PAYMENT PROCESSING OVERVIEW - …



Claim Data Interface

Overview

Agencies under the Governor’s jurisdiction report work-related injuries through a self-service portal into the Commonwealth’s enterprise computer system. Injury claims data is entered by supervisors or approved workers’ compensation representatives. When a workers’ compensation representative enters the claim, it is entered from a paper form completed by the supervisor. A copy of the current form and instructions is provided within this Appendix.

The workers’ compensation coordinator receives an e-mail notification through the enterprise computer system when a new claim is entered. This allows the coordinator to review the data and obtain any additional information that may be helpful to the Awarded Offeror before the claims information is interfaced to the Awarded Offeror.

Each night, with the exception of Saturday and Sunday, whether or not the workers’ compensation coordinator has reviewed the claim data, all claims data entered is batched into an interface file and made available to the Awarded Offeror. Incident only claims are not sent to the Awarded Offeror, but are maintained in the enterprise computer system in the event that the claimant needs to seek medical treatment or begins losing time from work at a later time.

For agencies that do not use the enterprise computer system, injury data is recorded on the paper claim form, and the form is either faxed or e-mailed as an attachment to the Awarded Offeror. The fax and e-mail options could be used in a rare case when the enterprise computer system would not be available.

Based on the claims data received, the Awarded Offeror shall complete and file the LIBC-344 form with the Bureau of Workers’ Compensation in accordance with their procedures, and a copy must be provided to the workers’ compensation coordinator and claimant.

Claim Changes

Workers’ compensation representatives and workers’ compensation coordinators have the ability to change claim data in the enterprise computer system after the data is interfaced. If data is changed, the entire claim is resent, and it is the responsibility of the awarded offeror to determine what data has changed so that the Awarded Offeror’s system can be updated. Recurrences of previously reported claims are not sent through the interface. Notification is typically provided directly to the adjuster by e-mail or telephone.

Interface Transfer File

Delivery of file occurs by FTP transfer from the Commonwealth’s Public FTP Server, using credentials provided by the Commonwealth. Files will be in an XML format provided by the Commonwealth, and named according to Commonwealth specifications. Files will be encrypted. Exact file formats will be provided by OA upon execution of the contract. Fields that will be transferred are at least those provided on the claim reporting form. The current file specifications are provided with this appendix for informational purposes.

Testing Requirements

Commonwealth testing standards require Unit Testing along with end-to-end Integration testing by the Office of Administration, Bureau of Integrated Enterprise Systems to ensure all functionality and interfaces work properly. A formal signoff by OA on full system testing is required to assure a quality implementation. The awarded offeror shall allow enough time to complete this testing and include this timeline in a full project plan that shall be submitted with the proposal. At a minimum the awarded offeror shall plan on all testing to be completed with formal signoff on system interfaces and functionality 30 days in advance of the implementation date. Should testing not be completed by this date due to awarded offeror delays, daily negotiations to solve the problems will begin between OA and the awarded offeror’s project manager. Upon completion of successful system testing the OA will provide formal notification that system functionality and interface testing is complete and the system is acceptable (reference Appendix E – Service Level Agreements).

| |COMMONWEALTH OF PENNSYLVANIA |Form JPA-797 |

|Date of Report |Workers’ Compensation Claim Form | |

| | | | |CSI Telephone 1-888-871-3606 |

|Complete Claim Form and Submit to Agency Workers’ Compensation Service Representative |

|For Input into ESS and Submission to CompServices, Inc. |

| | |

|Date of Injury | |Personnel Number | |Biweekly Salary at Injury | |Injury Type* |

| |

|Employee Information |

| | |

|Employee Name | |

| Last | |First | |M.I. | |Suffix | |Social Security Number |

| |

| Street or P.O. Box |City |State |Zip |4-Digit |

| |

| Residence County Name |Home Telephone Number | |

| | | | | |

| |

| Date of Birth |Gender |Married |Number of | |Employment Status | |Date of Hire |

| | |Male Female |Yes No |Dependents | | | | |

| | | | ( ( | ( ( |

|Employer Information |

| | | | | | |

| Dept. Code | |Department Name | | |Job Classification Name |

| | | | | | | | |

| |

|Organization Code |Organization Name |Name of Supervisor |

| | | | | | | |

| |

|Work Location Address |

| Street or P.O. Box |City |State |Zip |4-Digit |

| |

| County Name of Work Location |Tele Area Code |Telephone Number |

| | | | |- | | |

| |

|Injury Date Information |

| | | | | | | | | |

|Time of Injury | | | |Date Employer | |Shift Start Time | | |

| 24 Hr Military Time | Date of Death | |Knew of Injury | |24 Hr Military Time | |Type of Claim* |

| |

|Last Full Day Worked |Date Disability Began |Date Returned to Work |At Same Wages? |Occur During OT? |

| | Yes |No | |Yes |No |

| | | | | | | | ( ( | ( ( |

| | | | | |

|Injury Description Information |

| | | |

|Injury on Employer Premises? | | |

|Yes |No |If not in PA, List State |If not on Premises, List Address of Accident: |

| ( | ( | | | | | |

| | | |

| | | |

|Injury Description Information (Continued) |

| Cause Code* | |Cause of Injury Additional Information |

| | | | | |

| | | | | |

| Injury Type Code Primary* | Injury Type Code Secondary* |Type of Injury Additional Information and Severity |

| | | | | | | |

| | |Body Part Affected Additional Information (include orientation, |

| | |example: left, right, top, bottom) |

| Body Part Code Primary* | Body Part Code Secondary* | |

| | | | | | | |

| |

| All equipment, materials or chemicals employee was using when accident or illness occurred. |

| | | |

| |

|How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances directly responsible. Includes Who, |

|What, When, Where, Why, and How. The What shall be the job assignment the employee was performing when injured. |

| | | |

| |

|Any tools involved? |Any mechanical defect? |Unsafe Act? |Unsafe Condition? |Amputation? |

| Yes | No | Yes |No | Yes |No | Yes |No | Yes |No |

| ( ( | ( ( | ( ( | ( ( | ( ( |

| | | | | |

|Motor Vehicle Accident? |Safeguards or safety equipment provided? |Safeguards or safety equipment used? |

| Yes |No | |Yes |No | | |Yes |No | |

| ( ( | ( ( | ( ( |

|Medical Information |

| |

|Panel of Physicians? | |

| Yes |No | |Initial Treatment* | |

| ( ( | | |

| Medical Provider Name and Address: |

| | | |

| |

|Employer Comments and Signature: |

|Agree/Disagree with description of injury? Other information about injury, including the names and telephone numbers of any witnesses. |

| | | |

| Signature of Supervisor Completing Form | Date |

| |___________________________________ | |____________________ | |

| |

|Return all LIBC Forms to: |Name: |

| |Address: |

| |Telephone: |Fax: |

| |

|For Agency WC Service Representative: Enter through ESS and Submit to CompServices, Inc. |

|Date Submitted to CSI _______________ Signature__________________________________ |

* Denotes Drop Down Box Field in ESS – Code Descriptions Attached January 2004

Injury Code Descriptions for JPA-797 Form

Injury Type Initial Treatment Injury Type Code Body Part Code

Act 632/534 No Medical Treatment No Physical Injury Multiple Head Injury

Heart & Lung Type Minor by Employee Amputation Skull

Injury Leave Type Clinic Hospital Angina Pectoris Brain

No Special Benefits Type Panel Physician Burn Ear(s)

Work-Related Disability Leave Employee Physician Concussion Eye(s)

Emergency Care Contusion Nose

Type of Claim Hospitalized>24 hrs Crushing Teeth

Near Miss Dislocation Mouth

Incident Only Electric Shock Head - Soft Tissue

Medical Only Encucleation/Removal Facial Bones

Medical7 Day Lost Fracture Vertebrae

Death Freezing Neck - Disc

Hearing Loss/Imprmnt Neck - Spinal Cord

Cause Code…………………………. Cause Code (Cont'd) Heat Prostration Larynx

Burn-Acid Chem Step/Strik-Scraping Hernia Neck - Soft Tissue

Burn-Cntct w/ Object Step/Strk-Statnry Ob Infection Trachea

Burn-Temp Extremes Step/Strik-Sharp Obj Inflammation Mltple Upr Extrmtes

Burn-Fire or Flame Step On/Strike-Misc Laceration Upper Arm

Burn-Steam/Hot Fluid Struck-Cowrker Myocardial Infarctn Elbow

Burn-Dst/Gas/Fms/Vpr Struck-Fall/Fly Obj Poisoning-General Lower Arm

Burn-Welding Struck-Tool/Machine Puncture Wrist

Burn-Radiation Struck-Motor Veh Rupture Hand

Burn-Miscellaneous Struk-Machine In Use Severance Finger(s)

Caught In-Machinery Struck-Obj Handled Sprain Thumb

Burn-Cold Obj/ Subst Strk-Obj Hndl by Oth Strain Shaller

Caught In-Obj Handld Sruck/Inj By-Misc Syncope/Fainting Wrist(s) and Hand(s)

Caught In/Betwn-Misc Misc-Absorb/Ingest Asphyxiation Multiple Trunk

Brn-Abnml Air Presur Electrical Current Vascular Upper Back/Thracic

Cut/Inj By-Brkn Glas Inj By-Anmal/Insct Vision Loss Low Back/Lumbr Lumbo

Cut/Inj By-Hand Tool Inj By-Explosion All Other Injuries Back/Disc

Cut-Obj Liftd/Handld Forgn Matter in Eye Dust Disease Chest/Ribs

Cut/Inj By-Powr Tool Misc-Person/Crime Asbestosis Sacrum and Coccyx

Cut/Inj By-Misc Other than Phys Caus Black Lung Pelvis

Caught In-Collapse Rub/Abraid-Rept Motn Byssinosis Back - Spinal Cord

Fall/Slip-Diff Level Rub/Abraid-Misc Silicosis Internal Organs

Fall/Slip-Ladder Strain-Repitv Motion Rsprtry Disorders Heart

Fall/Slip-Liquid Misc-Cumulative Poisoning-Chemicals Mltple Lwr Extrmtes

Fal/Slp-Into Opening Misc-Other Poisoning-Metal Hip

Fall/Slip-Same Level Struck By Inmate/Pat Dermatitis Upper Leg

Slip-Did Not Fall Exp Misc Viral Infec Mental Disorder Knee

Fall/Slip-Misc Heat Exhaust/Stroke Radiation Lower Leg

Fall/Slip-Ice/Snow Exp to Skin Irritant Other Occ Disease Ankle

Fall/Slip-On Stairs Gunshot Wound Loss of Hearing Foot

Motr Veh-Water Veh Human Bite Contagious Disease Toe(s)

Motr Veh-Train Exposure to TB Cancer Great Toe

Motr Veh-Veh Colison Exp to Hepatitis B AIDS Lungs

Motr Veh-Hit Fxd Obj Exposure to HIV VDT-Related Disease Abdomen/Groin

Motr Veh-Airplane Microbiological Exp Mental Stress Buttocks

Motr Veh-Veh Upset Chem Exp-Absorption Carpel Tunnel Syndrm Lumbar/Sacral Vertbr

Motr Veh-Misc Chem Exp-Ingestion Hepatitis C Artificial Appliance

Strain/Inj By-Noise Chem Exp-Inhalation Other Cumulative Inj Insufficient Info

Strain/Inj By-Twist Mltpl Physical Inj No Physical Injury

Strain/Inj By-Jump Mltpl Inj Phys/Psych Multiple Body Parts

Strn/Inj-Hold/Carry Animal Bite Body Systems

Strain/Inj By-Lift Abrasion

Str/Inj By-Push/Pull Death

Strain/Inj By-Reach Human Bite

Str/Inj By-Tool/Mach Insect bite

Strain/Inj By-Misc Spinal Cord

Strain/Inj By-Throw Lyme Disease

Step/Strik-Machine Stab Wound

Step/Strk-Obj Handld Gunshot Wound

Interface File Specifications

This specification is provided for information purposes. It is subject to modifications, and the final format specifications will be provided upon award of the contract.

HEADER:

|FIELD |LENGTH |Example Value |

| | | |

|Record Type |6 Characters |“HEADER” Constant value |

|Create Date |8 Characters |“07012007” (MMDDYYYY) |

|Create Time |6 Characters |“013000” (HHMMSS) |

|As of Date |8 Characters |“07012007” (MMDDYYYY) |

|Contact Person Name |40 Characters |“John Smith” |

|Telephone Number |10 Characters |“7177059295” |

|Email Address |25 Characters |“jsmith@state.pa.us” |

|File Name |40 Characters |“INTF_nnnn.BUS.PARTNER.OUT.DAT” |

| | |Where nnnn is 4 char DFS FLOW object ID number, followed by a unique name(s), and |

| | |extension OUT.DAT separated by dots. |

|Record Count |8 Characters |“00000230”(count = all data records + header record) |

OUTPUT:

|SAP R/3 Field Name |Table |Type |Length |SAP Field Name Description |Comments/Rules |Position |

|RDATE |P0082 |DATS |8 |Report on | |5 |

|PERNR |P0000 |NUMC |8 |Personnel no | |13 |

|IDATE |P0082 |DATS |8 |Date of Illness | |21 |

|Calculate: |Q0008 P0008 |CURR |13 |Biweekly Salary at Injury |Right justify with 2 decimal places implied. Pad |29 |

|Use function module | | | | |with leading zeroes. | |

|ZHR_GET_SAL_ | | | | | | |

|RATES | | | | |( do not include or default zeros)  Per Diem wage | |

| | | | | |type 1250. | |

| | | | | | | |

| | | | | |As of injury date | |

|NACHIN |P0002 |CHAR |40 |Last name | |42 |

|VORNA |P0002 |CHAR |40 |First name | |82 |

|MIDNM |P0002 |CHAR |40 |Mid. Name | |122 |

|NAMZU |P0002 |CHAR |15 |Suffix | |162 |

|PERID |Q0002 |CHAR |20 |SSN |Left justify |177 |

|STRAS |P0006 |CHAR |60 |Address line 1 |Residence address |197 |

|ORT01 |P0006 |CHAR |40 |City/county |Residence address |257 |

|STATE |P0006 |CHAR |3 |State |Residence address |297 |

|PSTLZ |P0006 |CHAR |10 |Zip code |Residence address |300 |

|ZZ_COUNC |P0006 |CHAR |2 |Residence County |Residence address |310 |

|AREAC |Q0006 |NUMC |3 |Telephone number (area code) Personal | |312 |

| | | | |number | | |

|TELNR |Q0006 |CHAR |14 |Telephone number (Personal number) |Left justify |315 |

|GBDAT |P0002 |DATS |8 |Birth date | |329 |

|GESCH |P0002 |CHAR |1 |Gender |U = Unknown |337 |

| | | | | |M = Male | |

| | | | | |F = Female | |

|RCD05 |P00082 |CHAR |2 |Marital status | |338 |

|RCD04 |P00082 |CHAR |2 |Dependents | |340 |

|DAT01 |P0041 |DATS |8 |Z1 (Current Svc Date) |Find the date value for the corresponding Z1 date |342 |

| | | | | |type. | |

| | | | | | | |

| | | | | |As of injury date | |

|PERSK |P0001 |CHAR |2 |EE Subgroup |As of injury date |350 |

| | | | | | | |

| | | | | |FT = Full time | |

| | | | | |PT = Part time | |

| | | | | |VO = U9 | |

| | | | | |ZZ = all others | |

|WERKS |P0001 |CHAR |4 |Personnel area (Dept/Agency) |As of injury date |352 |

|STELL |P0001 |NUMC |8 |Job Key |As of injury date |356 |

|T513S-STLTX |T513S |CHAR |25 |Job key (text) | |364 |

|ORGEH |P0001 |NUMC |8 |Organization unit |As of injury date |389 |

|T527X-ORGTX |T527X |CHAR |25 |Organization unit (text) | |397 |

|P0006-STRAS |Infotype 6 |CHAR |30 |House no/street (Work Location) |As of injury date |422 |

| |subtype 10 | | | | | |

|P0006-LOCAT |Infotype 6 |CHAR |35 |House no/street (Work Location) |As of injury date |452 |

| |subtype 10 | | | | | |

|P0006-ORT01 |Infotype 6 |CHAR |20 |City (Work Location) |As of injury date |487 |

| |subtype 10 | | | | | |

|P0006-STATE |Infotype 6 |CHAR |3 |Region (State) Work Location |As of injury date |507 |

| |subtype 10 | | | | | |

|P0006-PSTLZ |Infotype 6 |CHAR |10 |Post code (Zip) Work Location |As of injury date |510 |

| |subtype 10 | | | | | |

|Q0006-AREAC |Infotype 6 |NUMC |3 |Area Code (Work Location) |As of injury date |520 |

| |subtype 10 | | | | | |

|Q0006-TELNR |Infotype 6 |CHAR |22 |Telephone no. (Work location) |Left justify |523 |

| |subtype 10 | | | |As of injury date | |

|CONTY |V_T5UTZ |CHAR |25 |County (Work County) |As of injury date |545 |

|ITIME |P0082 |TIMS |6 |Illness time | |570 |

|OTM05 |P0082 |TIMS |6 |Shift Start Time | |576 |

|P1001STEXT |Q1001 |CHAR |40 |Name (of Supervisor) |As of injury date |582 |

|AEDTM |P0082 |DATS |8 |Last Changed On (Flag) |This field is used by SAP for created and changed |622 |

| | | | | |records. | |

|Text - T01 | | |250 |All equipment….using when accident | |630 |

| | | | |occurred | | |

|Text - T02 | | |250 |How injury occurred | |880 |

|Text - T03 | | |250 |If not on premises, address of accident | |1130 |

|Text - T04 | | |250 |Medical Provider Info | |1380 |

|Text - T05 | | |250 |Additional Comments | |1630 |

|Average Weekly Wage |P0082-AVGS |NUMC |7 |AWW |Right justify with 2 decimal places implied. Pad |1880 |

| | | | | |with leading zeroes. | |

|RCD01 |PA0082 |CHAR |2 |Y0 - Type of Claim | |1887 |

|ODT02 |PA0082 |DATS |8 |Y1 - Date of Death | |1889 |

|ODT03 |PA0082 |DATS |8 |Y2 - Date Employer Knew | |1897 |

|ODT04 |PA0082 |DATS |8 |Y3 - Date of Illness | |1905 |

|ODT05 |PA0082 |DATS |8 |Y4 - Last Day Worked/Paid | |1913 |

|JNF05 |PA0082 |CHAR |1 |Y4 – Last Day Worked/Paid (yes/no) |Y=Yes/N=No |1921 |

|1VDT06 |PA0082 |DATS |8 |Y5 - Date Returned Work/Same Wage | |1922 |

|JNF06 |PA0082 |CHAR |1 |Y5 - Date Return Work/Same Wage |Y=Yes/N=No |1930 |

|JNF07 |PA0082 |CHAR |1 |Y6 - Injury on Premises/State |Y=Yes/N=No |1931 |

|REM07 |PA0082 |CHAR |20 |Y6 - Injury on Premises /State | |1932 |

|JNF08 |PA0082 |CHAR |1 |YA - Occur During OT? |Y=Yes/N=No |1952 |

|RCD09 |PA0082 |CHAR |2 |Z0 - Injury Type Code | |1953 |

|RCD10 |PA0082 |CHAR |2 |Z1 - Body Part Code | |1955 |

|RCD11 |PA0082 |CHAR |2 |Z2 - Cause Code | |1957 |

|REM12 |PA0082 |CHAR |20 |Z3 – Injury Type Info | |1959 |

|REM13 |PA0082 |CHAR |20 |Z4 – Body Part Info | |1979 |

|REM14 |PA0082 |CHAR |20 |Z5 – Cause Info | |1999 |

|RCD15 |PA0082 |CHAR |2 |Z6 - Injury Type Code 2 | |2019 |

|RCD16 |PA0082 |CHAR |2 |Z7 - Body Part Code 2 | |2021 |

|JNF17 |PA0082 |CHAR |1 |ZA - Equipment Guards Provided? |Y=Yes/N=No |2023 |

|JNF18 |PA0082 |CHAR |1 |ZB - Equipment Guards Used? |Y=Yes/N=No |2024 |

|JNF19 |PA0082 |CHAR |1 |ZC - Tools Involved? |Y=Yes/N=No |2025 |

|JNF20 |PA0082 |CHAR |1 |ZD – Mechanical Defect? |Y=Yes/N=No |2026 |

|JNF21 |PA0082 |CHAR |1 |ZE - Unsafe Act? |Y=Yes/N=No |2027 |

|JNF22 |PA0082 |CHAR |1 |ZF - Unsafe Condition? |Y=Yes/N=No |2028 |

|JNF23 |PA0082 |CHAR |1 |ZG – Amputation? |Y=Yes/N=No |2029 |

|JNF24 |PA0082 |CHAR |1 |ZH – Vehicle Accident? |Y=Yes/N=No |2030 |

|JNF25 |PA0082 |CHAR |1 |ZI – Panel?/Init Treatment |Y=Yes/N=No |2031 |

|RCD25 |PA0082 |CHAR |2 |ZI - Covered by Panel/treatment | |2032 |

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