As an adjuster, I handled a multi-state desk. The worst states were the ones that had EDI and forms, but for those particular states, neither was terribly time sensitive – they just needed to be done before the file could be closed. So for me, EDI was just a nuisance more than anything. That is, until Pennsylvania went to full EDI.
When PA went from FROIs and forms to FROIs and SROIs and forms, I thought I was going to rip my hair out! There was no other state that I handled where the timeliness of forms and EDI and the combination thereof could make or break a file. Even if I had done everything right and pulled the TNCP within the 90 day period, an EDI error on the SROI could still cause it to convert.
Frequently, my co-workers would come to me with questions about what form to file and couldn’t understand why there were so many forms and why the Bureau required an EDI transaction in addition to a form. By that time, I sat through multiple EDI training sessions and read through all of the information from the Bureau, I had gotten a grasp on the whole EDI thing:
When you get a claim; file an EDI (FROI-00)
When you deny a claim; file an EDI (FROI-04 or SROI-04) and file a Denial
When you accept a claim; file an EDI (SROI-IP or SROI-PY – don’t forget about the liability codes) and file the appropriate form accepting the claim
When you suspend benefits; file an EDI (SROI-S1) and file the appropriate form suspending benefits
When you close a claim; file an EDI (SROI-FN) and send the Final Statement of Account to the Claimant
… starting to get the picture? Every time something changes on the claim, make sure to file an EDI and a form!
Pretty soon the unnatural combination of EDI and forms starts to feel almost second nature. But if you ever have any questions about forms or EDI, please don’t hesitate to ask me. I can be reached by email at firstname.lastname@example.org or by phone at 724-940-2589.