VWC TAP Intro Deck

1
VAs Release 3 EDI Implementation Claims Adjus
ter Conference
Virginia Workers Compensation Commission
Technology Alignment Program (TAP)
9/18/2008
2
Agenda
Morning Sessions Opening Comments from Ms. Diamo
nd, VWC Chair Update on the Technology Alignment
Program Essence of Handling Claims in Virginia
Afternoon Sessions Business Scenarios Changes
at the Commission 2009 Initiatives
3
Todays Presenters
Virginia Diamond Commission Chair
Matthew Bryant TAP Program Director
Stephanie Brenzovich Awards Team Leader / EDI
SME Kathy Jones Claims Examiner / EDI SME Te
mple Mayo Deputy Commissioner
4
Part I Update on the Technology Alignment
Program
5
Glossary of terms
FROI Short for First Report of Injury
standard terminology used to denote initial
employer accident reports. SROI Short for Sub
sequent Report of Injury standard
terminology for a data report that is
submitted after a FROI involving such things as
payment activity or denial of a claim.
EDI The abbreviation for Electronic Data
Interchange the system and methods by which
carriers submit data electronically.
Release 3 The latest set of EDI standards
issued by the standards-issuing body (IAIABC).
Claims Administrator The primary person
accountable for submitting claims data via EDI
to the Commission.
6
Summary of the EDI Implementation
EDI reports will be submitted according to Vi
rginias Implementation Guide FROI reports SRO
I reports (payment start/stop, denials, quarterly
payment-to-date info) Some current paper reporti
ng obligations will continue until the Commission
provides notice that the paper method is retired

7
Vision
The Technology Alignment Program (TAP) is aimed
at leveraging industry available technology to
improve the overall efficiency, reliability and
accuracy of information transactions, thereby
greatly improving customer service and better
meeting the needs of internal and external
stakeholders.
8
VWC Guiding Principle
Use a Data-Driven approach tied to industry be
st practices within a flexible timeline
Establish realistic data requirements based only
on whats required, and no more
Build system according to IAIABC Claims R3 EDI
Specifications Rely on IAIABC Implementation Comm
ittee Associate Member Council for guidance
Employ a phased approach with Beta Testers High
Volume Carriers in the early waves (begins
10/1/08 ends 7/1/09), and Web Browser case
management for lower volumes
9
EDI Drivers
Facilitates goals of program Improves reliabilit
y and accuracy of data More timely data Improv
es efficiency of operations Allows access to mor
e integrated case record Avoids unnecessary dup
lication Better aligns VWC operating model with
the industry Facilitates statutory obligations
10
Program Milestones
Final Implementation Guide May 1, 2008
Complete IAIABC Sponsored EDI Training (Richmo
nd) June 3 5, 2008 Complete
EDI Beta Testing Start July 1, 2008 Complete
EDI Mandate Start - October 1, 2008 EDI
Mandate Complete - July 1, 2009
11
Phasing Approach for Carriers
All reporters are required to report workers
compensation information (Release 3 FROI and
SROI) electronically to the Commission by July 1,
2009. Wave A October 1, 2008 The following
entities will submit via EDI claims that occur
on or after October 1, 2008 Beta Testers Carrie
rs filing more than 1,000 non-minor claims
annually Wave B December 1, 2008 The follo
wing entities will submit via EDI claims that
occur on or after December 1, 2008, and will also
have to retroactively submit via EDI all claims
made between October 1 and November 30, 2008
Carriers filing between 100 and 999 non-minor
claims annually Wave A and B Notes All Carrier
s that fall into Waves A or B are required to
submit claims data via EDI for all accidents
occurring on or after October 1, 2008
Self-Insurers that are self-administered are
excluded from Wave A or B Note For Third Party
Administrators, the implementation date is
determined by a clients overall volume, not by
the TPAs volume with that client
Wave C March 1, 2009 The following entities
will be required to submit electronically claims
that occur on or after March 1, 2009
Self-Insurers that are self-administered (submit
via EDI if annual volume greater than 100
non-minor claims) Web Browser Reporters (Carriers
that submit less that 100 non-minor claims
annually)
12
TAP Timeline - Whats Next
13
Hybrid Claims
A hybrid claim is defined as a post 10/1 acciden
t that is reported before a Carrier is in EDI
status
Post 10/1 accidents Are kept in paper form u
ntil catch up processes are applied
Which go to the hearing docket are returned to
paper, and have the same look and feel as today
Eventually, docketed cases will evolve to
electronic format with the implementation of a
judicial system in Fall 2009
Note Pre 10/1 accidents are always reported via
paper
14
Highlighted Process ChangeCatch-Up Process for
Backlog Claims
The Commission has established this process to m
anage the backlog of claims which will occur for
those trading partners who implement after
October 1, 2008
The FROI 00 is used to report accidents after 10
/1/08 The SROI UR transaction then sweeps in al
l historical information regarding those claims
The EDI Initiative page contains the link to mor
e details on this process
15
What You Should do to Prepare for EDI

Understand your role in your organization
Review the data you need to have in place and
begin collecting it (see the crosswalk
documentation) Review the Implementation Guide
and supporting documents on the EDI Initiative
page Determine, from a system standpoint, how bes
t to comply with EDI requirements
Buy a new asset or modify existing
infrastructure Lease the infrastructure from a v
endor Use the Commissions Web Browser service (
if applicable based on non-minor claims volume)

16
Additional Information
- Webcast archives, FAQs, Commissions E
DI website http//www.vwc.state.va.us/EDI/EDIinit
iative.html
- Proposed changes to VAs regulations htt
p//www.vwc.state.va.us/reg_action.htm
- Technology Alignment Program Site, which cont
ains Implementation Guide, Forms, and Timeline i
nformation Whats New page Consolidated, categ
orized FAQ page Information on past/future train
ing opportunities
17
Conference Survey Group Profile

• Profile of Virginias Trading Partners
• 85 are either insurance carriers or Third Party
  Administrators
  
• 55 are front-line claims adjusters
• 82 are either self-administered or a TPA
• 86 have been in the industry at least 5 years
• 51 have been in the industry at least 15 years
• Data based on 110 responses through 9/12/08

18
Conference Survey Group Profile

• Annual total Virginia claim volume
• 30 handle more than 500 non-minor claims
• When looking at claims regardless of severity,
  the number jumps to 41

19
Conference Survey About EDI
Profile of Virginias Trading Partners

• 32 use a vendor
• 32 handle it themselves
• 30 arent sure
• 42 are ready or almost ready for the move to
  EDI
  
• 54 use EDI in other jurisdictions

20
Conference Survey Handling Claims

• 45 spend less than 5 days investigating claims
• 84 spend up to 10 days
• 52 do not pay either medical or indemnity during
  investigation
  
• 26 pay medical only during investigation

21
Conference Survey Handling Claims

• 41 complete agreement forms within 2 weeks of
  accepting a claim
  
• 11 wait until the worker returns to work to
  complete agreement forms
  
• 41 report waiting 2 to 4 weeks to get agreement
  forms returned
  
• The most common problems?
• Average weekly wage
• Periods of Disability

22
Conference Survey Views on VA

• 62 are very comfortable handling claims in
  Virginia
  
• Only 3 are uncomfortable
• 42 work only in Virginia
• 33 work in 4 or more jurisdictions
• 62 think that Virginia is unique in terms of
  claims handling, but fairly similar to other
  jurisdictions
  
• Two biggest areas of uniquenessThe Clear
  winners
  
• Forms
• Agreement and Awards processes

23
Part II The Essence of Handling a Claim in
Virginia
24
Whats Not Changing

• The Virginia Workers' Compensation Commissions
  Mission
  
• To administer the Workers' Compensation Act and
  its related funds and the Criminal Injuries
  Compensation Fund in a fair, unbiased and
  efficient manner.

25
Whats Not Changing

• Benefit Entitlements Under the Act
• Temporary Total Disability
• Permanent Total Disability
• Fatal Benefits for Dependents
• Applicable Annual Cost of Living Adjustment
• Temporary Partial Disability
• Permanent Partial Disability
• Lifetime Medical Benefit
• Reimbursement of mileage and out-of-pocket
  medical expenses

26
Whats Not Changing

• First Report of Injury must be filed within 10
  days of employer notification
  
• Paper Agreement Forms
• Statutes of Limitation
• Provisions of Rule 4.2
• Virginia is still an agreement state
• When you agree, forms need to be filed
  immediately

27
Claims Best Practices
Source IAIABC
28
Commission Data Sources and Submission Methods
EDI Paper ? Web
EDI (NCCI)
Paper ? Web
29
Accepted Claims Promptly Reported
30
Accepted Claims EDI vs. Paper Filings
31
Accepted Claims Process Details

• Accepted Claims, Promptly Reported
• Step 1 (information shared through EDI)
• Accident Occurs
• Parties Exchange Info
• Worker reports injury
• Employer notifies carrier (Question how long
  does it take the employer to report the accident
  to you??)
  
• Carrier files FROI with Commission via EDI
• Commission provides Guide to injured worker
• Step 2 (information shared through EDI)
• Accident Investigated (5-10 days)
• Decision to pay (SROI IP following by SROI QT)
• Voluntary Payment activity
• These are SROI EDI reports
• Does not establish compensability
• Commission does not start award process upon
  report of payment
  

32
Accepted Claims Process Details

• Step 3 (information shared through paper forms)
• Agreement forms processed by adjuster and filed
  with the Commission (total time to filing2-6
  weeks)
  
• Note You will be hearing from us if we dont
  hear from you
  
• Processes will be facilitated by internet
  submissions (later phase of Commissions
  modernization program)
  
• Step 4 (information shared through paper forms)
• Commission reviews agreement forms
• Standard award processing by Commission

33
Denied Claims Promptly Reported
34
Denied Claims EDI vs. Paper Filings
35
Denied Claims Process Details

• Step 1 (information shared through EDI)
• Accident Occurs
• Parties Exchange Info
• Worker reports injury
• Employer notifies carrier (Question how long
  does it take the employer to report the accident
  to you??)
  
• Carrier files FROI with Commission via EDI
• Commission provides Guide to injured worker
• Step 2 (information shared through EDI)
• Accident Investigated (5-10 days)
• Decision to deny (SROI 04)
• Typically no payment activity, but if there is .
  . .
  
• File SROI IP noting the payment activity
• Does not establish compensability
• Commission does not start award process upon
  report of payment

36
Denied Claims Process Details

• Step 3 (information shared through paper forms)
• Commission issues notice that claim was denied
• Parties do not process agreement forms because of
  denial
  
• Note The reported denial (SROI 04) indicates to
  us that you will not be submitting agreement
  forms
  
• Depending on timing and sequence, you might get
  an inquiry from us
  
• You pay, file SROI IP, then deny
• Or, you deny, file SROI 04, then decide to pay,
  and file SROI IP
  
• Step 4 (information shared through paper forms)
• Commission adjudicates claims
• Preview of coming attractions . . .
• Electronic case calendaring
• Online case management
• File review
• Discovery
• Electronic pleading submission

37
What Is Changing

• Procedural Requirements for filing a First Report
  of Injury
  
• Must be filed electronically for both minor and
  non-minor claims
  
• Reduced data set required
• Notification of Injury (blue letter) will be sent
  on all claims, including minor claims.
  

38
What Is Changing

• Some Commission forms will be retired
• Supplemental Agreement to Pay Benefits (Form 4A)
• Supplemental Agreement to Pay Varying Temporary
  Partial Benefits (Form 4G)
  
• Lump Sum Agreement (Form 12A)
• Report of Minor Injures (Form 45A)
• Report of Medical Costs (Form 45G)
• Applies to claims filed for post-10/1/08
  accident date. Pre-10/1/08 claims will still use
  the old forms.
  
• Continue to file EAR on paper until EDI
  production.
  

39
What Is Changing

• Some Agreement Forms have a new look or a new
  name
  
• Agreement to Pay Benefits (Form 4A)
• ? Award Agreement
• Termination of Wage Loss Award (Form 46)
• ? Same Name New Look
• Memorandum of Agreement for Payment of
  Compensation in a Fatal Case (Form 35)
  
• ? Fatal Award Agreement
• Claims for Benefits (Form 5)
• ? Claim Form Request for Hearing
• The Commission no longer requires specific
  paper color

40
What Is Changing

• The Commissions Notification letters
• Are easier to read with a larger font
• Are easier for Injured Workers to understand
• Contain Bar Codes (if a Jurisdictional Claim has
  been established)
  
• New Notification letters have been created
• Medical Payment Advisory
• Variance Order
• Injured Body Parts Update Notification

41
New Forms Preview First Report of Injury (FROI)

• Less info is required for reporting
• Will be available on Commission web site for
  paper submission prior to Claim Administrator
  becoming EDI enabled
  

42
New Forms Preview Notification of Injury

• Also known as the Blue Letter
• Will be sent on both minor and non-minor claims

43
New Forms Preview New Claim Administrator

• Notification of Injury New Claim Administrator
• New version of blue letter
• To advise when a new Claim Administrator takes
  over handling a claim
  

44
New Forms Preview Request for FROI

• Notification of Injury Request for FROI
• New version of blue letter
• Generated when the Commission learns of a new
  accident via means other than a FROI submission

45
New Forms Preview Award Agreement

• Award Agreement
• Handles all benefit types, including PT and lump
  sum for PPD
  
• Handles initial award additional (or subsequent)
  award or corrected award
  
• Reporting of TP wage no longer required (now
  allows for averaging)
  
• Contains a Bar Code

46
New Forms Preview Termination of Wage Loss Award

• Termination of Wage Loss Award
• Same name, new look
• No payment data (now reported through EDI)
• Only two options to choose from for Return to Work

47
New Forms Preview Fatal Award Agreement

• Fatal Award Agreement
• Only the appearance has changed
• VWC still requires filing of death certificate
  and if applicable, marriage license, and birth
  certificates of minor dependents

48
New Forms Preview 20-Day Order Claim Filed

• 20 Day Order - Claim Filed
• Used when benefits are requested by the Injured
  Worker by filing a claim form
  
• An Award Agreement w/ some pre-populated data
  will be attached
  
• This should be used if forms have not already
  been sent to the injured worker by the claims
  administrator
  

49
New Forms Preview 20-Day Order Response Form

• Order Response Form - Claim Filed
• New look
• Must still be returned in 20 days
• Make this the cover page when responding to the
  20-Day Order
  

50
New Forms Preview 20-Day Order Payments Made

• 20 Day Order -Payments Made
• An EDI-triggered process showing payments have
  been made
  
• An Award Agreement w/ some pre-populated data
  will be attached
  
• This should be used if forms have not already
  been sent to the injured worker
  

51
New Forms Preview Order Response Form- Payments
Made

• Order Response Form - Payments Made
• New look
• Must be returned in 20 days
• We ask you to make this the cover page when
  responding to the 20-day Order

52
New Forms Preview Notification of Award

• Notification of Award
• New look
• Will include the body parts agreed upon
• Will now award PT if agreed by parties

53
New Forms Preview Notification of Fatal Award

• Notification of Fatal Award
• New look

54
New Forms Preview Variance Order

• Variance Order
• New notice
• Generated when we note a difference between the
  amount reported thru EDI v. what was awarded
  
• Similar to our current Audit Letter

55
New Forms Preview Notification of Terminated
Award

• Notification of Terminated Award
• Replaces current Notification of Termination of
  Periods of Wage Loss Benefits
  
• Notifies parties of right to appeal

56
New Forms Preview Notification of Continuing
Award

• Notification of Continuing Award
• Generated when an EDI suspension is received but
  an Employers Application for Hearing or a TWLA
  is not

Updated 9-25-08
57
New Forms Preview Medical Payment Advisory

• Medical Payment Advisory
• Sent to Injured Worker when we receive notice of
  medical payments but no claim has been filed

58
New Forms Preview Notification of Denial

• Notification of Denial
• Completely new
• Commission will now notify Claims Adjusters with
  EAR filings because of a denial.

59
New Forms Preview Longshore Notification

• Longshore Notification
• Generated to advise injured worker his Virginia
  benefits have been denied

60
Part III Review of Business Scenarios
61
DirectionsIn Your Table Groups - 1) Read
Assigned Scenarios2) Determine Answers in Proper
Sequence3) Select Someone to Report to Group4)
Participate in Group DebriefWell Do the First
Two Together
Its Your Turn!
62
DirectionsItems with a number in front of them
are actions to be taken by the injured worker or
claim administrator Items with bullets (also
indented) are steps to be taken by the
Commission
About the Format
63
Business Scenario 1

• The Injured Worker
• Sustained a work place injury on 10/1/08
• Filed a Claim for Benefits with the VWC to assert
  his rights
  
• The Claim Administrator
• Has not been advised by the Employer that the
  Injured Worker sustained a work place injury.
  
• What information/documents should be filed to the
  
  
• VWC?

64
Business Scenario 1 Answer

• The Injured Worker will Submit
• The VWC will generate
• Claim Form Request for Hearing
• Notification of Injury Request for FROI
• The Claim Administrator should submit
• FROI 00
• Note If the Claim Administrator wishes to deny
  the claim,
  
• they should file a FROI 04 instead of a FROI 00
  and the
  
• VWC will generate a Notification of Denial.

65
Business Scenario 2

• The Injured Worker
• Sustained a work place injury on 10/2/08
• The Claim Administrator
• Denies the claim immediately (no medical or
  indemnity has been paid)
  
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

66
Business Scenario 2 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 04 with reason for denial
• Notification of Denial

67
Business Scenario 3

• The Injured Worker
• Sustained a work place injury on 10/5/08
• Lost 25 days from work and is still out
• Has medical bills totaling more than 1000
• The Claim Administrator
• Reports the injury to the VWC and pays benefits
  while still investigating the claim
  
• Denies the claim after investigating
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

68
Business Scenario 3 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• SROI 04 with reason for denial
• Notification of Denial
• Note If you are asked by the Commission whether
  you will
  
• be submitting agreement forms prior to you
  submitting the
  
• SROI 04, please submit the Order Response Form
  and
  
• then file the SROI 04.

69
Business Scenario 4

• The Injured Worker
• Sustained a work place injury on 10/12/08
• Did not lose time from work
• Had medical bills totaling less than 1000
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

70
Business Scenario 4 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI UR with a reduced data set
• Notification of Injury
• Note FROI 00 is acceptable as well and it is
  possible to mark the
  
• FROI 00 as a minor injury.

71
Business Scenario 5

• The Injured Worker
• Sustained a work place injury on 10/23/08
• Did not lose time from work
• Had medical bills totaling more than 1000
• The Claim Administrator
• Accepts the injury, makes payment and reports it
  to the VWC
  
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

72
Business Scenario 5 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI PY
• Medical Payment Advisory

73
Business Scenario 6

• The Injured Worker
• Sustained a work place injury on 10/28/08
• Did not lose time from work
• Had medical bills totaling 3500
• The Claim Administrator
• Reports the injury to the VWC and makes medical
  payments while still investigating the claim.
  
• Completed the investigation and decided to accept
  the claim
  
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

74
Business Scenario 6 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI PY
• Award Agreement Form showing the parties
  agreement to a Medical Only Award
  

75
Business Scenario 7

• The Injured Worker
• Sustained a work place injury on 11/07/08
• Lost 15 days from work and is still out
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

76
Business Scenario 7 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• Award Agreement form showing TT payments
• Notification of Award
• Note If the Award Agreement form is not
  received, the VWC will
  
• inquire after approximately one month to
  determine if the forms will be
  
• forthcoming.

77
Business Scenario 8

• The Injured Worker
• Sustained a work place injury on 11/16/08
• Lost 55 days of work
• Returned to work on light duty earning less than
  his/her pre-injury AWW and remains on partial
  duty
  
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

78
Business Scenario 8 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• Award Agreement form showing TT payments
• Notification of Award
• Award Agreement form showing TP payments
• Notification of Award

79
Business Scenario 9

• The Injured Worker
• Sustained a work place injury on 11/30/08
• Lost 40 days of work
• Returned to work on light duty earning less than
  his/her pre-injury AWW for 24 days
  
• Returned to work (full duty) earning equal to the
  pre-injury AWW
  
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

80
Business Scenario 9 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• Award Agreement form showing TT payments
• Notification of Award
• Award Agreement form showing TP payments
• Notification of Award
• SROI S1
• Notification of Continuing Award sent only if
  Termination form not timely filed
  
• Termination of Wage Loss Award form
• Notification of Terminated Award
• Note The SROI S1 is not a substitute for either
  a Termination of Wage Loss Award form
  
• or an Employers Application. Both are required.

Updated 9-25-08
81
Business Scenario 10

• The Injured Worker
• Sustained a work place injury on 12/03/08
• Lost 40 weeks from work
• Returned to work making pre-injury AWW
• Reached MMI and received a 10 loss of use rating
  from his treating physician.
  
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

82
Business Scenario 10 Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• Award Agreement form showing TT payments
• Notification of Award
• SROI S1
• Notification of Continuing Award sent only if
  Termination form not timely filed
  
• Termination of Wage Loss Award form
• Notification of Terminated Award
• SROI RB showing first PPD payment
• Award Agreement form showing PPD payments plus
  medicals
  
• Notification of Award
• SROI QT showing continuation of PPD Payments

Updated 9-25-08
83
Business Scenario 11

• The Injured Worker
• Sustained a work place injury on 12/14/08
• Lost 110 weeks from work
• Returned to work making pre-injury AWW
• Filed a Claim with the VWC for a disfigurement
  rating
  
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• The Virginia Workers Compensation Commission
• Reviewed the photos submitted and assigned a
  disfigurement rating of 48
  
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

84
Business Scenario 11Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• Award Agreement form showing TT payments
• Notification of Award
• SROI QT should be filed every quarter
• Variance Order sent only if there is a
  difference between payment amount of QT what is
  owed pursuant to Award
  
• SROI S1
• Notification of Continuing Award sent only if
  Termination form not timely filed
  
• Termination of Wage Loss Award form
• Notification of Terminated Award
• SROI RB showing first Disfigurement payments
  (The Claim Administrator received the rating via
  letter from the VWC)
  
• Award Agreement form showing Disfigurement
  payments
  
• Notification of Award
• SROI QT showing continuation of Disfigurement
  payments

Updated 9-25-08
85
Business Scenario 12

• The Injured Worker
• Sustained a work place injury and dies as a
  result of said injury on 12/29/08
  
• The Widow
• Files a Claim with the VWC and Claim
  Administrator seeking fatal benefits for herself
  and her three minor children
  
• The Claim Administrator
• Accepts the death as compensable and agrees to
  pay Fatal benefits
  
• Reports the injury/death to the VWC
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

86
Business Scenario 12Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• Fatal Award Agreement include death certificate
  supporting documentation for dependents
  
• Notification of Fatal Award
• SROI QT filed every quarter while Fatal
  benefits are being paid
  
• Variance Order sent only if there is a
  difference between payment amount of QT what is
  owed pursuant to Award

87
Business Scenario 13

• Pre-condition
• The Injured Worker Sustained a work place injury
  and dies as a result of said injury on 12/29/08
  
• The Claim Administrator accepted and the VWC
  awarded Fatal benefits to the widow and her three
  minor children
  
• The Widow
• Remarries and is no longer entitled to Fatal
  benefits
  
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

88
Business Scenario 13Answer

• The Claim Administrator should submit
• The VWC will generate
• SROI QT shows change in dependents
• Letter requesting additional information about
  change in dependents
  
• Letter stating which dependents are no longer
  entitled
  
• Notification of Fatal Award showing change in
  dependents

89
Business Scenario 14

• Pre-condition
• The Injured Worker Sustained a work place injury
  on 1/5/09
  
• Was released to light duty work by the treating
  physician and returned to work earning less than
  his/her pre-injury AWW
  
• The Claim Administrator accepted and the VWC
  awarded ongoing TP benefits
  
• The Injured Worker
• Was convicted of a felony nine months after
  injury while working light duty and sentenced to
  3 years in jail
  
• The Claim Administrator
• Suspends benefits due to the Injured Workers
  incarceration
  
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

90
Business Scenario 14Answer

• The Claim Administrator should submit
• The VWC will generate
• Employers Application
• The VWC will follow the current business
  processes followed when an Employers Application
  is filed
  
• SROI S5
• Notification of Continuing Award sent only if
  SROI S5 transaction is received prior to the
  Employers App.

Updated 9-25-08
91
Business Scenario 15

• Pre-condition
• The Injured Worker sustained a work place injury
  on 10/2/08
  
• The Claim Administrator accepted and the VWC
  awarded ongoing TT benefits
  
• The Injured Worker
• Is still out of work 14 months later
• Applies for a Cost of Living Adjustment
• The Virginia Workers Compensation Commission
• Evaluates the COLA request and approves it
• What should be submitted to the VWC by the Claim
  
  
• Administrator?

92
Business Scenario 15Answer

• The Claim Administrator should submit
• The VWC will generate
• SROI QT showing continuing payments and COLA
  increase
  
• Variance Order sent only if there is a
  difference between payment amount of QT what is
  owed pursuant to Award
  
• Note The Claim Administrator may pay COLA
  voluntarily without a request
  
• from the Injured Worker.

93
Business Scenario 16

• The Injured Worker
• Sustains a work place injury on11/02/08
• Lost 16 days from work and is still out
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• Is acquired by another company who continues to
  make payments to the Injured Worker
  
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

94
Business Scenario 16Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 00
• Notification of Injury
• SROI IP
• Award Agreement form showing TT payments
• Notification of Award
• FROI AQ
• Notification of Injury - New Claim Administrator
• SROI AP
• Variance Order sent only if there is a
  difference between payment amount on QT and what
  is owed pursuant to the Award
  

95
Business Scenario 17

• The Injured Worker
• Sustained a work place injury on 10/02/08
• Lost 25 days of work
• Returned to work (full duty) earning equal to the
  pre-injury AWW
  
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• Is not EDI ready until 01/01/09
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

96
Business Scenario 17Answer

• The Claim Administrator should submit
• The VWC will generate
• Paper FROI
• Notification of Injury
• Award Agreement form showing TT payments
• Notification of Award
• Termination of Wage Loss Award Form
• Notification of Terminated Award
• A sweep or catch-up transaction must be
  submitted
  
• to the Commission on this claim once the Claim
• Administrator becomes EDI enabled

97
Business Scenario 18

• The Injured Worker
• Sustained a work place injury on 08/15/2008
• Lost 30 days from work
• Returned to work (full duty) earning equal to the
  pre-injury AWW
  
• The Claim Administrator
• Accepts the injury and reports it to the VWC
• What should be submitted to the Commission by the
  Claim
  
• Administrator?

98
Business Scenario 18Answer

• The Claim Administrator should submit
• The VWC will generate
• Paper FROI/EAR
• Notification Letter (Blue Letter)
• Agreement to Pay Benefits showing TT payments
• Award Order
• Termination of Wage Loss Award Form
• Notification of Termination of Wage Loss
  Benefits
  

99
Business Scenario 19

• The Injured Worker
• Sustained a work place injury on 11/19/08
• Filed a claim under the Federal Longshore and
  Harbors Workers Compensation Act which was
  accepted
  
• Is receiving benefits pursuant to the LHWCA
• The Claim Administrator
• Accepts the injury as a VA claim but doesnt pay
  benefits due to the Injured Workers receipt of
  benefits pursuant to LHWCA
  
• What should be submitted to the VWC by the Claim
  
  
• Administrator?

100
Business Scenario 19Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 04 with Denial Reason Code 3D (no
  Jurisdiction) and a Denial Reason Narrative that
  specifies the claim is being paid under the
  Longshore Act
• Notification of Injury
• Longshore Notification
• Note If a FROI 00 is filed prior to determining
  that the
  
• claim is covered under the LHWCA, a SROI 04 with
  the
  
• reason for denial should be filed.

101
Business Scenario 20

• The Injured Worker
• Sustained a work place injury on 12/10/08
• Filed a claim under the Federal Longshore and
  Harbors Workers Compensation Act which was
  accepted
  
• Is receiving benefits pursuant to the LHWCA
• Requests an Award under the Virginia Workers
  Compensation Act
  
• The Claim Administrator
• Accepts the injury as a VA claim but doesnt pay
  benefits due to the Injured Workers receipt of
  benefits pursuant to LHWCA
  
• Agrees to an Award for Record Purposes Only under
  the Virginia Workers Compensation Act
  
• What should be submitted to the VWC by the Claim
  
  
• Administrator?

102
Business Scenario 20Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 04 with Denial Reason Code 3D (no
  Jurisdiction) and a Denial Reason Narrative that
  specifies the claim is being paid under the
  Longshore Act
• Notification of Injury
• Longshore Notification
• Award Agreement the form should note payments
  are being made pursuant to LHWCA
  
• Notification of Award with the sentence The
  Employer shall be given credit for payments made
  pursuant to the Federal Longshore and Harbor
  Workers Compensation Act.

103
Business Scenario 21

• The Injured Worker
• Sustained a work place injury on 12/10/08
• Received 60 weeks of benefits pursuant to the
  LHWCA
  
• Claimant goes back on Temporary Total Disability
  and is entitled to an Award and payment of that
  Award pursuant to the Virginia Workers
  Compensation Act
• The Claim Administrator
• Accepts the injury as a VA claim but doesnt pay
  benefits for the initial 60 weeks because the
  Injured Worker is receiving benefits pursuant to
  LHWCA
• Agrees to an Award for new TTD and payment of
  that Award pursuant to the VWC Act
  
• What should be submitted to the VWC by the Claim
  
  
• Administrator?

104
Business Scenario 21Answer

• The Claim Administrator should submit
• The VWC will generate
• FROI 04 with Denial Reason Code 3D (No
  Jurisdiction) and a Denial Reason Narrative that
  specifies the claim is being paid under the
  Longshore Act
• Notification of Injury
• Longshore Notification
• FROI 00
• SROI IP submitted when the VA benefits begin
• Award Agreement form showing TT payments
• Notification of Award
• Note If, for some reason, the claimant begins
  receiving benefits
  
• pursuant to the LHWCA again, the Claim
  Administrator must submit a SROI 04 with
  
• the Denial Reason Code 3D and a Denial Reason
  Narrative that specifies the claim is
  
• being paid under the Longshore Act. If you wish
  to terminate the Virginia Award, you
  
• must submit a Termination of Wage Loss Award or
  Employers App.
  

105
Part IV Commission Updates
106
Principles Guiding Organizational Change
Guiding Principle Improved Customer Service
The Commissions Pledge to its employees
Everyone will have an opportunity to grow
107
The Transition Teams Mission
The Transition Teams mission is to propose
organizational changes to make maximum use of new
technology to improve customer service
108
New Commission Departments
Image, analyze, and index post 10/1 accident inc
oming mail, route pre 10/1 accident incoming
mail, assign work tasks, and process outgoing mail
Correspondence Distribution
Assist customers through phone and mail response
s with claims issues and concerns
Customer Assistance
Ensure injured workers are awarded appropriate a
nd timely benefits ensure efficient preparation
of cases for hearing facilitate mediations
Benefits Administration
Review trends and conduct audits and training to
ensure compliance with Commission reporting
requirements

Compliance
109
Org Structure