Calculating 21-Day Compliance

The information provided here is intended to help workers’ compensation insurers improve their accuracy and timeliness in 21-day reporting as well as to maintain and/or increase their compliance percentage rate.

EDI Transactions used to calculate 21-Day Compliance include:

• SROI IP with Liability/Notice of Compensation Payable (NCP)
• SROI IP without Liability/Notice of Temporary Compensation Payable (NTCP)
• SROI IP with Liability and an Award Order Date/Agreement for Compensation
• FROI 04 or SROI 04/Notice of Compensation Denial (NCD)

The 21-Days are calculated using the later of either the “Date Employer had Knowledge of Date of Disability (DN 0281)” or the “Initial Date Disability Began (DN 0056)” from your SROI transaction or the “Date Employer Had Knowledge of the Injury (DN 0040)” from the FROI 04 and comparing this date against the received date of your accepted transaction.

Claim administrators are required to file the First Report of Injury (FROI) with the Bureau if an injured worker has missed a full day, shift, or turn of work. This is required within 7 days after the date disability begins for all injuries covered by Section 438 of the Act and within 48 hours for any injury resulting in death. However, to establish any claim in WCAIS, a FROI must be on file.

Except as otherwise provided by law, in computing a period of time prescribed or allowed by the Pennsylvania Workers’ Compensation Act Rules and Regulations; the day of the act, event or default after which the designated period of time begins to run may not be included. The last day of the period so computed shall be included, unless it is Saturday, Sunday or a legal holiday in this Commonwealth, in which event the period shall run until the end of the next day, which is neither a Saturday, Sunday nor a holiday. A part-day holiday shall be considered as other days and not as a holiday. Intermediate Saturdays, Sundays and holidays shall be included in the computation (PA Rules and Regulations section § 121.3a.).

• Determine whether your EDI transaction(s) were filed and accepted.
  
  
• If a claim administrator is intending to report intermittent periods of disability or delayed disability, this information needs to be included in the SROI IP by populating the “Current Date Disability Began (DN 0144)”. When this is provided, this field will be used for the 21-Day calculation rather than the “Initial Date Disability Began (DN 0056)”.
  
  
• Make certain the dates entered in the “Date Employer had Knowledge of Date of Disability”, “Initial Date Disability Began”, “Date Employer Had Knowledge of the Injury”, or “Current Date Disability Began” fields were submitted correctly.
  
  
• Medical only claims are not reviewed for timeliness. The Claim Type Code (DN0074) for a medical only claim must have a value of “M” or “B” else it will be reviewed for timeliness. When only medical bills are paid and a claim administrator wishes to generate a medical only form, and there are no indemnity or specific loss payments, claims should be coded as “M” or “B”.
  
  
• If a claim administrator chooses to use an Agreement to initiate payment and update a claim status, they must file a SROI IP with Liability and an Award Order Date. However, the Bureau will accept Agreements for Compensation bearing only the adjuster’s signature to preserve the 21-Day filing credit. The Agreement will not however establish compensation until it is signed by both the adjuster and the injured worker. Date of Notice on the Agreement form does not establish the file date. Absent a U.S. Postal Service Postmark, the file date is equal to the date of receipt in the Bureau.

Bureau Compliance Formula Incorporates:

Section 406.1 (a): The employer and insurer shall promptly investigate each injury reported or known to the employer and shall proceed promptly to commence the payment of compensation due either pursuant to an agreement upon the compensation payable or a notice of compensation payable as provided in section 407 or pursuant to a notice of temporary compensation payable as set forth in subsection (d), on forms prescribed by the department and furnished by the insurer. The first installment of compensation shall be paid not later than the twenty-first day after the employer has notice or knowledge of the employee’s disability. Interest shall accrue on all due and unpaid compensation at the rate of ten per centum per annum. Any payment of compensation prior or subsequent to an agreement or notice of compensation payable or a notice of temporary compensation payable or greater in amount than provided therein shall, to the extent of the amount of such payment or payments, discharge the liability of the employer with respect to such case.

Section 406.1 (c): If the insurer controverts the right to compensation it shall promptly notify the employee or his dependent, on a form prescribed by the department, stating the grounds upon which the right to compensation is controverted and shall forthwith furnish a copy or copies to the department.

Section 438 (a): An employer shall report all injuries received by employees in the course of or resulting from their employment immediately to the employer’s insurer. If the employer is self-insured such injuries shall be reported to the person responsible for management of the employer’s compensation program.

Section 438 (b): An employer shall report such injuries to the Department of Labor and Industry by filing directly with the department on the form it prescribes a report of injury within forty-eight hours for every injury resulting in death, and mailing within seven days after the date of injury for all other injuries except those resulting in disability continuing less than the day, shift, or turn in which the injury was received. A copy of this report to the department shall be mailed to the employer’s insurer forthwith.

Section 407: On or after the seventh day after any injury shall have occurred, the employer or insurer and employee or his dependents may agree upon the compensation payable to the employee or his dependents under this act; but any agreement made prior to the seventh day after the injury shall have occurred, or permitting a commutation of payments contrary to the provisions of this act, or varying the amount to be paid or the period during which compensation shall be payable as provided in this act, shall be wholly null and void. It shall be unlawful for any employer to accept a receipt showing the payment of compensation when in fact no such payment has been made.

Where payment of compensation is commenced without an agreement, the employer or insurer shall simultaneously give notice of compensation payable to the employee or his dependent, on a form prescribed by the department, identifying such payments as compensation under this act and shall forthwith furnish a copy or copies to the department as required by rules and regulations. It shall be the duty of the department to examine the notice to determine whether it conforms to the provisions of this act and rules and regulations hereunder.

All agreements made in accordance with the provisions of this section shall be on a form prescribed by the department, signed by all parties in interest, and a copy or copies thereof forwarded to the department as required by rules and regulations. It shall be the duty of the department to examine the agreement to determine whether it conforms to the provisions of this act and rules and regulations hereunder.

All notices of compensation payable and agreements for compensation and all supplemental agreements for the modification, suspension, reinstatement, or termination thereof, and all receipts executed by any injured employee of whatever age, or by any dependent to whom compensation is payable under section three hundred and seven, and who has attained the age of sixteen years, shall be valid and binding unless modified or set aside as hereinafter provided.

Section 121.3. (Filing of forms under the Rules and Regulations)
(a) Forms must be in the format prescribed by the Bureau. All references to forms mean paper forms or an electronic format prescribed by the Bureau.
(b) The Bureau may return forms that are not properly completed or filed. If a form is returned, the Bureau will notify the submitting party as to the reason the form was returned. For a form returned for the first time, the Bureau will preserve the filing date if the submitting party files a corrected version of the form within 14 days of the written notice of the return of the form.
(c) The filing date is the date indicated on the United States Postal Service postmark or postal receipt. If the postmark or postal receipt is absent or unreadable, the filing date is the date of receipt by the Bureau. In all other instances, including electronic filing or hand-delivery, the filing date is the Bureau’s date of receipt.

The Flow of a Pennsylvania Workers' Compensation Claim document explains the process of a claim in both non-litigated and litigated situations.