodic                                                                                                           4                                                                                 9a8c644e-bb5e-49c2-83fe-7be96d0a02f9.xls

								
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