WCIS e.News
#7    September 5, 2000

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Occasional announcements and technical updates regarding
California's Workers' Compensation Information System (WCIS),
from the California Division of Workers' Compensation
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Use of "Final" and "Annual" Subsequent Reports

The California Division of Workers’ Compensation has received many questions about the reporting standards for Final (FN) and Annual (AN) transactions. These are two specialized EDI transactions that have similar but not identical uses and requirements.

Two regulatory requirements are involved: Section 9702(d) of the WCIS Regulations that states, "each claims administrator shall submit to the WCIS ... the following data elements, whenever indemnity benefits of a particular type and amount are started, changed, suspended, restarted, stopped, delayed, or denied, or when a claim is closed or reopened...". And Section 9702(g) that states, "claims administrators shall, for each claim with any payment in any benefit category, including medical, in the previous calendar year, report the total paid in each payment category through the previous calendar year…"

Following the IAIABC transaction standards for EDI, the required transaction for Section 9702(d) "when a claim is closed" would be a Maintenance Type Code of "FN" (Final) and the required transaction for section 9702(g) would be a Maintenance Type Code of "AN" (Annual). Several claims administrators have asked whether the FN and AN reports are so similar that it would be sufficient to report only one at the time that the claim closes.

The answer is… it depends upon whether or not indemnity payments have been made on the claim. WCIS handles the Final and Annual transactions differently, so neither works for every purpose.

For medical-only claims with no indemnity payments, a sufficient final report would be the Annual transaction (AN) with Claim Status = "closed." A Final transaction (FN) need not be sent.

However, for claims with indemnity benefits, a claims administrator may not substitute the Annual transaction for the Final transaction. A Final transaction must still be sent when a claim with indemnity benefits closes, because the Final transaction initiates a claim closing process in WCIS that re-checks the overall status of the claim. If there is no activity on the claim after the Final transaction has been sent, and if the Final transaction included data on both indemnity benefits and "Other Benefits," then sending the Annual transaction would be unnecessary for that claim the following January.

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