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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
