Remember the good old days when denying a petition was as easy as checking a box 1 denial which covered everything? Those days have past and the new way to deny Claims is more complex.
Somehow the Bureau took a denial with 5 options and made it more complicated by providing us with 27 different codes which will check one of the 5 boxes. And not only are there 27 codes, but all of the 1 codes don’t fill into box one! In Pennsylvania workers’ compensation, we live and die by the Bureau documents, so it is incredibly important to generate the correct document with the intended information with your FROI or SROI-04. Below is a cheat sheet of the denial codes and the corresponding block on the denial form so you can make sure you are generating the form that you intended to.
1. The employee did not suffer a work-related injury. The definition of injury also includes
aggravation of a pre-existing condition or disease contracted as a result of employment.
1D: Not Statutory Definition of Accident
2A: Idiopathic Condition
2B: Pre-existing Condition
2C: Stress non-work related
2D: No Medical Evidence of Injury
2E: No Injury Per Statutory Definition
2F: Accident not major contributing cause of injury
2. The injury was not within the scope of employment.
1A: Coming and Going
1C: Willful Intent to Injure Oneself
1E: Deviation from Employment
1F: Recreational/Social Activity
3. The employee was not employed by the defendant.
3A: No Employee/Employer Relationship
3B: Independent Contractor
3C: Not Statutory Definition of Employee
3I: Employee not reported to PEO
4. The employee did not give notice of his/her injury or disease to the employer within 120
days within the meaning of Sections 311-313 of the Workers’ Compensation Act.
5A: Failure to Report Accident Timely
5. Other good cause; please explain fully in the space below.*
1H: Subsequent Intervening Accident
3D: No Jurisdiction
3E: No Policy in Effect on Date of Accident
3F: Statute Limitations Expired
3G: Statutory Exemptions (Sole Proprietor, Corporate Officer, etc.)
3H: Elected Other Coverage (24hr, Collective Bargaining, Opted Out)
4A: Injury Primarily Occasioned by Intoxication or Use of Any Drug
4B: Substance Use/Abuse, Violation of Drug-Free Work Place Policy in effect
5B: Right to Reserve
*Remember to put the explanation in data element 0197 in 50 characters or less!
Please contact Liz Sooy (724-940-2589 or firstname.lastname@example.org) if you would like a laminated handout of this information for your desk or if you have any questions about EDI.