Texas Claims EDI Imp Guide Version 11.doc

Texas Department of Insurance
Division of Workers’ Compensation
Texas Claims State Reporting
Electronic Data Interchange (EDI)
Implementation Guide
Version April 2008
TABLE OF CONTENTS
SECTION 1 – CLAIMS EDI – AN OVERVIEW 7
History 7
Rules and Regulations 7
Transaction Types 8
Division Processing Actions and Production Schedule 8
Monitoring 8
Where To Get Help 9
SECTION 2 – SUBMITTER PROFILE INFORMATION 13
EDI Trading Partner Profile 13
Transmissions Method 13
Previously Rejected Transactions 13
SECTION 3 – TEST TRANSMISSION GUIDELINES 17
STEP plete EDI Trading Partner Profile 17
STEP 2 Transmission Mode Set Up 17
STEP 3 Test Criteria 17
STEP 4 Prepare Initial Test File 18
STEP 5 Submit Test Data to DWC 18
STEP 6 Acknowledgments 18
STEP 7 Correct Errors/Submit Remaining Test Files 19
STEP 8 Production Approvals 19
SECTION 4 – CLAIMS EDI TERMINOLOGY 21
FROI/SROI vs 148/A49 21
TERMINOLOGY 21
SECTION 5 – TEXAS REPORTING CRITERIA 29
FIRST REPORT OF INJURY ACTIONS OR EVENTS 29
SUBSEQUENT REPORT OF INJURY ACTIONS OR EVENTS 30
SECTION 6 – EVENTS, ELEMENTS, AND EDITS 33
SECTION 7 – PRODUCTION 71
EDI Basics 71
Guidance 71
FROI Matching Logic 73
Form Sequence Validation 74
SECTION 8 – ACKNOWLEDGMENTS /TRAFFIC REPORTS 77
Acknowledgments (AK1/824) 77
Traffic Report 77
SECTION 9 – SCENARIOS AND FAQS 83
Scenarios 83
FAQs 137
Appendix A – SFTP Naming Convention 143
Appendix B – Flat File Format 145
Header Record (HD1) Flat File Format 145
First Report of Injury Record (148) Flat File Format 146
Subsequent Report of Injury Record (A49) Flat File Format 148
Trailer Record (TR1) Flat File Format 150
Acknowledgment Record (TR1) Flat File Format 151
Appendix C – Revision Control History 153
SECTION 1 – CLAIMS EDI–AN OVERVIEW
CLAIMS EDI – AN OVERVIEW 7
History 7
Rules and Regulations 7
Texas Workers’ Compensation Act 7
Division Rules 8
Transaction Types 8
Division Processing Actions and Production Schedule 8
Division Proc