Free INTRODUCTION - New Mexico


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Workers' Compensation Administration
Albuquerque 841-6000 In-State Toll Free 1-800-255-7965 Economic Research Bureau 841-6072 2410 Centre Ave. SE P O Box 27198 Albuquerque, NM 87125-7198

EDI GUIDE
To Completing and Filing an Electronic Copy For:
EMPLOYER'S FIRST REPORT OF INJURY OR ILLNESS Form ( E1.2 ) NOTICE OF BENEFIT PAYMENT Form ( E6.2 )

Phone Numbers
Farmington 599-9746/1-800-568-7310 Las Cruces 524-6246/1-800-870-6826 Las Vegas 454-9251/1-800-281-7889 Lovington 396-3437/1-800-934-2450 Roswell 1-505-623-3781 Santa Fe 1-505-476-7381

E4 Booklet (EDI) December 2007

Data Collection Requirements

EDI Guide Book (December 2007)

TABLE OF CONTENTS
Introduction .......................................................................................................................................................................................... page 3 EDI General Filing Requirements ...................................................................................................................................................... page 3 EDI Required Capabilities .................................................................................................................................................................. page 3 FROI Technical Filing Requirements ................................................................................................................................................ page 4 Special Requirements........................................................................................................................................................................ page 4 IAIABC 148 Record Definitions and Values...................................................................................................................................... page 4 Error Processing................................................................................................................................................................................... page 8 Reading the Acknowledgment Record ............................................................................................................................................... page 8 EDI Notice of Benefit Payment Filing Requirements........................................................................................................................ page 10 When to File Under EDI ................................................................................................................................................................... page 10 How the Filing Process Works.......................................................................................................................................................... page 10 Information Needed to Establish EDI Filing .................................................................................................................................... page 10 EDI Report Records Format ............................................................................................................................................................. page 10 Technical Filing Requirements ......................................................................................................................................................... page 11 Special Requirements........................................................................................................................................................................ page 12 IAIABC A49 Record Definitions and Values..................................................................................................................................... page 12 Variable Counter Segment................................................................................................................................................................ page 14 Payment Adjustment Segment .......................................................................................................................................................... page 15 Benefit Adjustment Segment ............................................................................................................................................................ page 16 PTD/Reduced Earnings/Recoveries Segment ................................................................................................................................... page 16 Error Processing For Notice of Benefit Payment .............................................................................................................................. page 16 References ............................................................................................................................................................................................. page 18 Appendix 1 ............................................................................................................................................................................................ page 19 Table A First Report of Injury (148 Record) .................................................................................................................................... page 20 Table B Event Table ......................................................................................................................................................................... page 21 Table C 148 Record Requirements ................................................................................................................................................... page 22 Figure A Part of Body Codes............................................................................................................................................................ page 24 Figure B Nature of Injury Codes....................................................................................................................................................... page 25 Figure C Cause of Injury Codes........................................................................................................................................................ page 26 Appendix 2 ............................................................................................................................................................................................ page 27 EDI Transaction Flow Chart............................................................................................................................................................. page 28 Table D Event Table for A49 Record ............................................................................................................................................... page 29 IAIABC Subsequent Report Release 1A (A49 Record) ................................................................................................................... page 30 Table E Transmission Header Record............................................................................................................................................... page 31 Table F Detail Acknowledgment ...................................................................................................................................................... page 32 Table G Trailer Record ..................................................................................................................................................................... page 33 Data Element Mapping Table A49 Flat File ..................................................................................................................................... page 34 EDI Trading Partner Profile.............................................................................................................................................................. page 37 Appendix 3 ............................................................................................................................................................................................ page 38 EDI Test Phase Requirements........................................................................................................................................................... page 39 Glossary of Terms and Tables............................................................................................................................................................. page 41 Appendix 4 ............................................................................................................................................................................................ page 42 IAIABC Standards: Error Message Dictionary.......................................................................................................................... page 42

Workers' Compensation Administration 1

Data Collection Requirements

EDI Guide Book (December 2007)

INTRODUCTION
Electronic Data Interchange (EDI) is the computer-to-computer exchange of formatted business documents between enterprises, a system which has been rapidly expanding in the last decade. In workers' compensation, EDI refers to the electronic transmission of accident and claims information from claims administrators (insurers, self-insured employers and third party administrators) to a state agency. The electronic transfer of accident information replaces the paper copies of the First Report of Injury or Illness (FROI) and the Notice of Benefit Payment which reports subsequent payment information. The International Association of Industrial Boards and Commissions (IAIABC) has been working with the insurance industry since 1991 in developing the standard formats and procedures which make electronic reporting possible. The IAIABC EDI Development committee has produced an "EDI Implementation Guide" which is the recommended reference for claims administrators in implementing EDI processing of workers' compensation information in New Mexico. With the guide, claims administrators system personnel will be able to understand specific details of reporting the Notice of Benefit Payment data in the EDI flat file format (see glossary of terms in Appendix 2) required in New Mexico. The guide also provides information on trigger events and the reporting processes of EDI.

WHY EDI?
Most claims administrators already keep computerized claims records The claims reporting process is both paper and labor extensive Duplication of data entry on computer and paper reports increases the probability of errors As workers' compensation costs continue to escalate, EDI is viewed as an avenue to reduce costs and enhance productivity EDI is a time-saving, more efficient means of processing claims

Where is the New Mexico Workers' Compensation Administration in this process? The WCA has been accepting FROI by EDI since April 1,1994. In 1999, New Mexico began requiring parties processing more than 200 lost time claims per year to file by EDI. By January 1, 2000, claims administrators processing more than 100 indemnity claims per year were required to file using EDI. The mandatory requirements for filing the Notice of Benefit Payments have been in effect since January 1, 1998.

EDI GENERAL FILING REQUIREMENTS
New Mexico law requires that every employer or employer's representative file a FROI with the WCA within the time frames and criteria outlined in NMSA 1978. 52-1-58. Under EDI processing, a claims administrator may electronically file a FROI with the WCA in lieu of a paper copy. Organizations filing by EDI become the agent of the employer and are under the same legal filing requirements as the employer. Once the claims administrator has entered into a written EDI filing agreement with the WCA, and has passed the testing requirements (which entails the filing of a Trading Partner Profile), the employer no longer files a paper copy of the FROI with the WCA (See Appendix 2) . The New Mexico WCA requires that EDI transmissions be received by 9:00 a.m., Mountain Time on business days to ensure processing on that day. The reporting party creates a file of FROIs from its data base system. These files must follow the record format as defined by the IAIABC 148 record schema. The files that are created are sent to the WCA electronic mailbox by the use of a communication software package. The WCA processes each report record through an edit program that checks for errors. The WCA then sends an acknowledgment file to the reporting party detailing the status of each record filed. The reporting party may contact the WCA (at phone number 505-841-6072) regarding any rejection of records. Reports that pass the edits are processed into the workers' compensation database.

EDI REQUIRED CAPABILITIES
In order for workers' compensation information to be filed electronically with the WCA, the claims administrator must have the capability to: Construct a data file in the ASCII format of the IAIABC record schema. Transmit the data file through electronic mail. Provide the information within the required parameters.

Currently, the WCA is using the Value Added Networks, the Internet and other vendors that send flat file transmissions. The WCA neither endorses nor requires that a particular software vendor be used. However, the software must meet certain WCA system requirements. As technology changes the WCA transmission requirements are subject to change. For further information on software compatibility contact the WCA Information Systems Bureau. Prior to reading New Mexico's EDI requirements, the claims administrator should be familiar with the IAIABC EDI manual. To obtain this manual please contact the IAIABC and ask for the Claims EDI Process, Version 1.

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EDI Guide Book (December 2007)

FROI TECHNICAL FILING REQUIREMENTS
The following rules apply for submission of the FROI: Maintenance Type Code = 00: Used for the original first report transmitted between partners, including the re-transmission of an original first report that was rejected due to critical errors. All mandatory fields and non-null required fields must be completed for transmission of the record. Maintenance Type Code = 01: (Cancellation) The original first report was sent in error and is now required to be eliminated from the WCA's data base. A previous original report must have been filed. Only mandatory fields are required for transmission of the record. Maintenance Type Code = 02: (Change) A change is made to the original first report. The change is made not as a result of a warning error from the WCA. A previous original report must have been filed. All mandatory fields and non-null required fields must be completed for transmission of the record. Maintenance Type Code = 04: (Denial) Used by the reporting party to indicate that the employer denies that an injury or illness has occurred. In New Mexico the First Report of Injury or Illness is not considered a claim for benefits until the Notice of Benefit Payment has been filed. A previous original report must have been filed. Only mandatory fields are required for transmission of the record. Maintenance Type Code = CO: (Correction) The reporting party uses this code when a warning error or non-critical error has been identified by the WCA. Since an original report has previously been filed with the WCA, the reporting party files a correction including all mandatory and non-null required fields with the transmission. Maintenance Type Code = AU: (Acquired) Used to identify that a claim or injury report has been acquired from a prior claims administrator. The claims administrator transmitting the FROI records must ensure that the Federal Employer Identification Number (FEIN) for each organization they represent is correct.

SPECIAL REQUIREMENTS
The WCA uses the injured worker's Social Security Number and date of injury to establish a unique claim file. If either of these data elements have been reported in error, the claims administrator must first delete the original First Report sent and then transmit a new original report with the WCA. Note: if a Notice of Benefit Payment has been filed with the WCA prior to the discovery of the SSN or date of injury error, the claims administrator must call the Information Systems Management Bureau of the WCA to correct the error.

IAIABC 148 RECORD DEFINITIONS AND VALUES
These definitions can be found in the IAIABC EDI manual and are reproduced here to be New Mexico specific. Appendix 1, Table A provides specific information for use in developing the 148 record. M = Mandatory field. A data element having this designation must be included in every transmission of a record. If a mandatory field element is not contained in the 148 transmission a critical error will result and the record will be sent back to the sender. (See Error Processing below for details). C = Conditional field. A nun-null data element having this designation must be transmitted with every first report record. This information is usually time sensitive and is not provided at every stage of the claims process. Once the information is known it must be provided to the WCA at all of the following reporting events. O = Optional field. A non-null data element having this designation may be transmitted. Once transmitted, this field should be transmitted with every First Report. Definitions: [001] Transaction Set ID: Identifies the transaction being sent by the reporting party. For the FROI, Transaction Set ID = 148. [002] Maintenance Type Code (Previously Maintenance Reason Code): Defines the specific purpose of individual records within the transaction being transmitted. Values: 00 = Original 01 = Cancel 02 = Change 04 = Denial CO = Correction AU = Acquired Workers' Compensation Administration 3

Data Collection Requirements EDI Guide Book (December 2007) [003] Maintenance Type Code Date (Previously Maintenance Reason Code Date): Designates the date corresponding to the Maintenance Type Code. {format CCYYMMDD} [004] Jurisdiction: The governing body or territory whose statutes apply to the complaint, claim or work injury. In New Mexico, Jurisdiction = NM. Agency claim Number: The number assigned by the agency or commission to identify a specific claim. In New Mexico, the claim number is not assigned until a Notice of Benefit Payment (subsequent report) has been received by the WCA or a complaint has been filed with the Clerk's office. The Claim Number consists of the prefix WCAYY {YY = year of filing} plus five digits. Insurer FEIN: The Federal Identification Number of the Insurance Company or Self-Insured handling the claim financially (financially responsible party). Insurer's Name: The name of the insurance carrier or self-insured employer financially responsible for handling the claim or potential claim. Third Party Administrator FEIN: The Federal Identification Number of the Claims Administrator contracted by the insurance carrier or self-insured employer to adjust and file claim information with jurisdiction. Third Party Administrator Name: The name of the Claims Administrator handling the claim on behalf of the insurance carrier or self-insured employer.

[005]

[006]

[007]

[008]

[009]

[010/011] Claims Administrator Address, Lines 1 and 2: The mailing address of the reporting party submitting statistical reports to the WCA. [012] [013] [014] [015] Claims Administrator City: The city of the reporting party's processing facility's mailing address. Claims Administrator State: The state of the reporting party's processing facility's mailing address. Claims Administrator Postal Code: The zip/postal code of the reporting party's processing facility's mailing address. Claims Administrator Claim Number: This number is assigned by the Claims Administrator or Third Party Administrator for identification of a specific claim within their system. The Claims Administrator must assign a number for this field. This number is a mandatory field because it is used by the WCA as the unique claim identifier. Employer FEIN: Federal Identification Number of the injured worker's employer. Insured Name: The name insured of the policy, typically the parent company in a hierarchically structured organization. Employer Name: The name of the business entity employing or statutorily responsible for the claimant.

[016] [017] [018]

[019/020] Employer Address, Lines 1 and 2: The mailing address of the injured worker's employer responsible for submitting the FROI to the claims administrator. [021] [022] [023] [024] Employer City: The city address location of the injured worker's employer. Employer State: The state address location of the injured worker's employer. Employer Postal Code: The zip/postal code of the injured worker's employer. Self-Insurance Indicator: Identifies the employer as one who retains the risks arising from its operation and bears the financial responsibility. {Values: Y = yes, N = No}. NAICS Code (North American Industrial Classification System): The code representing the nature of the employer's business. These codes are assigned from the NAICS manual published by the Federal Office of Management and Budget. These codes are typically assigned by the U.S. Department of Labor. (Note: SIC codes still may be provided until 1/1/2002). Insured Report Number: A number determined by the insured to identify a specific claim for a company location. Insured Location Number: A code defined by the employer to identify the location of the accident. This number should reflect the location of the accident by store location or department location. (Mandatory field in 2009). For main location of employer at address on First Report, then location number should be assigned "0001" . For injuries occurring at different location (put in street abbreviation - city abbreviation: (example; menual-abq)) Workers' Compensation Administration 4

[025]

[026] [027]

Data Collection Requirements EDI Guide Book (December 2007) [028] Policy Number: The unique number assigned to the contract/policy by the insurance carrier or third party administrator for that employer or association group. [029] [030] [031] Policy Effective: Date that the contract/policy under which the claim occurred became effective. {Format CCYYMMDD}. Policy Expiration: Date that the contract/policy under which the claim occurred expired. {Format CCYYMMDD}. Date of Injury: For traumatic injury (injury resulting from a single incident), the date on which the accident occurred. For occupational disease or cumulative injury, the date of last injurious exposure to the cause or substance creating the condition. In New Mexico, for a traumatic injury, enter the date of occurrence. For an occupational illness arising from the workers' activity or exposure over an extended period, enter the date of diagnosis or the date first reported to the employer as possibly work-related, whichever is earlier. The item is very important because it is used along with the Social Security Number for identification and computer tacking of the FROI. It is a primary key in establishing a claim within the workers' compensation system. {Format CCYYMMDD}. Time of Injury: For traumatic injury, the time at which the accident occurred. {Format HHMMSS}. Postal Code of Injury Site: The zip/postal code that corresponds to the location where the injury occurred. This information is checked for a valid code. A "TE" transaction accepted with errors is sent back to sender if postal code is not New Mexico specific. The WCA does not review or monitor "TE" errors in this field. Employer's Premises Indicator: Denotes whether the accident occurred at the employer's address specified in items 19 through 23 {Values: Y = Yes, N = No}. Nature of Injury Code: Code corresponding to the major characteristic of the injury such as a sprain, fracture, burn, etc. (See Appendix 1, Figure A for list of codes). Part of Body Injury Code: Corresponds to the claimant's part of body injured. (See Appendix A, Figure B for list of codes). Cause of Injury Code: Corresponds to what caused the accident or illness, or how it occurred. (See Appendix A, Figure C for list of codes). Accident Description/Cause: Text description of how the accident happened, or what caused the illness. This description can be up to 150 characters. Initial Treatment: The code used to identify the extent of medical treatment received by the claimant immediately following the accident. The code is used to determine the severity of the injury and to inform medical cost containment programs. Values: 00 = No medical treatment 01 = Minor on-site remedies by employer medical 02 = Minor clinic/hospital medical remedies and diagnostic testing 03 = Emergency evaluation, diagnostic testing and medical procedures 04 = Hospitalization > 24 hours 05 = Future major medical/lost time anticipated (i.e., hernia case) Date Reported to Employer: The date the injured worker reported an accident or illness to a representative of the employer. {Format CCYYMMDD}. Date Reported to Claims Administrator: The date the claims administrator received notice of the accident. Note: This date should be updated on a compensable injury as to the date the employer informed the claim administrator that the injury lost more than seven days (7) days from work. {Format CCYYMMDD}. Social Security Number: Identification number assigned the injured worker by the Social Security Administration. This data element is a primary key in identifying workers' compensation claim within the WCA database. Employee Last Name: The legal last name of the injured worker at the time of the accident or illness. Employee First Name: The legal first name of the injured worker at the time of the accident or illness. Employee Middle Initial: The first letter character of the injured worker's middle name.

[032] [033]

[034]

[035]

[036] [037]

[038]

[039]

[040]

[041]

[042]

[043] [044] [045]

[046/047] Employee Address, Lines 1 and 2: The current mailing address of the injured worker. [048] Employee City: The current city location of the injured worker. Workers' Compensation Administration 5

Data Collection Requirements [049] Employee State: The current state location of the injured worker. [050] [051] [052] Employee Postal Code: The current zip/postal code of the injured worker. Employee Phone: The current telephone number of the injured worker.

EDI Guide Book (December 2007)

Date of Birth: The birth date of the injured worker. This date must be older than the date of hire or the date of injury. {Format CCYYMMDD}. Gender Code: Values: M = Male F = Female U = Unknown Marital Status Code: Values: U = Widowed, Divorced, Single, Unmarried S = Separated

[053]

[054]

M = Married K = Unknown

[055] [056] [057]

Number of dependents: The number of children injured worker has at the time of injury. Date disability Began: The first day on which the claimant originally lost time from work due to the occupational injury or illness. Date of Death: The date the claimant died. In New Mexico, this date is more specifically defined to be the date that the injured worker died due to his or her work-related injury or illness reported. {Format CCYYMMDD}. Employment Status Code: A code used to indicate the employee's primary work code status at the time of the injury with the covered employer. New Mexico uses the ANSI values. Values PW = Piece Worker VO = Volunteer SL = Seasonal Worker AD = Apprenticeship Full Time FT = Full Time AP = Apprenticeship Part Time PT = Part Time RT = Retired NE = Not Employed DS = Disabled OS = On Strike ZZ = Other Class Code: Corresponds to the primary occupation in which the claimant was engaged at the time of the accident or illness. The values are obtained through the NCCI Class Code Classification Manual. (See References). Occupation Description: A descriptive text identifying the primary occupation of the claimant at the time of the accident, injury or illness. (Example: Janitor, Laborer, Supervisor dock area). Please be as specific as possible. Date of Hire: The date the injured worker began his or her employment with the employer under which the claim is being filed. If there have been multiple periods of employment, this is the beginning date of the current employment period. Wage: The claimant's reported pre-injury wage for the wage period defined. This amount may include estimated commissions and living or travel allotment earnings. (For New Mexico, the default value for the FROI when a wage amount is unknown is 0.00). Wage Period: A code assigned indicating the time period during which the wage is earned. Values: 01 = Weekly 02 = Bi-Weekly 04 = Monthly 06 = Daily Number of Days Worked: The number of the injured worker's regular scheduled workdays per week. {Values: 01, 02, 03, 04, 05, 06, 07}. Date Last Day Worked: The date the employee last worked. This date will not reflect dates on which the employee was absent from work in a paid status; vacation, comp time, sick leave, military leave, etc. {Format CCYYMMDD}. Full Wages Paid for Date of Injury: Defines whether full wages for the date of the accident or illness were paid to the injured worker by the employer. {Values: Y = Yes, N = No}. Salary Continued Indicator: For workers' compensation indicates whether the employer is continuing to pay the injured worker's regular wages without charge to employee benefits (vacation time, sick leave, etc.) during an absence caused by a work injury. This indicator is also used to indicate if the injured worker is being paid by the employer under an injury time program. Note: the 8th day of loss begins from the date the injury time (I-Time) ends. { Y = Yes, N = No}. Workers' Compensation Administration 6

[058]

[059]

[060]

[061]

[062]

[063]

[064]

[065]

[066]

[067]

Data Collection Requirements EDI Guide Book (December 2007) [068] Date of Return to Work: The date, following the most recent disability period, on which the claimant returned to work.

ERROR PROCESSING
In Appendix 1 (see Table C), the EDI edit notes outline the technical and business edits of the 148 record by the WCA. The technical edits of a 148 file are processed within 24 hours or the next business day of the receipt date. The technical edits review the mandatory data elements values of each record and ensure the accuracy of the information. The business edits ensure that the record meets the processing requirements in the order of the record transactions accepted by the EDI methodology. In the case of the 148 record, a business edit would be the one that would ensure that an original 148 record was on file with the WCA data base before processing a deletion, correction or change record. The technical edits create a detailed acknowledgment record for the claims administrator to review to ensure that all records sent were accepted by the WCA (see Appendix 2, Figure D). Records that have been accepted with non-critical errors should be examined by the claims administrator for discrepancies and corrections should be made as soon as possible.

READING THE ACKNOWLEDGMENT RECORD
The claims administrator submitting a FROI is responsible for reviewing the acknowledgment records to ensure that all the reports sent to the WCA were processed. Records that are assigned a "TR" or "TE" in the detail acknowledgment file need further action by the claims administrator. The following transaction codes are used by the claims administrator to determine the status of their claim data submitted: TR = the 148 record was rejected due to critical errors in processing: TE = the 148 record was accepted with non-critical errors: TA = the 148 record was accepted, no errors.

The claims administrator should maintain all acknowledgment files for approximately five years. The IAIABC EDI manual must be obtained to read error messages. Please see Section 6 in the IAIABC EDI manual for the error matrix. For testing procedures, please see Appendix 3.

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EDI Guide Book (December 2007)

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EDI Guide Book (December 2007)

EDI NOTICE OF BENEFIT PAYMENT FILING REQUIREMENTS
New Mexico law requires that the claims administrator file a Notice of Benefit Payment (known under EDI as the Subsequent Report) with the WCA within the time limits and reporting process outline in 52-1-58, 52-3-52, and 52-1-60. Under EDI processing, claims administrators may file the Notice of Benefit Payment for several insurance carriers or self-insured employers. Organizations filing by EDI become the agent of the self-insured employer or insurance carrier and are under the same legal filing requirements as the individual claims administrator. Once the claims administrator has completed an E7 (see Appendix 2) and entered into an EDI filing agreement with the WCA for production, the claims administrator no longer needs to file paper copies of the FROI or Notice of Benefit Payment reports with the WCA.

WHEN TO FILE UNDER EDI
The claims administrator is required to file the Notice of Benefit Payment within 10 days after the initial payment of disability to the injured worker. For controverted claims having payment, the administrator has 50 days from the filing of the order to submit a subsequent report. The claims administrator must also file within 30 days of a change in benefit payment or a final payment. For medical-only benefits, the claims administrator is required to file a Notice of Benefit Payment within 180 days of an initial payment totaling $300 or more to the health care provider. The claims administrator is also required to file a closing payment of a medical-only claim within 180 days of this payment. The WCA daily processing time for the Notice of Benefit Payment reports (E6.2) is between 7:00 a.m. and 9:00 a.m. Mountain Time on business days. Transmissions received after 9:00 a.m. will be processed the following business day.

HOW THE FILING PROCESS WORKS
The process of sending subsequent reports is shown in Figure A (see Appendix 2). The reporting party creates a file on Notice of Benefit Payment (Subsequent) Reports from its data base system. These files must be structured in ASCII format as defined by the IAIABC A49 record schema and include the header and trailer records for each file. The files are sent via the value-added network or Internet by the use of a communication software package. Within 24 hours or the next business day of receipt of the transmitted data file, the WCA processes each report record through an edit program. Reports that pass the edits are processed into the WCA database. The edits are based on the data matching the required possible values for each mandatory field within the A49 record. The WCA sends a detailed acknowledgment record outlining both the business and technical edits to the claims administrator within 48 hours of processing the files.

INFORMATION NEEDED TO ESTABLISH EDI FILING
Prior to an EDI filing, the reporting party must have completed a current EDI Trading Partner Profile (E7) form with the WCA databank. This form requests information on the reporting party and each organization it represents. This information is important in identifying and tracking individual claims. The E7 information must be kept current! E7 information includes a local address for insurers with contact person, phone number, Federal Identification Number (FEIN) and electronic mailbox identification. Additionally, the reporting party must include an address with contact person and phone number. FEIN numbers must be identified for all organizations being represented. The WCA also requires the file class designation (see glossary of terms and e-mail address) for the transmission of data files for reporting organizations using the ADVANTIS Network. Please contact the WCA Economic Research Bureau for further information.

EDI REPORT RECORDS FORMAT
The reporting party should have a clear understanding of the EDI report record. The Subsequent Report (Notice of Benefit Payment) is filed in the IAIABC A49 record format shown in Table B (see Appendix 2). Table B shows the data elements, data field names, the New Mexico technical required elements, the data element position number, field length and format, and column positions. The data elements definition and values are explained in the next section. The Header and Trailer record formats are shown in tables C and E respectively. The header record is the first record in every file sent to the administration by the claims administrator. This record describes the file, the date of transmission and the sender information. The trailer record follows all the records in the file and gives the record count of the number of records to be processed. The reporting organization must be aware that the record lengths remain constant for all records. Each data field within the record has a WCA technical requirement designation (i.e. M = Mandatory, C = Required, O = Optional). Data elements that are not available or have no values will have a blank entry in that field except for the following technical requirements designated under the TECH REQ. NM column (see Table B): M = Mandatory field. A data element having this designation must be included in every transmission of a record. If a mandatory field element is not contained in the A49 transmission, a critical error will result and the record will be sent back to the sender (see Error Processing below for details). C = Conditional field. A non-null data element having this designation must be transmitted with every Notice of Benefit Payment record. This information is usually time sensitive and is not provided at every stage of the claim process. Once the information is known it must be provided to the WCA at all of the following reporting events. Workers' Compensation Administration 9

Data Collection Requirements EDI Guide Book (December 2007) O = Optional field. A non-null data element having this designation may be transmitted. Once transmitted, this field should be transmitted with every subsequent report.

TECHNICAL FILING REQUIREMENTS
The following rules apply for submission of the Notice of Benefits Payment: Maintenance Type Code = IP (Initial Payment): Used for the initial payment subsequent report transmitted between partners, including the retransmission of an initial payment subsequent report that was rejected due to critical errors. Note: the IP is used only for the first E6.2 for an indemnity claim or upon the first payment of indemnity benefits after a medical payment (PY). Reporting Rules: An accepted FROI must have been filed with the WCA for the same worker SSN and Date of Injury prior to the filing of the IP. An IP may not be filed for only indemnity benefits and only one IP is accepted by the WCA for each case. Note: for claims that began as PY, an IP can only be used when the claim type = L. Maintenance Type Code = PY (Payment, Medical-only or Notification): This code is used for an initial payment of medical claims or for initial payment of attorney fees or funeral expenses. Claims that begin as medical-only or are for notification purposes and have a subsequent indemnity payment require a PY and a follow up IP report (see EDI flow charts). Reporting rules: An accepted FROI must have been filed with the WCA for the same worker SSN and Date of Injury prior to filing a PY. Maintenance Type Code = CB (Change in Indemnity Benefits): A change in Payment/Adjustment Code has been made or a new indemnity transaction of an additional Payment/Adjustment Code has occurred. This code is used in the following situation: A claim is paid for more than one disability type at different times during the payment period of the claim. For example, a claim has payment beginning for TTD benefits and after MMI, the claim is paid under Permanent Partial Disability (PPD) benefits. Reporting rules: An accepted IP Notice of Benefit Payment has been filed for the same worker SSN and Injury Date prior to the filing of the change in indemnity benefits. Maintenance Type Code = FN (Closing Payment): This report is filed for the completion of disability benefits paid to the worker. Final medical payments are also reported under this purpose code for medical-only claims. Medical-only claims should be closed to after 90 days of no action from the last payment date. The claim status for medical payments after the final payment is "reopen/closed". Note: once an FN has been filed to and accepted by the WCA, all subsequent reports for the same claim must also be reported as an FN. Reporting rules: A PY for medical-only payments has been filed and accepted or an IP Notice of Benefit Payment report has been filed and accepted for the same worker SSN and Injury Date prior to the filing of the final payment report. Maintenance Type Code = 02 (Change): A change is made to the Notice of Benefit Payment previously filed. The change is made as a result of a warning error from the WCA. A previous E6.2 report must have been filed. All mandatory fields and non-null required fields must be completed for transmission of the record. Reporting rules: An accepted IP or PY Notice of Benefit Payment report has been filed for the same worker SSN and Injury Date prior to the filing of the change. If a Notice of Benefit Payment report has been filed with the wrong SSN or injury date, the claims administrator must email the change of SSN or date of injury to the WCA. Maintenance Type Code = CO (Correction): The reporting party uses this code when a warning error or noncritical error has been identified by the WCA in a particular report. Since this Notice of Benefit Payment report has been filed with the WCA, the reporting party must file a correction including all mandatory and non-null required fields with the transmission. Reporting rules: An accepted IP or PY Notice of Benefit Payment report has been filed for the same worker SSN and injury date prior to filing the correction. Maintenance Type Code = AP (Acquired Claim): This code is used to indicate that indemnity benefits have been paid by the acquiring claims administrator. An AU report (see glossary) for a FROI needs to be sent to update the new carrier and claims administrator information. Reporting rules: An accepted IP or PY Notice of Benefit Payment report has been filed for the same worker SSN and injury date to the filing of the acquired claim and an AU report has changed the carrier information on the FROI.

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EDI Guide Book (December 2007)

SPECIAL REQUIREMENTS
The reporting party transmitting the A49 records must ensure that the FEIN for the claims administrator is complete. The WCA uses the injured worker's SSN and Date of Injury to establish a unique claim file. If either of these data elements has been reported in error after the filing of a Notice of Benefit Payment report, the reporting party must contact the WCA to make the necessary changes. The claims administrator may call (505) 841-6072 and ask to speak to the EDI administrator, or the claims administrator can e-mail the SSN and Date of Injury changes to [email protected] Note: The NAIC (or SIC) Code must have been provided on the 148 record (i.e. FROI) prior to the submission of the A49 record. All records without an NAIC (or SIC) Code on the FROI will be returned to the sender at the time of the A49 transmission.

IAIABC A49 RECORD DEFINITIONS AND VALUES
These definitions can be found in the IAIABC EDI Manual and are reproduced here to be New Mexico specific. Each field is defined in the order it appears in the A49 record and is identified with a data number consistent with the IAIABC EDI Manual {i.e. DN001}. [DN001] Transaction Set ID: Identifies the transaction being sent by the reporting party. For the Notice of Benefit Payment, Transaction Set ID = A49. [DN002] Maintenance Type Code (Maintenance Reason Code): Defines the specific purpose of individual records within the transaction being transmitted (see above definition). Values: IP = Initial Payment PY = Initial Payment of medical-only benefits or attorney fees or funeral expenses CB = Change in Benefit Payments FN = Final Notice, Closing Payment of medical or indemnity benefits 02 = Change CO = Correction AP = Acquired Payment [DN003] Maintenance Type Code Date (Maintenance Reason Code Date): Designates the date corresponding to the Transaction Set Purpose Code {Format CCYYMMDD}. [DN004] Jurisdiction: The governing body or territory whose statutes apply to the complaint, claim or work injury. In New Mexico, Jurisdiction = NM. [DN005] Agency Claim Number: The number assigned by the New Mexico WCA to identify a specific claim. In New Mexico the claim number is not assigned until Notice of Benefit Payment has been received by the WCA or a complaint has been filed with the Clerk's office. The Claim Number will have the prefix WCAYY {YY = year of filing}. [DN006] Insurer FEIN: The Federal Employer's Identification Number of the carrier or self-insured assuming the employer's financial responsibility for workers' compensation claim(s). [DN008] Third Party Administrator FEIN (Claims Administrator FEIN): The Federal Identification Number of the Third Party Administrator (TPA), Independent Adjuster or Claims Administrator that adjusts the claim on behalf of the carrier, self-insured employer, group or pool. [DN014] Claims Administrator Postal Code: The Zip Code of the claims administrator's or Third Party Administrator's processing facility's mailing address for the FROI, Notice of Benefit Payment report or claim. The code has the 5 digit base with a possible 4 digit extension. [DN015] Claim Administrator's Claim Number: This number is assigned by the claims administrator or third party administrator for identifying a specific claim within their system. The claims administrator must assign a number for this field. This number is a mandatory field because it is used by the WCA as the unique claim identifier. [DN026] Insured Report Number: A number determined by the insured (employer) to identify a specific claim. [DN031] Date of Injury: For traumatic injury, the date on which the accident occurred. In some cases for occupational disease or cumulative injury, this is the date of last injurious exposure to the cause or substance creating the condition. In New Mexico for a traumatic injury (injury resulting from a single accident), enter the date of occurrence. For an occupational illness, arising from the worker's activity or exposure over an extended period, enter the date of diagnosis or the date first reported to the employer as possible work related, whichever is earlier. This item is very important because it is used along with the SSN for identification and computer tracking of the FROI information. It is a primary key in establishing a claim within the workers' compensation system {Format CCYYMMDD}. Workers' Compensation Administration 11

Data Collection Requirements

EDI Guide Book (December 2007)

[DN042] Social Security Number: Identification number assigned to the injured worker by the Social Security Administration. This field is a primary key in identifying a workers' compensation claim within the WCA database. [DN055] Number of Dependents: The number of children under 19 that are dependent on the resources of the injured or ill worker at the time of the accident including the number of children under the age of 23 that are attending an accredited college or university. [DN056] Date Disability Began: The first day on which the employee lost time from work due to the occupation disease or injury. [DN057] Employee Date of Death: The date the injured/ill worker died as a result of the accident or injuries sustained during the accident. [DN062] Wage: The average wage of the employee at the time of the injury as calculated by the Claims Administrator for the wage period. [DN063] Wage Period: A code assigned indicating the time period during which the wage is earned. Values: 01 = Weekly 04 = Monthly [DN064] Number of Days Worked: The number of the injured worker's regularly scheduled workdays per week. Values: 01, 02, 03, 04, 05, 06, 07. [DN067] Salary Continued Indicator: Indicates whether the employer is continuing to pay the injured worker's regular wages without charge to employee benefits (vacation time, sick time, etc.) during an absence caused by a work injury. This indicator is also used to indicate if the injured worker is being paid by the employer under an injury time program. Note: the 8th day of loss time begins the day after the Injury time has ended. Values: Y = Yes, N = No. [DN069] Pre-Existing Disability: This identifies the existence of a disability that existed prior to the occupational injury or disease. [DN070] Date of Maximum Medical Improvement: The date, indicated by the treating physician, after which further recovery from or lasting improvements to an injury or disease can no longer be anticipated, based upon reasonable medical probability. [DN071] Return to Work Qualifier: A code identifying the employee's return to work status, with or without physical restrictions. The qualifier must be completed if there is a return to work or release to Return-to-Work data. Values: 1 - Actual RTW without physical restrictions 2 - Actual RTW with physical restrictions 5 - Released to RTW without physical restrictions 6 - Released to RTW with physical restrictions [DN072] Date of Return/Release to Work: The date, following the most recent disability period, on which the employee actually returned to work, or was released to return to work, as identified by the Return to Work Qualifier. (See EDI IAIABC Guide for implementation notes). [DN073] Claims Status: A code representing the current status of the claim. Values: O = Open: Future benefit payments are anticipated. C = Closed: Future indemnity payments are not anticipated. R = Reopen: Claim was closed but is reopened for future payments not anticipated. X = Reopened/Closed: Claim was reopened for one additional payment. No future payments anticipated. [DN074] Claim Type: A code representing the current benefit classification of the claim. Values: M = Medical-only: This claim has only medical benefits paid in behalf of the injured or ill worker. I = Indemnity: This claim is identified by the payment of any disability compensation paid to the worker during the life of the claim. N = Notification only: For initial payment of attorney fees or funeral expenses without any medical or indemnity benefits being paid. L = Became lost time: The claim began as a medical-only claim and became an indemnity claim after more than seven days of work time was lost by the worker as a result of the accident. [DN075] Agreement to Compensate Code: A code used to identify the condition under which compensation benefits are being paid. Values: Without Liability = W, With Liability = L. [DN076] Date of Representation: The date the claims administrator recognizes that the claimant has secured legal representation. [DN077] Late Reason Code: A code which identifies the reason a payment/report was not made within New Mexico's requirements. For all codes for all states, see IAIABC Manual. Values: Workers' Compensation Administration 12

Data Collection Requirements Delays: L1 No excuse L2 Late notification, employer L3 Late notification, employee L4 Unauthorized health care L5 Late notification, health care provider L6 Late notification, assigned risk L7 Late investigation L8 Technical processing delay or computer failure L9 Manual processing delay LL Late due to previous disability payment Coverage C1 Coverage, lack of information C2 Coverage, acquired claim with change of TPA C3 Coverage, no initial coverage by employer Disputes: These codes may only be used if there is a WCA court case for the claim D1 Dispute concerning coverage D2 Dispute concerning compensability, in whole D3 Dispute concerning compensability, in part D4 Dispute concerning disability, in whole D5 Dispute concerning disability, in part D6 Dispute concerning impairment

EDI Guide Book (December 2007)

VARIABLE COUNTER SEGMENT
[DN078] Number of Permanent Impairments: Number of permanent impairment occurrences (values 0 -10). Note: New Mexico is not currently using this information. [DN079] Number of Payments/Adjustments: Number of weekly payments/adjustments occurrences (values 0 -10). Note: New Mexico requires Payments/Adjustments information. [DN080] Number of Benefit Adjustments: Number of benefit adjustment occurrences (values 0 - 10). Note: New Mexico does not require this information at this time. Value can be set to zero. [DN081] Number of PTD/Reduced Earnings/Recoveries: Number of paid to date/reduced earnings/recovery occurrences (values 0 -25). Note: New Mexico requires this information. [DN082] Number of Death Dependent/Payee Relationships: Number of death/dependent payee segment occurrences (values 0 - 12). Note: New Mexico does not currently require this information. Value can be set to zero.

PERMANENT IMPAIRMENT SEGMENT
(This section is not currently required by New Mexico)

Workers' Compensation Administration 13

Data Collection Requirements

EDI Guide Book (December 2007)

PAYMENT ADJUSTMENT SEGMENT
EDI COMPARISON CHART

SPECIFIC

COMPROMISED/LUMP

DESCRIPTION

500

Unspecified or Unknown

010

510

Fatal

020

520

Permanent Total Disability

021

521

Permanent Total Supplemental

030

530

Permanent Partial Scheduled Disability

040

540

Permanent Partial Unscheduled Disability

050

550

Temporary Total Disability

051

551

Temporary Total Catastrophic Disability

070

570

Temporary Partial Disability

090

590

Permanent Partial Disfigurement

New Mexico Acceptable Values: {050, 550, 051, 551} Temporary Total Disability Benefits Paid to Date: These are benefits paid to the claimant during the period in which the claimant is unable to work as the result of the injury or illness. The claimant may fully recover and the payment period precedes the date of Maximum Medical Improvement (MMI). {070, 570} Temporary Partial Disability Benefits Paid to Date: Benefits paid or payable for the period during which the claimant, as a result of a disability from which he or she is expected to fully recover, is unable to perform work for his or her regular pay, but is receiving a reduced rate of pay prior to the date of MMI. {030, 530, 040, 540, 090, 590} Permanent Partial Disability Benefits Paid to Date: Benefits paid or payable as established by a statutory list (schedule) of payments for certain injuries or based on whole body not covered by a schedule. Note: for whole body non-scheduled injuries the claimant is paid based on a statutory formula. {020, 520, 021, 521} Permanent Total Disability Benefits Paid to Date: Benefits paid or payable for the loss of or the permanent loss of use of both hands, arms, legs, feet, eyes or any two of the body members and for a brain injury impairment of greater than 29% defined by the AMA. {010, 510} Death Benefits Paid to Date: Benefits paid or payable for the death of the claimant resulting from a work related accident or occupational injury or disease. Workers' Compensation Administration 14

Data Collection Requirements EDI Guide Book (December 2007) {500} Unspecified Benefits Paid to Date: Amounts that cannot be assigned to a specific benefit type. These payments also include compromised settlements in which the parties agree that no injury or illness has occurred. [DN085] Payment/Adjustment Code: Code that identifies the type of indemnity payment made to the injured or ill worker. [DN086] Payment/Adjustment Paid to Date: The cumulative amount paid for the payment/adjustment identified by the associated payment/adjustment code. The cumulative amount represents the total amount paid to date for one code defined within the EDI comparison chart. [DN087] Payment/Adjustment Weekly Amount: The net weekly rate for the payment/adjustment code that is paid as modified by any applicable benefit adjustments. [DN088] Payment/Adjustment Start Date: The beginning date that benefits are due to the claimant for the defined disability during the payment period. For the initial payment, this date is the compensability date for the initial disability benefits paid to the injured or ill worker. For workers under an injury time program (I-Time), the start date is the day following the end of the Injury time period. [DN089] Payment/Adjustment End Date: The last date of a benefit period for which disability benefits were paid. [DN090] Payment/Adjustment Weeks Paid: The number of whole weeks paid for benefits based on the payment/adjustment code. [DN091] Payment/Adjustment Days Paid: The number of days, less than a week, paid for benefits based on this payment/adjustment code.

BENEFIT ADJUSTMENT SEGMENT
(This section is not currently required by New Mexico)

PTD/REDUCED EARNINGS/RECOVERIES SEGMENT
[DN095] Paid to Date/Reduced Earnings/Recovery Code: This code identifies the benefits paid in behalf of the injured or ill worker that is additional to possible disability payments as defined in the payment adjustment codes. These benefits include medical services, attorney fees, vocational rehabilitation and funeral expenses. New Mexico Accepted Values: 300 = Funeral expenses paid to date 330 = Employer's legal expenses paid to date 340 = Claimant's legal expenses paid to date 350 = Total payments to physicians paid to date 360 = Hospital costs paid to date 370 = Other medical paid to date 380 = Vocational rehabilitation evaluation paid to date 390 = Vocational rehabilitation education paid to date 400 = Other vocational rehabilitation paid to date 420 = Expert witnesses fees paid to date 450 = Medication paid to date 460 = Physical therapy 450 is the sum of the costs of all medication prescribed by the physician for treatment of the accidental work injury or illness. 460 is the sum of all physical therapy costs. Physical therapy is defined by the AMA Physicians' Current Procedural Terminology as that which is performed on the injured or ill worker by a physical therapist, osteopathic physician or chiropractor. [DN096] Paid to Date/Reduced Earnings/Recovery Amount: The amount defined by the Paid to Date/Reduced Earnings/Recovery Amount codes.

DEATH/DEPENDENT PAYEE RELATIONSHIP SEGMENT
(This section is not currently required by New Mexico)

ERROR PROCESSING FOR NOTICE OF BENEFIT PAYMENT
In the appendix, the EDI mapping table outlines the technical and business requirements of the A49 record by New Mexico. The technical edits are processed within 24 hours of the receipt date. The technical edits review each record's mandatory data element values and ensure the accuracy of the information. The business edits ensure that the record meets the processing requirements in the order of the transactions accepted by the New Mexico EDI methodology (see EDI flow charts). In the case of the A49 record, a business edit would be one that would ensure that an original 148 record had been processed prior to the submission of an A49 record. Workers' Compensation Administration 15

Data Collection Requirements

EDI Guide Book (December 2007)

The technical edits create a detail acknowledgment record for the claims administrator to review to ensure that all records sent were accepted by the WCA (see Notice of Benefit Payment Appendix, Data Element Mapping Table). Records that have been accepted with non-critical errors require corrections within 10 days of processing. Records that have been rejected have critical errors. They need to be corrected and resubmitted to the WCA as soon as possible in order to prevent violation of deadline requirements. Penalties can be assessed for violations. Claims administrators submitting the Notice of Benefit Payment Report is responsible for reviewing the acknowledgment records to ensure that all the reports sent have been processed by the New Mexico WCA. Records that are indicated by the detail acknowledgment file to have the following acknowledgment codes need further action by the claims administrator. TR = The A49 record was rejected due to critical errors TE = The A49 record was accepted with non-critical errors

The claims administrator should maintain all acknowledgment files for approximately five years. For further information on error processing, please refer to the IAIABC EDI manual.

Workers' Compensation Administration 16

Data Collection Requirements

EDI Guide Book (December 2007)

REFERENCES
North American Industry Classification System, United States, 1997. Published by the Federal Office of Management and Budget. EDI Implementation Guide, 1995. Published by the International Association of Industrial Accident Boards and Commissions (IAIABC) EDI Development Committee. Call for Detailed Claim Information: Instruction Manual, 1999. Published by the National Council on Compensation Insurance (NCCI).

Workers' Compensation Administration 17

Data Collection Requirements

EDI Guide Book (December 2007)

APPENDIX 1

1. ...................................................................Table A: First Report Of Injury (148 Record) (7/01/99) 2. ...................................................................Table B: Event Table 3. ...................................................................Table C: 148 Record Requirements (Technical/Business Edits) 4. ...................................................................Figure A: Part Of Body Codes 5. ...................................................................Figure B: Nature Of Inury Codes 6. ...................................................................Figure C: Cause Of Injury Codes

Workers' Compensation Administration 18

Data Collection Requirements

EDI Guide Book (December 2007)

TABLE A
GROUP TRANSACTION

FIRST REPORT OF INJURY (148 RECORD) (7/01/99)
STATE FIELDS/DEFINED ELEMENTS TRANSACTION SET ID MAINTENANCE TYPE CODE MAINTENANCE TYPE CODE DATE JURISDICTION AGENCY CLAIM NUMBER INSURER FEIN INSURER NAME THIRD PARTY ADMINISTRATOR FEIN THIRD PARTY ADMINISTRATOR NAME CLAIM ADMINISTRATOR ADDRESS LINE 1 CLAIM ADMINISTRATOR ADDRESS LINE 2 CLAIM ADMINISTRATOR CITY CLAIM ADMINISTRATOR STATE CLAIM ADMINISTRATOR POSTAL CODE CLAIM ADMINISTRATOR'S CLAIM NO. EMPLOYER FEIN INSURED NAME EMPLOYER NAME EMPLOYER ADDRESS LINE 1 EMPLOYER ADDRESS LINE 2 EMPLOYER CITY EMPLOYER STATE EMPLOYER POSTAL CODE SELF INSURED INDICATOR SIC CODE INSURED REPORT NUMBER INSURED LOCATION NUMBER POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE OF INJURY TIME OF INJURY POSTAL CODE OF INJURY SITE EMPLOYER'S PREMISES INDICATOR NATURE OF INJURY CODE PART OF BODY INJURED CODE CAUSE OF INJURY CODE ACCIDENT DESCRIPTION/CAUSE INITIAL TREATMENT DATE REPORTED TO EMPLOYER DATE REPORTED TO CLAIMS SOCIAL SECURITY NUMBER EMPLOYEE LAST NAME EMPLOYEE FIRST NAME EMPLOYEE MIDDLE INITIAL EMPLOYEE ADDRESS LINE 1 EMPLOYEE ADDRESS LINE 2 EMPLOYEE CITY EMPLOYEE STATE EMPLOYEE POSTAL CODE EMPLOYEE PHONE DATE OF BIRTH GENDER CODE MARITAL STATUS CODE NUMBER OF DEPENDENTS DATE DISABILITY BEGAN EMPLOYEE DATE OF DEATH EMPLOYMENT STATUS CODE CLASS CODE OCCUPATION DESCRIPTION DATE OF HIRE WAGE WAGE PERIOD NUMBER OF DAYS WORKED DATE LAST DAY WORKED FULL WAGES PAID FOR DATE OF INJURY SALARY CONTINUED INDICATOR DATE OF RETURN TO WORK NAMES TRNS_SET_ID MTC MTC_DT JURIS AGCY_CLM_NBR INSURER_FEIN INSURER_NAME TPA_FEIN TPA_NAME CLM_ADM_ADDR_1 CLM_ADM_ADDR_2 CLM_ADM_CITY CLM_ADM_STATE CLM_ADM_POSTAL CLM_ADM_CLM_NBR EMPLR_FEIN INSD_NAME EMPLR_NAME EMPLR_ADDR_1 EMPLR_ADDR_2 EMPLR_CITY EMPLR_STATE EMPLR_POSTAL SELF_INSD_IND SIC_CODE INSD_RPT_NBR INSD_LOC_NBR POL_NUM POL_EFF POL_EXP DT_INJ TIME_INJ POSTAL_INJ_SITE EMPLR_PREMIS_IND NATURE_INJ_CD PART_BODY_INJ_CD CAUSE_INJ_CD ACC_DESC_TXT INIT_TREAT_CD DT_REP_EMPLR DT_REP_CLM_ADM SSN EE_L_NAME EE_F_NAME EE_MI EE_ADDR1 EE_ADDR2 EE_CITY EE_STATE EE_POSTAL EE_PHONE DT_BIRTH GENDER_CD MARITAL_CD NBR_DEPS DT_DIS_BGN EE_DT_DEATH EMPLYMNT_STATUS CLASS_CD OCCUP_DESCR DT_HIRE WAGE WAGE_PERIOD NBR_DYS_WKD DT_LAST_DY_WED RULL_WAGES_L_DAY SAL_CONT_IND DT_RTW TECH REQ. NM M M M C O M M C C C O C C C M M O M M O M M M M C O O O O O M O M O M M M M M M M M M M O M O M M M O M M M C C C O C M M M M O O O C C ELEM ENT POSITI ON 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 LNG 3 2 8 2 25 9 30 9 30 30 30 15 2 9 25 9 30 30 30 30 15 2 9 1 6 10 15 30 8 8 8 4 9 1 2 2 2 150 2 8 8 9 30 15 1 30 30 15 2 9 10 8 1 1 2 8 8 2 4 30 8 11 2 1 8 1 1 8 FORMAT F_TYPE A/N A/N DATE A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N DATE DATE DATE HHMM A/N A/N A/N A/N A/N A/N A/N DATE DATE A/N A/N A/N A/N A/N A/N A/N A/N A/N A/N DATE A/N A/N A/N DATE DATE A/N A/N A/N DATE (11) 9,2 A/N A/N DATE A/N A/N DATE POSITION BEG 1 4 6 14 16 41 50 80 89 119 149 179 194 196 205 230 239 269 299 329 359 374 376 385 386 392 402 417 447 455 463 471 475 484 485 487 489 491 641 643 651 659 668 698 713 714 744 774 789 791 800 810 818 819 820 822 830 838 840 844 874 882 893 895 896 904 905 906 END 3 5 13 15 40 49 79 88 118 148 178 193 195 204 229 238 268 298 328 358 373 375 384 385 391 401 416 446 454 462 470 474 483 484 486 488 490 640 642 650 658 667 697 712 713 743 773 788 790 799 809 817 818 819 821 829 837 839 843 873 881 892 894 895 903 904 905 913

JURISDICTION CLAIM

INSURED

POLICY

ACCIDENT

CLAIMANT

EMPLOYMENT

M = Mandatory C=Required O = Optional

Workers' Compensation Administration 19

Data Collection Requirements

EDI Guide Book (December 2007)

EVENT TABLE
Report Type 148 MTC 00

TABLE B NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION Revised 12/15/06
MTC Description Original Report Prod Level P Report Trigger Criteria O = New Claim O = Cum. Med. O = Lost Time O = Employee death > $300 > 7 days Value Report Due Criteria C = Date of compensability C = Date HCP was initially paid C = Date employer was notified C = Date of Death Report Value <= 3 days <= 90 days <= 10 days < = 10 days Resend original report w/new SSN/DOI Notes

01

Cancellation

P

O = Incorrect SSN/DOI O = Change of mandatory field elements O = Claim is acquired by new claims administrator O = Change of nonmandatory fields

N/A

C = Immediate

02

Change Acquired/ Unallocated Correction

P

N/A

C = Immediate C = Claim_Adm notified C = Immediate < = 10 days

AU CO

P P

O = Occurrence C = Criteria

Workers' Compensation Administration 20

Data Collection Requirements

EDI Guide Book (December 2007)

TABLE C 148 Record Requirements (Technical/Business Edits)
Data #
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15

MTC Requirements Field Name 00
TRANSACTION SET ID MAINTENANCE TYPE CODE MAINT. TYPE CODE DATE JURISDICTION AGENCY CLAIM NUMBER INSURER FEIN INSURER NAME THIRD PARTY ADMIN FEIN THIRD PARTY ADMIN NAME CLAIM ADMIN ADDRESS LINE 1 CLAIM ADMIN ADDRESS LINE 2 CLAIM ADMIN CITY CLAIM ADMIN STATE CLAIM ADMIN POSTAL CODE CLAIM ADMIN CLAIM NUMBER EMPLOYER FEIN INSURED NAME EMPLOYER NAME EMPLOYER ADDRESS LINE 1 EMPLOYER ADDRESS LINE 2 EMPLOYER CITY EMPLOYER STATE EMPLOYER POSTAL CODE SELF INSURED INDICATOR NAICS CODE INSURED REPORT NUMBER INSURED LOCATION NUMBER POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE DATE OF INJURY TIME OF INJURY POSTAL CODE OF INJURY SITE EMPLOYER PREMISES INDICATOR NATURE OF INJURY CODE PART OF BODY INJURY CODE CAUSE OF INJURY CODE ACCIDENT DESCRIPTION / CAUSE INITIAL TREATMENT M M M C O M M C C C O C C C M

Values Required 01
M M M C O M M C C C O C C C M

Notes/ Problems/ Errors

AU
M M M C O M M C C C O C C C M

02,CO
M M M C O M M C C C O C C C M

04
M M M C O M M C C C O C C C M 9 DIGIT NUMERIC THIS NUMBER IS UNIQUE AND MUST NOT CHANGE DURING PROCESS OF A49 RECORD EMPLOYER FEIN MAY BE CHECKED WITH AGENCY'S INFORMATION 9 DIGIT NUMERIC THIS NUMBER IS COMPARED WITH ADM FILE (REQUIRED IF NOT NULL) 9 DIGIT NUMERIC 148 00,01,AU,02,CO,04 (CCYYMMDD) NM 00 MUST BE ON FILE BEFORE OTHER MTCs ARE PROCESSED DATE IS AFTER INJURY DATE THIS NUMBER IS NOT ASSIGNED UNTIL A49(IP) OR (PY) IS ACCEPTED ** THIS NUMBER IS COMPARED WITH TRADING PARTNER INSURER FILE

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

M O M M O M M M M C O O O O O M O M O M

M O M M O M M M M C O O O O O M O M O M

M O M M O M M M M C O O O O O M O M O M

M O M M O M M M M C O O O O O M O M O M

M O M M O M M M M C O O O O O M O M O M

9 DIGIT NUMERIC

6 DIGITS POSSIBLE

THIS FIELD MUST BE "Y" IF SELFINSURED SEE NAICS NAMUAL/MUST EXIST IF ZIP SENT **

CCYYMMDD

DATE IS AFTER DATE OF HIRE AND AFTER BIRTH DATE. "TE" IS GENERATED FOR DATE < 10 YEARS. *PRIMARY KEY COMPARED WITH ALL POSTAL CODES IN N.M. "TE" IS GENERATED FOR OUT OF STATE POSTAL CODES

9 DIGIT NUMERIC

SEE FIGURE B

36

M

M

M

M

M

SEE FIGURE A

35 36 39

M M M

M M M

M M M

M M M

M M M

SEE FIGURE C

2 DIGIT CODE MUST BE VALID WITHIN THE NCCI VALUES ASSIGNED 2 DIGIT CODE MUST BE VALID WITHIN THE NCCI VALUES ASSIGNED 2 DIGIT CODE MUST BE VALID WITHIN THE NCCI VALUES ASSIGNED

00, 01, 02, 03, 04, 05

CODE MUST BE WITHIN ACCEPTABLE VALUES

Workers' Compensation Administration 21

Data Collection Requirements Data #
40

EDI Guide Book (December 2007) MTC Requirements 00
M

Field Name
DATE REPORTED TO EMPLOYER DATE REPORTED TO CLAIMS ADMINISTRATOR

01
M

AU
M

02,CO
M

04
M

Values Required
CCYYMMDD

Notes/ Problems/ Errors
DATE IS AFTER OR ON DATE OF INJURY DATE IS AFTER OR ON DATE OF INJURY. (Should be updated for date employer notifies Administrator on Compensability) THIS, WITH DATE OF INJURY, UNIQUELY DETERMINES REPORT. DUPLICATES ARE SENT BACK. * PRIMARY KEY REPORT IS GENERATED TO CHECK VALID SSN WITH NAME

41

M

M

M

M

M

CCYYMMDD

42

SOCIAL CECURITY NUMBER

M

M

M

M

M

9 DIGIT NUMERIC

43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68

EMPLOYEE LAST NAME EMPLOYEE FISRT NAME EMPLOYEE MIDDLE INITIAL EMPLOYEE ADDRESS LINE 1 EMPLOYEE ADDRESS LINE 2 EMPLOYEE CITY EMPLOYEE STATE EMPLOYEE POSTAL CODE EMPLOYEE TELEPHONE # DATE OF BIRTH GENDER CODE MARITAL STATUS CODE NUMBER OF DEPENDENTS DATE DISABILITY BEGAN EMPLOYEE DATE OF DEATH EMPLOYMENT STATUS CODE CLASS CODE OCCUPATION DESCRIPTION DATE OF HIRE WAGE WAGE PERIOD NUMBER OF DAYS WORKED DATE LAST DAY WORKED FULL WAGES PAID FOR SALARY CONTINUED INDICATOR DATE RETURNED TO WORK

M M O M O M M M O M M M C C C O C M M M M O O O C C

M M O M O M M M O M M M C C C O C M M M M O O O C C

M M O M O M M M O M M M C C C O C M M M M O O O C C

M M O M O M M M O M M M C C C O C M M M M O O O C C

M M O M O M M M O M M M C C C O C M M M M O O O C C CCYYMMDD 05, 04, 01, 02 CCYYMMDD CCYYMMDD CCYYMMDD SEE VALUES DEFINED CCYYMMDD M, F, U U, M, S, K

MUST BE BEFORE DATE OF HIRE CODE MUST BE WITHIN ACCEPTABLE VALUES CODE MUST BE WITHIN ACCEPTABLE VALUES DATE IS ON OR AFTER DATE OF INJURY OR ILLNESS *** DATE IS ON OR AFTER DATE OF INJURY OR ILLNESS CODE MUST BE WITHIN ACCEPTABLE VALUES OR NULL CODES ARE ASSIGNED BY NCCI CODE STRUCTURE TEXTUAL INFORMATION MUST BE PROVIDED MUST BE PRIOR TO DATE OF INJURY MUST BE >= 0.00 CODE MUST BE WITHIN ACCEPTABLE VALUES

IS "Y" IF WAGE WAS PAID IN LIEU OF BENEFITS

** To change as of 1/1/2002 *** Must be completed for lost-time claims

Workers' Compensation Administration 22

Data Collection Requirements CALL FOR DETAILED CLAIM INFORMATION Instruction Manual Effective 09/23/2002 Code Part of Body I. HEAD 10 11 12 13 14 15 16 17 18 19 Multiple Head Injury Skull Brain Ear(s) Eye(s) Nose Teeth Mouth Other Facial Soft Tissue Facial Bones II. NECK 20 21 22 23 24 25 26 Multiple Injury Vertebrae Disc Spinal Cord Larynx Soft Tissue Trachea

Figure A

EDI Guide Book (December 2007) SECTION 5 PAGE 7 Original Printing

TABLE 7: PART OF BODY CODES
Code Part of Body IV. TRUNK 40 41 42 43 44 45 46 47 48 49 Multiple Trunk Upper Back Area (Thoracic Area) Lower Back Area (Inc: Lumbar & Lumbo-Sacral) Disc Chest (Inc: Ribs, Sternum & Soft Tissue) Sacrum & Coccyx Pelvis Spinal Cord Internal Organs Heart V. LOWER EXTREMITIES 50 51 52 53 54 55 56 57 Multiple Lower Extremities Hip Upper Leg Knee Lower Leg Ankle Foot Toe(s) Great Toe

III. UPPER EXTREMITIES 30 31 32 33 34 35 36 37 38 39 Multiple Upper Extremities Upper Arm (Inc: Clavicle & Scapula) Elbow Lower Arm Wrist Hand Finger(s) Thumb Shoulder(s) Wrist and Hands

58

VI. MULTIPLE BODY PARTS 60 61 62 63 64 65 66 90 91 Lungs Abdomen (Inc: Groin) Buttocks Lumbar and/or Sacral Vertebrae (NOC Trunk) Artificial Appliance Insufficient Info to Properly ID No Physical Injury Multiple Body Parts Body Systems & Multiple Body Parts

99 Whole Body Copyright 1995, National Council on Compensation Insurance, Inc. All rights reserved. Reprinted with permission.

Workers' Compensation Administration 23

Data Collection Requirements CALL FOR DETAILED CLAIM INFORMATION Instruction Manual Effective 09/23/2002 Code Nature of Injury I. SPECIFIC INJURY 01 02 03 04 07 10 13 16 19 22 25 28 30 31 32 34 36 37 40 41 42 43 46 47 49 52 53 54 55 58 No Physical Injury Amputation

Figure B

EDI Guide Book (December 2007) SECTION 5 PAGE 7 Original Printing

TABLE 8: NATURE OF INURY CODES
Code Nature of Injury II. OCCUP. DISEASE OR CUM. INJURY 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 Dust Disease, NOC (All Other Pneumoconiosis) Asbestosis Area (Thoracic Area) Black Lung Byssinosis Silicosis (Ribs, Sternum & Soft Tissue) Respiratory Disorders (Gases, Fumes, Chemicals, etc.) Poisoning, Chemical (Other than Metal) Poisoning, Metal Dermatitis Mental Disorder Radiation All Other Occupation Disease Injury, NOC Loss of Hearing Contagious Disease Cancer AIDS* VDT Related Disease* Mental Stress Carpal Tunnel Syndrome Hepatitis C All Other Cumulative Injuries, NOC

Angina Pectoris (Assoc. w/Heart Disease) Burn Concussion Contusion Crushing Dislocation Electric Shock Enucleation (Removal of, e.g: Tumor, Eye, etc) Foreign Body Fracture Freezing Hearing Loss or Impairment Heat Prostration Hernia Infection Inflammation Laceration Myocardial Infarction (Heart Attack) Poisoning, General (Not OD or Cumulative) Puncture Rupture Severance Sprain Strain Syncope Asphyxiation Vascular Loss Vision Loss

III. MULTIPLE INJURIES 90 91 Multiple - Physical Injuries Only Multiple Injuries, both Physical & Psychological

59 All Other Specific Injuries, NOC *Effective for claims having accident dates of 1/1/90 and subsequent. Copyright 1995, National Council on Compensation Insurance, Inc. All rights reserved. Reprinted with permission.

Workers' Compensation Administration 24

Data Collection Requirements CALL FOR DETAILED CLAIM INFORMATION Instruction Manual Effective 09/23/2002
Code 01 02 03 04 05 06 07 08 09 11 14 84 Cause of Injury

Figure C

TABLE 9: CAUSE OF INJURY CODES
Code 52 53 54 55 56 57 58 59 61 97 60 Cause of Injury

EDI Guide Book (December 2007) SECTION 5 PAGE 8 Original Printing

I. BURN OR SCALD HEAT OR COLD EXPOSURE Chemicals Host Objects or Substances Temperature Extremes File or Flame Steam or Hot Fluids Dust, Gases, Fumes or Vapors Welding Operations Radiation Contact With, NOC Cold Objects or Substances Abnormal Air Pressure Electrical Current II. CAUGHT IN OR BETWEEN

VI. STRAIN OR INJURY BY Continual Noise Twisting Jumping Holding or Carrying Lifting Pushing or Pulling Reaching Using Tool or Machinery Wielding or Throwing Repetitive Motion Strain or Injury by, NOC VII. STRIKING AGAINST OR STEPPING ON Moving Parts of Machine Objects Being Lifted or Handled Sanding, Scraping, Cleaning Operations Stationary Object Stepping on Sharp Object Striking Against or Stepping On, NOC VIII. STRUCK OR INJURED BY

65 66 67 68 69 70

10 12 13 20

Machine or Machinery Object Handled Caught In, Under or Between, NOC Collapsing Materials (Slides of Earth) III. CUT, PUNCTURE, SCRAPE INJURED BY Broken Glass Hand Tool, Utensil (Not Powered) Object Being Lifted or Handled Powered Hand Tool, Appliance Caught, Puncture, Scrape, NOC IV. FALL OR SLIP From Different Level (Elevation) From Ladder or Scaffolding From Liquid or Grease Spills Into Openings On Same Level Slipped, Did Not Fall On Ice or Snow On Stairs Fall, Slip, Trip, NOC V. MOTOR VEHICLE Crash of Water Vehicle Crash of Rail Vehicle Collision or Sideswipe with Another Vehicle Collision with a Fixed Object Crash of Airplane Vehicle Upset Motor Vehicle, NOC

15 16 17 18 19

74 75 76 77 78 79 80 85 86 81

Fellow Worker or Patient Falling or Flying Object Hand Tool or Machine in Use Motor Vehicle Moving Parts of Machine Object Being Lifted or Handled Object Handled by Others Animal or Insect Explosion or Flare back Struck or Injured, NOC IX. RUBBED OR ABRADED BY

25 26 27 28 29 30 32 33 31

94 95

Repetitive Motion Rubbed or Abraded, NOC X. MISCELLANEOUS CAUSES Absorption, Ingestion, or Inhalation, NOC Foreign Matter (Body) in Eye(s) Person in Act of a Crime Other than Physical Cause of Injury Mold Terrorism Cumulative, NOC Other - Miscellaneous, NOC

40 41 45 46 47 48 50

82 87 89 90 91 96 98 99

Copyright 1995, National Council on Compensation Insurance, Inc. All rights reserved. Reprinted with permission.

Workers' Compensation Administration 25

Data Collection Requirements

EDI Guide Book (December 2007)

APPENDIX 2 1. .................................................................... EDI Transaction Flow Chart 2. .................................................................... Table D: Event Table for A49 Record 3 ..................................................................... IAIABC Subsequent Report Release 1A (A49 Record) 4 ..................................................................... Transmission Header Record 5 ..................................................................... Table E: Detail Acknowledgment 6 ..................................................................... Table F: Trailer Record 7 ..................................................................... Table G: Data Element Mapping Table A49 Flat File 8 ..................................................................... EDI Trading Partner Profile

Workers' Compensation Administration 26

Data Collection Requirements EDI Transaction Flow Chart
Orig. 148? YES YES TSI=148 MTC=00 TSI=148 MTC=01 Delete current 148? NO Change record values? YES TSI=148 MTC=02 NO Acquire claim? NO

EDI Guide Book (December 2007)

NO

Correct values?

YES TSI=148 MTC=AU

YES TSI=148 MTC=CO

STOP

NO

Payment made?

YES NO

NO

Initial Payment?

YES

Medical only/other?

NO

Initial Indem?

YES TSI=A49 MTC=PY CLM_TYPE=M,N CLM_STS=O

YES TSI=A49 MTC=IP CLM_TYPE=I CLM STS=O

STOP

NO NO NO

Final payment?

NO

Change/ correction?

Became Indem? YES TSI=A49 MTC=IP CLM_TYPE=L CLM_STS=O

Benefit change? YES TSI=A49 MTC=CB CLM_TYPE=I,L CLM_STS=O

YES TSI=A49 MTC=FN CLM_TYPE=M CLM STS=C,X

YES TSI=A49 MTC=02,CO CLM_TYPE=M CLM_STS=O

NO NO Acquired? NO Correction?

Change values? YES TSI=A49 MTC=02

YES TSI=A49 MTC=AP

YES TSI=A49 MTC=CO

Closing indem. Payment?

NO

Note: for each transaction box, send record to WCA. Revised 9/23/96

YES TSI=A49 MTC=FN CLM_TYPE=I,L CLM STS=C X

Workers' Compensation Administration 27

Data Collection Requirements

EDI Guide Book (December 2007)

Table D
Report Type A49

Event Table for A49 Record Revised: 12/15/06
Value > $1.00 Report Due Criteria Date from first indemnity payment Date from first indemnity payment Date from first payment to HCP Date from claim admin. notification Payment changes from one disability type to another (e.g., TTD to PPD) Value <= 10 days

MTC IP

MTC Description Initial Payment

Report Trigger Criteria Claim type = I O = cum. Indem. $ Claim Type = L O = Cum. Indem. $ Note Prior "PY" has been filed.

> $1.00

<= 10 days

PY

Payment Report

Claim Type = M, N O = cum. Meds. or other payments O = When claim admin. is notified of change Claim Type = I, L O = First change in payment adjustment code Claim type = I, L, M, N O = Final payment of indemnity benefits O = Change of mandatory field elements O = Change of mandatory fields

> $300.00

<= 90 days

AP

Acquired Payment

<= 10 days

CB

Change in benefit type

Days from report trigger

<= 30 days

FN 02 CO

Final Notice Change Correction

Days from report trigger N/A C = Immediate C = Immediate

<= 30 days

O = Occurrence C = Criteria

Workers' Compensation Administration 28

Data Collection Requirements
IAIABC SUBSEQUENT REPORT RELEASE 1A (A49 RECORD)
11/2/92 GROUPING TRANSACTION STATE FIELDS/DEFINED ELEMENTS TRANSACTION SET ID MAINTENANCE TYPE CODE MAINTENANCE TYPE CODE DATE JURISDICTION CLAIM ADMINISTRATOR JURISDICTION INSURER FEIN THIRD PARTY ADMINITRATOR FEIN CLAIM ADMININISTER POSTAL CODE CLAIMANT SOCIAL SECURITY NUMBER NUMBER OF DEPENDENTS PRE-EXISTING DISABILITY DATE DISABILITY BEGAN DATE OF MAX MEDICAL IMPROVEMENT RETURN TO WORK QUALIFIER DATE OF RETURN/RELEASE TO WORK EMPLOYEEDATE OF DEATH WAGE WAGE WAGE PERIOD NUMBER OF DAYS WORKED SALARY CONTINUED INDICATOR ACCIDENT DATE OF INJURY INSURED REPORT NUMBER CLAIM ADMINISTRATOR'S CLAIM NUMBER AGENCY CLAIM NUMBER CLAIM STATUS CLAIM STATUS CLAIM TYPE AGREEMENT TO COMPENSATE CODE DATE OF REPRESENTATION PAYMENTS VARIABLE SEGMENT COUNTERS LATE REASON CODE NUMBER OF PERMANENT IMPAIRMENTS NUMBERR OF PAYMENTS/ADJUSTMENTS NUMBER OF BENEFIT ADJUSTMENTS NUMBER OF PTD/REDUCED EARNINGS/RECOVERIES NUMBER OF DEATH DEP/PAYEE RELATIONSHIPS VARIABLE SEGMENTS PERMANENT IMPAIRMENTS Occurs NRB. PERMANENT IMPAIRMENTS times. PERMANENT IMPAIRMENT BODY PART CODE PERMANENT IMPAIRMANT PERCENT PYMNTS/ADJS Occurs NBR. of PYMNT/ADJS times. PYMNT/ADJ CODE PYMNT/ADJ PAID TO DATE PYMNT/ADJ AMOUNT PYMNT/ADJ START DATE PYMNT/ADJ END DATE PYMNT/ADJ WEEKS PAID PYMNT/ADJ DAYS PAID PYMNT/ADJ_CD PYMNT/ADJ_PTD PYMNT/ADJ_AMT PYMNT/ADJ_START PYMNT/ADJ_END PYMNT/ADJ_WKS PYMNT/ADJ_DAYS IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC C C O C O C C PERM_IMP_BDY_PT PERM_IMP_PCNT IAIABC IAIABC O O NAMES TRNS_SET_ID TRNS_SET_PC TRNS_SET_DT JURIS CLM_ADM_CD IND_ADJ_CD CLM_ADM_POSTAL SSN NBR_DEPS PRE_EXIS_DIS DT_DIS_BGN DT_MED_MAX RTW_QUAL DT_RTN/RLSE_WK DT_DEATH WAGE WAGE_PERIOD NBR_DYS_WKD SAL_CONT_IND DT_INJ INSD_RPT_NBR CLM_ADM_CLM_NBR AGCY_CLM_NBR CLM_STATUS CLM_TYPE AGRMNT_COMP_CD DT_REP LT_RSN_CD NBR_PERM_IMP NBR_PYMNTS/ADJS NBR_BEN_REDUC NBR_PTD/RE/RECOV NBR_DEATH_RELAT ELEMENT SOURCE ANSI 329 ANSI BGN01 ANSI BGN03 IAIABC IAIABC IAIABC IAIABC DCI Fld 10 IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC ANSI DIS IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC IAIABC NM REQ M M M O M C O M O O M C O* O* C M M O C M O M O M M O O O M M M M M

EDI Guide Book (December 2007)

MAX OCC 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 6 1 1 10 1 1 1 1 1 1 1 10

IAIABC FORMAT 3 A/N 2 A/N DATE 2 A/N 9 A/N 9 A/N 9 A/N 9 A/N 2N 1 A/N DATE DATE 1 A/N DATE DATE '$9.2 2 A/N 1N 1 A/N DATE 25 A/N 25 A/N 25 A/N 1 A/N 1 A/N 1 A/N DATE 2 A/N 2N 2N 2N 2N 2N

POSITIONS BEG 1 4 6 14 16 25 34 43 52 54 55 63 71 72 80 88 99 101 102 103 111 136 161 186 187 188 189 197 199 201 203 205 207 END 3 5 13 15 24 33 42 51 53 54 62 70 71 79 87 98 100 101 102 110 135 160 185 186 187 188 196 198 200 202 204 206 208

3 A/N 3.2 N

1 4

3 8

3 A/N '$9.2 '$9.2 DATE DATE 4N 1N

1 4 15 26 34 42 46

3 14 25 33 41 45 46

BENEFIT REDUCTIONS Occurs NBR. BENEFIT REDUCTIONS times. BENEFIT REDUCTION CODE BENEFIT REDUCTION AMOUNT BENEFIT REDUCTION START DATE PTD/REDUCED EARNINGS/RECOVERIES PTD/REDUCED EARNINGS/RECOV CODE PTD/REDUCED EARNINGS/RECOV AMOUNT DEATH DEP/PAYEE RELATIONSHIPS DEPENDENT/PAYEE RELATIONSHIP NEW MEXICO WORKERS' COMPENSATION REQUIREMENTS: DEP/PAYEE_RELAT IAIABC PTD/RE/RECOV_CD PTD/RE/RECOV_AMT IAIABC IAIABC C C O BEN_REDUC_CD BEN_REDUC_AMT BEN_START_DT IAIABC IAIABC IAIABC O O O

1 1 1 25 1 1 12 1

4 A/N '$9.2 DATE

1 5 16

4 15 23

3 A/N '$9.2

1 4

3 14

2 A/N

1

2

(M) = Mandatory, (C) = Required, (O) = Optional

Workers' Compensation Administration 29

Data Collection Requirements

EDI Guide Book (December 2007)

TRANSMISSION HEADER RECORD
TABLE E

GROUP

DATA ELEMENT NAME

VALUES

TEC REQ NM

LENGTH

Format F_TYPE

POSITION

BEG TRANSACTION SET ID SENDER ID SENDER FEIN FILLER (reserved) SENDER POSTAL CODE RECEIVER ID RECEIVER FEIN FILLER (RESERVED) RECEIVER POSTAL CODE DATE TRANSMISSION SENT (ccyymmdd) M M TRANSMISSION HEADER RECORD HD1 M M 3 25 9 7 9 25 9 7 9 A/N A/N A/N A/N A/N A/N A/N A/N A/N DATE 54 29 1 4

END 3 28

53

61

TIME TRANSMISSION SENT

(hhmmss)

M

TIME

62

67

ORIGINAL TRANSMISSION DATE

(ccyymmdd)

O

DATE

68

75

ORIGINAL TRANSMISSION TIME

(hhmmss)

O

TIME

76

81

TEST/PRODUCTION INDICATOR

M

1

A/N

82

82

TEST PRODUCTION INTERCHANGE VERSION ID

T P M 5 A/N 83 87

TRANSMISSION TYPE CODES 148,A49,POC, AK1 RELEASE NUMBER

3

2

Workers' Compensation Administration 30

Data Collection Requirements

EDI Guide Book (December 2007)

DETAIL ACKNOWLEDGMENT
Table F
POSITION TECH REQ LENGTH FORMAT VALUES NM F_TYPE BEG TRANSACTION SET ID ACKNOWLEDGEMENT DETAIL RECORD RECORD SEQUENCE NBR DATE PROCESSED TIME PROCESSED CLAIM ADMINISTRATOR CODE CLAIM ADMINISTRATOR POSTAL CODE INDEPENDENT ADJUSTOR CODE ACKNOWLEDGEMENT TRANSACTION SET ID FIRST REPORT OF INJURY SUBSEQUENT REPORT APPLICATION ACKNOWLEDGEMENT CODE TRANSACTION ACCEPTED TRANSACTION REJECTED TRANSACTION ACCEPTED WITH ERRORS INSURED REPORT NUMBER CLAIM ADJUSTOR CLAIM NUMBER AGENCY CLAIM NUMBER TRANSACTION SET PURPOSE CODE (FROM ORIGINGAL TRANS) TRANSACTION SET DATE REQUEST CODE (PURPOSE) NONE CONTACT SENDER FREE FORM NUMBER OF ERRORS ERROR CODE ELEMENT NUMBER ELEMENT ERROR NUMBER VARIABLE SEGMENT NUMBER 4 3 2 N N N 209 213 216 212 215 217 0 1 0 M 60 2 A/N N 147 207 206 208 TA TR TE C C C M M 0 3 25 25 25 2 A/N A/N A/N A/N DATE A/N 59 84 109 134 136 144 83 108 133 135 143 146 148 A49 M 2 A/N 57 58 AK1 M M M M M C M 9 9 9 3 9 N DATE TIME A/N A/N A/N A/N 4 13 21 27 36 45 54 12 20 26 35 44 53 56 M 3 A/N 1 END 3

GROUP

DATA ELEMENT NAME

Workers' Compensation Administration 31

Data Collection Requirements

EDI Guide Book (December 2007)

TRAILER RECORD
Table G TECH REQ GROUP TRANSACTION SET ID TRANSMISSION TRAILER DETAIL RECORD COUNT TR1 M 9 N 4 12 DATA ELEMENT NAME VALUES NM M LENGTH 3 F_TYPE A/N BEG 1 END 3 FORMAT POSITION

Implementation Notes: A trailer Record will end each transmission Definitions: Detail Record Count: This is the number of detail records contained in transmission. It does not include a header.

Workers' Compensation Administration 32

Data Collection Requirements Data Element Mapping Table A49 Flat File Revision Date 11/20/96
Data # 1 2 IAIABC Data Fields Transaction Set ID Maintenance Type Code Format 3 A/N 2 A/N NM Req. M M Valid Values A49 IP,CB,FN,PY,AP, CO,02,S8

EDI Guide Book (December 2007)

3 4 6 8 14 42 55 69 56 70 71 72 57 62 63 64 67

Maintenance Type Code Date Jurisdiction Insurer FEIN Third Party Admin FEIN Claim Administrator Postal Code Social Security Number Number of Dependents Pre-existing Disability Date Disability Began Date of Maximum Medical Improvement Return to Work Qualifier Date of Return/Release to Work Employee Date of Death Wage Wage_Period Number of Days Worked Salary Continued Indicator

DATE 2 A/N 9 A/N 9 A/N 9 A/N 9 A/N 2N 1 A/N DATE DATE 1 A/N DATE DATE $9.2 1 A/N 1N 1 A/N

M O M C O M O O M C C* C* O* O M M O O

Date Greater than DOI NM

Processing Notes All records have TSI = A49 Note: IP or PY must be processed prior to any other MTC codes. If PY is processed first and claim turns into an indemnity claim, then an IP is sent with a claim type = L. A CB is processed when the disability payment changes. For IP the MTC date is the first payment date. For CB the MTC date is the date the first payment is made for the new disability. For FN the MTC date is the date that the last indemnity payment was made to the injured worker.

Primary Field Y,N Date >= DOI Date >= DOI 1, 2, 5, 6

This SSN must be the same SSN sent for the First Report of Injury or Illness. Note: The SSN and DOI are matched with the FROI.

This date must be completed for PPD benefits being paid. If RTW Date then Qualifier must exist. If not, error: 020 For RTW Qualifier = 1 or 2 For RTW Qualifier = 5 or 6 If death benefits or funeral expenses are greater than zero, then this field must not be null. If disability payments are being paid, then the wage must be greater than zero.

Date >= DOI Wage > 0.00 1 = weekly 4 = monthly 1, 2, 3, 4, 5, 6 Y, N

31 26 15 5 73 74 75 76 77

Date of Injury Insured Report Number Claims Administrator's Claim Number Agency Claim Number Claim Status Claim Type Agreement to Compensate Code Date of Representation Late Reason Code PAYMENT/ ADJUSTMENTS

DATE 25 A/N 25 A/N 25 A/N 1 A/N 1 A/N 1 A/N DATE 2 A/N

M O M C M M O O O

Primary Field

This field is indicated as "Y" if the salary of the injured or ill worker is continuing to be paid instead of disability payments for the lost time incurred. The DOI field with the SSN field is matched with the First Report of Injury or Illness with the same information before assigning a case number. If a First Report of Injury or Illness is not found for the same SSN and DOI the report is rejected. This number is checked with suspense to ensure correct record.

Wca_number > YY50000 O, C, R, X M, I, L, N Y, N L1 - L9, LL, C1,D1 - D6 VARIABLE SEGMENT 050, 550, 051, 551

This agency claim number is returned to the claim administrator after the PY or IP is accepted by the WCA. Claim type "N" or "M" is used for MTC = PY only. For medical-only claims filed as PY originally and becoming indemnity, an IP is sent with a claim type = I.

85 86 87 88 89 90 91 85 86 87 88 89 90

(Disability = TTD) Paymnt-Adjust-Code Pymnt/adj Paid-to-Date Pymnt/adj Weekly Amt Pymnt/adj Start Date Pymnt/adj End Date Pymnt/adj Weeks Pymnt/adj Days (Disability = TPD) Pymnt/adj Code Pymnt/adj Paid-to-Date Pymnt/adj Weekly Amt Pymnt/adj Start Date Pymnt/adj End Date Pymnt/adj Weeks

3 A/N $9.2 $9.2 DATE * DATE * 4N 1N 3 A/N $9.2 $9.2 DATE * DATE * 4N

C C O C O C C C C O C O C

070, 570

For the payment of Temporary Total (TTD) indemnity benefits this field must be completed as payment adjustment code = 050, or 550, or 051, or 551. If TTD benefits are being paid then Paid-to-Date > 0.00 and Payment Start Date = eighth day of disability for an IP where benefits are being paid for less than 28 days. In New Mexico for benefits paid for 28 consecutive days form the Date of Injury, the payment adjustment start date = the Date of Injury (DOI). This number must be completed for the total duration of the disability payment. This number must be completed for the total duration of the disability payment. For the Temporary Partial (TPD) payment of indemnity benefits this field must be completed as payment adjustment code - 70 or 570. If TPD benefits are being paid then Paid-To-Date > 0.00 and the return to work date must be completed. If the TPD benefits are the first benefits to be paid to the injured worker, then for the MTC = IP, the payment adjustment start date = the first date on which TPD payment is occurring. This number must be completed for the total duration of the disability payment.

Workers' Compensation Administration 33

Data Collection Requirements
Data # 91 IAIABC Data Fields Pymnt/adj Days Format 1N NM Req. C Valid Values

EDI Guide Book (December 2007)
Processing Notes This number must be completed for the total duration of the disability payment. For the Permanent Partial (PPD) payment of indemnity benefits this field must be completed as payment adjustment code = 030 or 530, or 040, or 540, or 090, or 590. If PPD benefits are being paid then PaidTo-Date > 0.00 and the maximum medical improvement date must be completed. If the PPD benefits are the first benefits to be paid to the injured worker, then for the MTC = IP, the payment adjustment start date = the first date on which PPD payment is beginning.

85

(Disability = PPD) Paymnt-Adjust-Code

3 A/N

C

030, 530, 040, 540, 090, 590

86 87 88 89 90 91

Pymnt/adj Paid-to-Date Pymnt/adj Weekly Amt Pymnt/adj Start Date Pymnt/adj End Date Pymnt/adj Weeks Pymnt/adj Days

$9.2 $9.2 DATE * DATE * 4N 1N

C O C O C C This number must be completed for the total duration of the disability payment. This number must be completed for the total duration of the disability payment. For the Permanent Total (PTD) payment of indemnity benefits this field must be completed as payment adjustment code = 020, 0r 520, or 021, 0r 521. If PTD benefits are being paid then Paid-To-Date > 0.00. If the PTD benefits are the first benefits to be paid to the injured worker, then for the MTC = IP, the payment adjustment start date = the first date on which PTD payment is beginning.

85

(Disability = PTD) Paymnt-Adjust-Code

3 A/N

C

020, 520, 021, 521

86 87 88 89 90 91

Pymnt/adj Paid-to-Date Pymnt/adj Weekly Amt Pymnt/adj Start Date Pymnt/adj End Date Pymnt/adj Weeks Pymnt/adj Days

$9.2 $9.2 DATE * DATE * 4N 1N

C O C O C C This number must be completed for the total duration of the disability payment. This number must be completed for the total duration of the disability payment. For the Death (DTH) payment of indemnity benefits this field must be completed as payment adjustment code = 010 or 510. If DTH benefits are being paid then Paid-To-Date > 0.00 and the Date of Death is not null. If the DTH benefits are the first benefits to be paid to the injured worker's beneficiary, then for the MTC = IP, the payment adjustment start date = the first date on which DTH payment is beginning.

85

(Disability = DTH) Paymnt-Adjust-Code

3 A/N

C

010, 510

86 87 88 89 90 91

Pymnt/adj Paid-to-Date Pymnt/adj Weekly Amt Pymnt/adj Start Date Pymnt/adj End Date Pymnt/adj Weeks Pymnt/adj Days

$9.2 $9.2 DATE * DATE * 4N 1N

C O C O C C This number must be completed for the total duration of the disability payment. This number must be completed for the total duration of the disability payment. For the unknown or compromised payment of indemnity benefits this field must be completed as payment adjustment code = 500. If unknown or compromised benefits are being paid then Paid-To-Date > 0.00. If these benefits are the first benefits to be paid to the injured worker, then for the MTC = IP, the payment adjustment start date = the first date on which payment is beginning.

85

(Disability = Unknown) Paymnt-Adjust-Code

3 A/N

C

500

86 87 88 89 90 91

Pymnt/adj Paid-to-Date Pymnt/adj Weekly Amt Pymnt/adj Start Date Pymnt/adj End Date Pymnt/adj Weeks Pymnt/adj Days PTD/REDUCED EARNINGS/ RECOVERIES PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt

$9.2 $9.2 DATE * DATE * 4N 1N

C O C O C C This number must be completed for the total duration of the disability payment. This number must be completed for the total duration of the disability payment.

95 96 95 96 95 96 95 96 95 96

3 A/N $9.2 3 A/N $9.2 3 A/N $9.2 3 A/N $9.2 3 A/N $9.2

C C C C C C C C C C

300 330 340 350 360

Funeral Expenses paid to date for payment recovery amount > 0, then date of death is not null. Employer's legal expenses. Claimant's legal expenses. Total payments to physicians. Hospital paid-to-date.

Workers' Compensation Administration 34

Data Collection Requirements
Data # 95 96 95 96 95 96 95 96 95 96 IAIABC Data Fields PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt PTD/Re/Recov_Cd PTD/Re/Recov_Amt Format 3 A/N $9.2 3 A/N $9.2 3 A/N $9.2 3 A/N $9.2 3 A/N $9.2 NM Req. C C C C C C C C C C Valid Values 370 380, 390, 400 420 460 450 Processing Notes

EDI Guide Book (December 2007)

Medical paid-to-date (other). Vocational rehabilitation and related costs paid-to-date. Legal testimony costs. Physical therapy costs paid-to-date. Medication paid-to-date.

M = Mandatory Fields C = Required, Non-null Fields O = Optional Fields Note: All M and C fields are sent with each record. If you have sent a C field in a previous record, you must send that field in subsequent records. An MTC = IP with Claim Type = L, requires an update of a record that was assigned as a medical-only. A medical-only that has an MTC = FN can be reopened under MTC = IP and Claim type = L. * For each individual payment of indemnity benefits a start payment date and end payment date should be completed. Note: For workers' with Injury-time (where wages continued to be paid), the start date is the first day after the end of the Injury time period.

Workers' Compensation Administration 35

Data Collection Requirements

EDI Guide Book (December 2007)

New Mexico Workers' Compensation Administration

EDI TRADING PARTNER PROFILE
Reporting Purpose Code PARTNER TYPE:

TPA Employer

Carrier Other

Service Bureau Sender Administrator

Jurisdiction

TRADING PARTNER:

Name: Mail/Address: City: Postal Code: Contact Person: Fax #:
FILE TRANSMISSION:

FEIN:

State:

Phone:

148 (FROI) Medical

POC Other Monthly Quarterly

FILE TYPE:

Paper

Flat File ANSI

A49 (Sub. Report)

FREQUENCY OF REPORTING:Weekly

Semi-Annually Annually

DAY OF WEEK:

Sat. Wed.

Sun.

Mon. Fri.

Daily
NETWORK:

Bi-weekly

Tue. Production

Thur.

Start Date Start Date

MAIL BOX ACCT. ID: USER ID: MESSAGE CLASS: ORGANIZATIONS REPORTING UNDER SENDER ADMINISTRATOR:

Test

Claim Administrator Name

FEIN

Type

Postal Code

Agreement Person

Title

Signature

Date

WCA E7/10/13/95 Workers' Compensation Administration 36

Data Collection Requirements

EDI Guide Book (December 2007)

APPENDIX 3 1 .....................................................................EDI Test Phase Requirements

Workers' Compensation Administration 37

Data Collection Requirements

EDI Guide Book (December 2007)

EDI TEST PHASE REQUIREMENTS January 27, 2000
Any company using EDI to submit claims to the New Mexico Workers' Compensation Administration (WCA) must: 1. 2. 3. Be IAIABC certified or licensed in New Mexico Adhere to the EDI Guide to Completing and Filing Employers' First Report of Injury or Illness and Notice of Benefit Payment E4 Booklet (EDI) dated April, 2000. Successfully complete test phase with WCA.

When a company is IAIABC certified or licensed to file in New Mexico, a WCA Trading Partner Profile form must be completed and submitted by email or fax. Trading Partner Profiles being emailed should be sent to [email protected] A revised Trading Partner Profile form (E7) must accompany any changes to the profile in the future. Trading Partner Profile forms that are faxed must be sent to the attention of Mark Llewellyn, fax #: (505) 841-6840. Each company who submits a profile form will be notified by email when the information is entered into the WCA system. A test phase schedule will be determined at that time. Any company using EDI to submit claims must inform WCA of any changes to their programs or systems prior to implementation of those changes. When a company implements this type of changes, they are required to complete another test phase successfully before their data will be processed as production data. E-1 (First Report of Injury): Any dummy data can be submitted. E-6 (Subsequent report): E-6 forms must be sent on claims that were previously submitted, accepted and loaded into the WCA production database. When sending E-6 data for test purposes, the WCA claim number field is left blank. Test Phase Requirements There is no strict timeframe that must be followed when performing the EDI test phase. Any rejection rate over 3% is considered unacceptable. The following items will be tested and reviewed: 1. Test data should be transmitted on a schedule similar to the schedule that allows test data to be submitted for a minimum of three (3) consecutive days. Each company should submit every claim type during test phase including initial, subsequent report and a change report. For 148 testing { 00,01,02,04,CO, AU }, for testing A49 { PY, IP, CB, FN, etc.). Header Format 3.1 Header Length 3.2 Appropriate Fein numbers 3.3 Appropriate date formats Trailer Format 4.1 Trailer Length 148 Data File (E-1) 5.1 Record Length 5.2 Date Format 5.3 Appropriate code entries (ex: wage period must be entered as 01 or 04). 5.4 Mandatory Fields 5.5 Appropriate values entered into mandatory fields A49 Data File (E-6) 6.1 Record Length 6.2 Date Format 6.3 Code Entries 6.4 Variable Length Counters 6.5 Variable length Segment Entries 6.6 Mandatory Fields 6.7 Appropriate values entered into mandatory fields Workers' Compensation Administration 38

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3.

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6.

Data Collection Requirements Notification

EDI Guide Book (December 2007)

When several consecutive days test data has been transmitted to WCA and passed all test requirements, WCA will notify your company via e-mail or letter. This notification will include the date you can begin sending "production" instead of "test" data. If "production" data is received, before formal notification is sent from WCA stating that the company should move from test to production, that batch of data will be returned to the sender without being processed.

Workers' Compensation Administration 39

Data Collection Requirements

EDI Guide Book (December 2007)

GLOSSARY OF TERMS AND TABLES
New Mexico Specific Acquired Claim A49 Record A workers' compensation claim that is transferred from one claims administrator to another administrator. The electronic data interchange (EDI) ASCII record format of the Notice of Benefit Payment (E6.2). Note: this record is a variable length record. American Standard Code for Information Interchange. This allows information to be exchanged between computers or electronic equipment produced by different manufacturers. ASCII also refers to the file format of data transferred between informational trading partners. The term "flat file" is synonymous with ASCII format. This refers to an acquired First Report of Injury or Illness by a claims administrator from another administrator. This report is sent to the Workers' Compensation Administration (WCA) to change the carrier or claims administration information on the First Report of Injury or Illness (E1.2). The WCA's software program process that ensures the record transmitted by the claims administrator meets the reporting event requirement of EDI. The program also checks to see if a required report has been filed prior to the most recent report submitted. The insurance carrier, third party administrator, self-insured employer, or any claims coordinator designated by the employer or another claims payer to provide claims processing services on workers' compensation claims. The workers' Compensation Claim type as designated by M = Medical, I = Indemnity, L = became Lost time, or N = Notification. This name abbreviation is used primarily in Figure A. The Workers' Compensation Claim Status as designated by O = Open, C = Closed, R = Reopened, X = Reopened/Closed. This name abbreviation is used primarily in Figure A. This is the Trading Partner Profile Report. Each claims administrator must submit a Trading Partner Profile to the workers' Compensation Administration. This enables the Administration to monitor the insurance carriers and selfinsured employers reporting via EDI or paper for each statistical report. The file name given by the sender party of an EDI transmissions file as determined by the type of records sent. This designation is used only by trading partners on the ADVANTIS network. Refers to the data structure of the data fields within one record type (i.e., 148 Record, A49 Record). The first record in every file. It describes the records sent, the date of transmission and sender identification

ASCII

AU Report

Business Edits

Claims Administrator

Clm_Type

Clm_Sts

E7 Report

File Class Designation

Format Header Record information. Indemnity accident. Medical-only MTC

Disability payments paid directly to the worker or to the worker's dependents as the result of the work-related

Medical benefits paid by the insurance agent in behalf of the worker as the result of the work-related accident. Maintenance Type Code or Maintenance Reason Code. Defines the specific purpose as to why a particular report is being submitted to the New Mexico WCA. Outlines the sequence of reporting for workers' compensation claims. In the Event Tables, this refers to that event, during the course of the claim, requiring the claims administrator to submit a statistical report to the WCA. In New Mexico, the Notice of Benefit Payment (form E6.2). The New Mexico WCA's software programming process that matches each record's fields with the mandatory values possible for that data field. If the mandatory requirements are not met, the record is not processed into the WCA database. The last record in a file. It defines the total number of records to be processed within the file.

Reporting Rule Report Trigger

Subsequent Report Technical Edits

Trailer Record

Workers' Compensation Administration 40

Data Collection Requirements EDI Guide Book (December 2007) TSI An abbreviation for Transaction Set ID. This identifies the New Mexico statistical report being submitted to the WCA (i.e., 148 = First Report of Injury or Illness; A49 = Notice of Benefit Payment). Value Added Network Refers to an electronic data transmission service.

TABLE DESCRIPTIONS
Data Element Mapping Defines the data formats and possible values for each MTC process of the A49 record. Table Table B Table C Table D Table E Outlines the Notice of Benefit Payment record layout and defines which data fields are mandatory for New Mexico. Outlines the Header Record Structure with possible values. Outlines the Acknowledgment Record structure with possible values. Outlines the Trailer Record structure.

Workers' Compensation Administration 41