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					                                                                                  FROI 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.

CO MTC - Georgia does not accept corrections.



                Maintenance Type                     Event Rule                       Report Trigger                      When is the Report Due?
 Report
                                                                                                                                                             Paper Form(s)        Receiver
  Type
              Code        Description     Criteria     From         Thru       Criteria      Trigger Value         Value      Due Type         From

                                                                                                                                          B - (From Date
                                                                                                                                           of Disability)
                                                                                          All lost time claim (>                                                                    EE,
  FROI          00          Original          2                                   C                                 21            C                               WC-1
                                                                                          7 days)                                           Injuries after                         Others
                                                                                                                                          6.30.09 are due
                                                                                                                                               in EDI

                                                                                          Previously EDI
                                                                                          established Claim.
                                                                                          Change of FROI
                                                                                          data elements,
  FROI          02          Change            3                                   M                                 n/a          n/a      H- (Immediate)           NA                NA
                                                                                          based on Element
                                                                                          Requirement table,
                                                                                          initiated by the
                                                                                          administrator.


                                                                                            Serves a 'dual'
                                                                                             purpose as an
                                                                                                                                           C- (From Date                            EE,
  FROI          04           Denial           3                                   M       Original FROI and a       21            C                               WC-1
                                                                                                                                              of Injury)                           Others
                                                                                              Denial of the
                                                                                             Original FROI




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                                                                                  FROI 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.

CO MTC - Georgia does not accept corrections.



                Maintenance Type                     Event Rule                       Report Trigger                      When is the Report Due?
 Report
                                                                                                                                                             Paper Form(s)        Receiver
  Type
              Code        Description     Criteria     From         Thru       Criteria      Trigger Value        Value       Due Type         From




                                                                                          AQ initially
                           Acquired/                                                      submitted that
  FROI          AU                            3                                   M                                 n/a          n/a      H- (Immediate)           NA                NA
                          Unallocated                                                     resulted in TR
                                                                                          acknowledgment




                                                                                          Rule 61 (b) (4) (G)
                                                                                          Within 90 days of
                           Acquired/
  FROI         AQ                             3                                   M       receipt of an open        n/a          n/a      H- (Immediate)           NA                NA
                          Unallocated
                                                                                          case by the new
                                                                                          TPA.




                                                                                          In case Jurisdiction
                                                                                                                                            J - (From
  FROI         UR        Upon Request         3                                   J       needs to know any          5            B                                NA                NA
                                                                                                                                          Report Trigger)
                                                                                          information.




         Rev. 06-09-08                                               432867b4-7e79-4c93-bf62-eb8a9308eaee.xls                                                     Page 2 Of Pages
                                                                                  FROI 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.

CO MTC - Georgia does not accept corrections.



                Maintenance Type                      Event Rule                      Report Trigger                      When is the Report Due?
 Report
                                                                                                                                                               Paper Form(s)      Receiver
  Type
              Code        Description     Criteria       From       Thru       Criteria      Trigger Value        Value       Due Type            From


                                                                                          Previously EDI
  FROI          01          Cancel            3                                   M                                 n/a           n/a       H- (Immediate)          NA               NA
                                                                                          established Claim.



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




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                                                                                      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
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 req
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 Cr
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, th
to the EDI transaction, this form(s) must be sent to the Receiver indicated.

CO / CD MTC - Georgia does not accept these MTC's

 Report        Maintenance Type                       Event Rule                                   Report Trigger                                         When is the Report Due?
  Type      Code      Description          Criteria     From         Thru      Criteria Trigger Value                                             Value         Due Type

  SROI       02            Change              3                                  J      Change of SROI data elements, based on                     n/a             n/a
                                                                                         Element Requirement table.


  SROI       04            Denial              3                                  M      Board Rule O.C.G.A. 34-9-221(a-j).                         81               C




  SROI       AP      Acquired/Payment          3                                  J      FROI AQ or AU previously filed and first benefit           n/a             n/a
                                                                                         payment of acquired claim made by the new claim
                                                                                         administrator.




  SROI       CB      Change in Benefit         3                                  J      Change in benefit type. Board Rule requires that           n/a             n/a
                          Type                                                           a paper WC-2 and a WC-104 be filed the same
                                                                                         day as the EDI transaction and then affirm
                                                                                         suspension narrative DN0233.
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                                                                            Event Table

Report       Maintenance Type                  Event Rule                                Report Trigger                                When is the Report Due?
 Type     Code      Description     Criteria     From        Thru    Criteria Trigger Value                                    Value         Due Type

SROI       EP      Employer Paid       3                                J      Employer Paying Benefits                         n/a             n/a

SROI      ER        Employer           3                                J      Employer has reinstated benefits.                n/a             n/a
                  Reinstatement
SROI       FN          Final           3                                J      Closure of a claim                               n/a             n/a

SROI       FN          Final           3                                J      Final closure of claim with settlement.          30               C




SROI       IP     Initial Payment      3                               C       Ruling has been made to accept the claim         20               C




SROI       IP     Initial Payment      3                               C       Initial TT payment of claim                      21               C




SROI       IP     Initial Payment      3                                J      Initial PP Payment of claim due to receipt of    21               C
                                                                               report indicating percentage of PP


SROI       IP     Initial Payment      3                                J      Initial Temporary Partial Payment                21               C




SROI      PD       Partial Denial      3                                J      Partial denial of benefits                       n/a             n/a




SROI       PY     Payment Report       3                                J      Payment Information                              n/a             n/a




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                                                                               Event Table

Report       Maintenance Type                     Event Rule                                Report Trigger                               When is the Report Due?
 Type     Code      Description        Criteria     From        Thru    Criteria Trigger Value                                   Value         Due Type

SROI      RB     Reinstatement of         3                                J      Benefits re-instated                            n/a             n/a
                     Benefits


SROI      RE     Reduced Earnings         3                               F       The injured employee has returned/been          n/a             n/a
                                                                                  released to return to work and actual
                                                                                  earnings results in a change in Gross Weekly
                                                                                  Amount.
SROI       S1   Suspension, RTW,          3                                J      Suspended due to the reason that employee       n/a             n/a
                   or Medically                                                   is qualified to return to work.
                Determined/Qualifi
                     ed RTW
SROI       S2     Suspension,             3                                J      Suspension due to medical non-compliance.       n/a             n/a
                  Medical Non-                                                    Board Rule 221 requires that a paper WC-2
                   compliance                                                     and a Physician's Reports be filed the same
                                                                                  day as the EDI transaction and then affirm
                                                                                  suspension narrative DN0233.

SROI       S3     Suspension,             3                                J      Suspension due to administrative non-           n/a             n/a
                Administrative Non-                                               compliance. Board Rule requires that a paper
                   compliance                                                     WC-2 and a WC-240 be filed the same day
                                                                                  as the EDI transaction and then affirm
                                                                                  suspension narrative DN0233.
SROI       S4      Suspension,            3                                J      Benefit suspended in case the employee          n/a             n/a
                  Claimant Death                                                  died.


SROI       S5      Suspension,            3                                J      Suspended due to the reason that claimant is    n/a             n/a
                Incarceration (Post-                                              incarcerated, if the incarceration is "post-
                    Conviction)                                                   conviction".



SROI       S6       Suspension,           3                                J      Claimants whereabouts unknown.                  n/a             n/a
                     Claimant's
                   Whereabouts
                     Unknown
       Rev. 09-04-08                                           432867b4-7e79-4c93-bf62-eb8a9308eaee.xls                                       Page 6 Of Pages
                                                                              Event Table

Report       Maintenance Type                    Event Rule                                Report Trigger                                When is the Report Due?
 Type     Code      Description    Criteria        From        Thru    Criteria Trigger Value                                    Value         Due Type

SROI       S7      Suspension,         3                                  J        Benefits exhausted                             n/a             n/a
                     Benefits
                    Exhausted

SROI       S8      Suspension,         3                                  J        Suspended due to Jurisdiction change.          n/a             n/a
                   Jurisdiction
                     Change


SROI      SD       Suspension,         3                                  J        Directed by Jursidiction                       n/a             n/a
                   Directed by
                   Jurisdiction


                                  Rule Date                            Report                                              Report Due Type
                                  Criteria                             Trigger
                                                                       Criteria
                                                                       Codes
                                  1=Date of
                                  Injury
                                  2=EDI                                A = New                                             B = Business Days
                                  Mandate                               Claim
                                  Date
                                  3=Jurisdicti                           B=                                                C = Calendar Days
                                  on defined                          Cumulative
                                                                       Medical $
                                                                         Paid
                                                                       C = Lost
                                                                        Time
                                                                         D=                                                Report Due From
                                                                      Cumulative                                           Codes
                                                                        Wage
                                                                      Replaceme
                                                                       nt Paid
                                                                      E = Days
                                                                        Open
                                                                         F=                                                A = From Date of
                                                                      Formula                                              Accident/Injury


       Rev. 09-04-08                                          432867b4-7e79-4c93-bf62-eb8a9308eaee.xls                                         Page 7 Of Pages
                                                                        Event Table

Report      Maintenance Type                Event Rule                                Report Trigger                  When is the Report Due?
 Type    Code      Description   Criteria     From        Thru    Criteria Trigger Value                      Value         Due Type

                                                                     J=                                B = From Date of
                                                                 Jurisdiction                          Disability
                                                                   Defined
                                                                     L=                                C = From Employer
                                                                 Determinati                           Notification
                                                                    on of
                                                                 Compensa
                                                                  ble Death
                                                                  M = MTC                              D = From Claim
                                                                  Defined                              Administrator
                                                                                                       Notification
                                                                     N=                                E = From
                                                                 Cumulative                            Jurisdiction
                                                                 Indemnity $                           Notification
                                                                    Paid

                                                                   Q=                                  F = From Carrier
                                                                 Employee                              Notification
                                                                  Death
                                                                                                       G = From Initial
                                                                                                       Payment (IP)
                                                                                                       H = Immediate
                                                                                                       I = From Date of
                                                                                                       Death
                                                                                                       J = From Report
                                                                                                       Trigger
                                                                                                       K = Prior to Final
                                                                                                       Report (FN)




     Rev. 09-04-08                                       432867b4-7e79-4c93-bf62-eb8a9308eaee.xls                           Page 8 Of Pages
                                                                      Event Table

 relates EDI information to the circumstances
ns relative to reporting requirements based on


RU) where the (Trigger Criteria-Trigger Value), the
er Form(s) is indicated, this implies that in addition




 eport Due?                    Paper        Receiver
           From               Form(s)

        H- (Immediate)          NA             NA




       J - (From Report    WC-3 / WC2       EE, ER ,
            Trigger)       (If any one of    Others
                             the IP, AP,
                             EP MTC is
                               received
                                before
                              receipt of
                           SROI 04 only
                             then WC-2
                             and WC-3
                                will be
                            created else
                             only WC-3
                                will be
                               created)

        H- (Immediate)         WC-4         EE, ER ,
                                             Others




        H- (Immediate)      WC-2 / WC-      EE, ER ,
                               2A            Others


               Rev. 09-04-08                             432867b4-7e79-4c93-bf62-eb8a9308eaee.xls   Page 9 Of Pages
                                                            Event Table

eport Due?               Paper      Receiver
          From          Form(s)

     H- (Immediate)      WC-2       EE, ER ,
                                     Others
     H- (Immediate)      WC-2       EE, ER ,
                                     Others

     H- (Immediate)      WC-4       EE, ER ,
                                     Others
    J - (From Report     WC-4       EE, ER ,
         Trigger)                    Others



       E - (From       WC-2 / WC-   EE, ER ,
      Jurisdiction        2A         Others
      Notification)

     B - (From Date    WC-2 / WC-   EE, ER ,
      of Disability)      2A         Others



       D - (From       WC-2 / WC-   EE, ER ,
       Employer           2A         Others
      Notification)

     B - (From Date    WC-2 / WC-   EE, ER ,
      of Disability)      2A         Others



     H- (Immediate)      WC-3       EE, ER ,
                                     Others



     H- (Immediate)      WC-2       EE, ER ,
                                     Others




           Rev. 09-04-08                       432867b4-7e79-4c93-bf62-eb8a9308eaee.xls   Page 10 Of Pages
                                                            Event Table

eport Due?               Paper      Receiver
          From          Form(s)

     H- (Immediate)   WC-4 / WC-2   EE, ER ,
                                     Others



     H- (Immediate)      WC-2       EE, ER ,
                                     Others



     H- (Immediate)      WC-2       EE, ER ,
                                     Others



     H- (Immediate)      WC-2       EE, ER ,
                                     Others




     H- (Immediate)      WC-2       EE, ER ,
                                     Others




     H- (Immediate)      WC-2       EE, ER ,
                                     Others



     H- (Immediate)      WC-2       EE, ER ,
                                     Others




     H- (Immediate)      WC-2       EE, ER ,
                                     Others


           Rev. 09-04-08                       432867b4-7e79-4c93-bf62-eb8a9308eaee.xls   Page 11 Of Pages
                                                               Event Table

eport Due?               Paper         Receiver
          From          Form(s)

     H- (Immediate)   WC-2 / WC-       EE, ER ,
                         2A             Others



     H- (Immediate)       WC-2         EE, ER ,
                                        Others




     H- (Immediate)       WC-2           n/a




                      Receiver Codes




                      EE = Employee



                      ER = Employer




                      PR = Provider

                      Other Parties




           Rev. 09-04-08                          432867b4-7e79-4c93-bf62-eb8a9308eaee.xls   Page 12 Of Pages
                                                        Event Table

eport Due?             Paper    Receiver
          From        Form(s)




           Rev. 09-04-08                   432867b4-7e79-4c93-bf62-eb8a9308eaee.xls   Page 13 Of Pages
                                                                                         Periodic 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” 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.


               Maintenance Type                     Event Rule                       Report Trigger                             Periodic Qualifiers                               Periodic Report Due
 Report
  Type       Code      Description       Criteria       From       Thru       Criteria      Trigger Value                   Status                     Activity           Value        Due Type              From

 Periodic     AN          Annual             3                                               1 year after sub                   3                                         365              C
                                                                                               annual report.
                                                                                             Recurring yearly
                                                                                         after the sub annual
                                                                                         till the claim closure.                                                                                          J - (From
                                                                                                                                                                                                        Report Trigger)
 Periodic     SA        Sub-Annual           3                                            within 180 days of                    3                                         180              C
                                                                                           the first date of                                                                                              J - (From
                                                                                               disability                                                                                               Report Trigger)
 Periodic     SA        Sub-Annual           3                                            90 days from AQ                       3                                          90              C              J - (From
                                                                                                                                                                                                        Report Trigger)

                                       Event Rule Criteria                                                         Status Qualifier                                                 Due Type
                                                                                                                   1 = Open (If claim is open at time of Report
                                       1=Date of Injury                                                            Trigger)                                                         B = Business Days
                                                                                                                   2 = Closed (If claim has closed since the last
                                       2=EDI Mandate Date                                                          periodic report)                                                 C =Calendar Days
                                                                                                                   3 = Either (if claim is open or has closed since the
                                       3=Jurisdiction defined                                                      last periodic report)


                                                                                                                   Activity Qualifier
                                                                                                                   E = Either (either IL or MB)
                                                                                                                   IL = Indemnity (If Claim Type Code = Indemnity or
                                                                                                                   Became Lost Time)


                                                                                                                   J = Jurisdiction defined (define details in column)
                                                                                                                   MB = Medical Only (If Claim Type Code = Medical
                                                                                                                   Only or Became Medical Only)




     Rev. 07-18-08                                                              432867b4-7e79-4c93-bf62-eb8a9308eaee.xls                                                                       Page 14 Of Pages

				
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