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Philadelphia

106 Chesley Drive

Media, PA 19063

P: (610) 627-9100

F: (610) 627-9717 

Pittsburgh

6000 Brooktree Road

Suite 300

Wexford, PA 15090

P: (724) 940-2977

F: (724) 940-2970 

Delaware

Barley Mill House

3701 Kennett Pike

Suite 100

Greenville, DE 19807

P: (302) 308-6100

F: (302) 308-6106

Copyright© 2019 Carpenter, McCadden & Lane, LLP

What Happened to My Block One Denial?

January 17, 2018

 

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

1B: Horseplay

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

5C: Misrepresentation

*Remember to put the explanation in data element 0197 in 50 characters or less!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please contact Liz Sooy (724-940-2589 or esooy@cml-law.net) if you would like a laminated handout of this information for your desk or if you have any questions about EDI.

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