Basics of Detailed Claim Information (DCI) Reporting ...Presenter Biographies Christopher Mercer manages NCCI’s Medical Data and Detailed Claim Information Validation

1

1© Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved.

Presented by: Mitch Cohen and Chris Mercer

Basics of Detailed Claim Information (DCI) Reporting Requirements


The whirling gears of progress have put the gear makers out of work.

2


Objective

Provide an overall understanding of Detailed Claim Information reporting, editing, and compliance under the Detailed Claim Information program.


Agenda

Overview

Tools and Resources

File Layout

Certification Requirements

Sampling Requirements

Elements and Report Types

Editing

Reports

Compliance Programs

3


Overview


Detailed Claim Information (DCI)

Detailed Claim Information is:• A method to collect detailed information on

Indemnity Claims for legislative pricing and research

Indemnity Claims (or Lost-Time Claims):• A claim in which compensation is paid to an

injured worker for lost wages due to a work-related injury

4


DCI Data Usage

Detailed Claim Information is used for:

Used extensively for a variety of purposes:

Legislative Pricing

State Advisory Forums

ResearchStudies

Comparison of Wages to

BenefitsAttorney

InvolvementLump-SumPayments


Participation Eligibility

Market Share

1% average over latest 3 years in at least 3 states

5% in latest year in 1 state

Carrier State Premium

Total State Premium

Participation Based on NAIC and Financial

Call Data

Part2

5


Participant Reporting Requirements

Once a carrier meets the eligibility criteria, it is required to:

• Report for all applicable DCI states

• Continue reporting even if below the eligibility threshold

• Report DCI for all companies aligned within an affiliate group

Reporting obligation remains with any carrier/group that was required to report prior to a merger or acquisition.


Special Participation Eligibility

Carrier participation is mandatory for all workers compensation writers in:

Massachusetts Texas

6


DE

Alaska Hawaii

WA

OR

WY

CA

MT

ID

NVUT

AZ

CO

NM

TX

OK

KS

NE

SD

ND MN

IA

MO

AR

LA

MS

TN

AL GA

FL

WI

IL IN

MI

PA

KY

WV

OH

NY

VA

NC

SC

MD

NJ

CT

ME

VTNH MA

RI

NCCI States Participating Independent

Bureaus Mandatory Participation Non-Participating

Participation State Map


Tools and Resources

7


ncci.com


ncci.com

8


ncci.com


DCI Resources

Manuals

• Detailed Claim Information Reporting Guidebook• Including edit matrices

• Electronic Transmission User’s Guide• Statistical Plan

Communications

• DCI and DQ Circular/FYI Series • Web Articles

9


DCI Resources

Online Tools

• Detailed Claim Information via DCA Access®

Online• Data Manager Dashboard

Webinars

• Detailed Claim Information Education• Data Quality Education


File Layout

10


DCI Record

Detailed Claim Information Reporting Guidebook

• Record Type Code = 1

• Submitted to NCCI as a flat text file

• 500 bytes • Texas = 600 bytes

Part5


Submission Control Record Field No. Field Title/Description Class Position Bytes1 Record Type Code—Enter “9.” N 1 1

2 Carrier Group Code—Report the code assigned by NCCI that corresponds to the dominant insurer in a carrier group.

N 2–6 5

3 Filler—Fill positions 7–41 of this record with nines.

N 7–41 35

4 Record Total—Report the total of all Record Type 1 records. Do not count the Submission Control Record in this total. Field is right-justified and left zero-filled for totals less than eight characters.

N 42–49 8

5 Reserved for Future Use 50–250 201

Only one Submission Control Record must be reportedNot included in the Record Total

11


Electronic Submissions

Flat File

DCI RecordsOne

Submission Control Record

File naming conventions: Production = V2DCI.Max 30 characters.txt Certification = V2DCI.Max 30 characters.tstPre-Edit = V2DCIPR.Max 30 characters.txt


DCI Submission Options

Online Keying • Detailed Claim Information via DCA Access®

Online

Batch Submissions• Data Transfer via the Internet (DTVI)

• Browser Mailbox• Secure FTP

• Data Encryption• PGP

12


Certification Requirements


Purpose of Certification

• Checks Ability for Carrier to Submit• FTP connection• Access for DTVI and the Detailed Claim

Information tool

• Checks File Naming Convention Is Correct

• File Formatting Correct

Note: Does not test ability to apply sampling methodology nor test data quality

13


Electronic Certification Testing

For general certification requirements, refer to the following manuals:

• Electronic Transmission User’s Guide• Data Provider Profile Form

• Provides user information • Provides authorization to DTVI, Detailed Claim

Information tool, and Data Manager Dashboard• Required for each data reporting group• Acceptable file names

• Detailed Claim Information Reporting Guidebook


Electronic Certification Testing

Test file should contain at least 25 to 50 transactions

• Must include the Submission Control Record

• Original reports only or Original andcorresponding Subsequent in same submission

If DCI transactions are free of errors, the test submission passes the certification.

14


TPA Requirement

For each TPA/vendor/outside data provider:

Service Provider Data

Tool Access Addendum

Service Provider

Agreement

Data Provider Profile Form


Recap: True or False?

NCCI does certification testing to validate a carrier’s ability to apply the DCI sampling methodology

DCI is used for legislative pricing and research

DCI batch submissions are mailed to NCCI on a 3480 cartridge and must be in EBCDIC format

15


Sampling Requirements


Reported to Insurer (RTI) Date

• Triggers first loss valuation

• Determines valuation level for reporting claims that become Death or Permanent Total Disability

• May have different definition in your database

Par3

16


Valuation of Claims

Subsequent Valuation

12 months after the preceding

valuation

Due within 3 months after

valuation

Up to 138 months from RTI

Initial Valuation

18 months after RTI

Due to NCCI by 21st month

Texas6 months after

RTI

Due to NCCI by 9th month


Valuation Example

2013 2014 2015 2016 2017 2018

Reported to Insurer 7/2013

018Value

1/2015

Due by 4/2015

030Value 1/2016

Due by 4/2016

042Value

1/2017

Due by 4/2017

054Value

1/2018

Due by 4/2018

Subsequent valuation level through 138

17


Claim Selection Process

• The claim selection process begins 18 months after the RTI date (6 months for Texas)

• Performed on a monthly basis for each state that the carrier is reporting

• Sampling occurs only once for each RTI date


Claim Selection Process

Excluded

Non-DCI Claims

Required

All Death and Permanent

Total Disabilities

Sampled

Percentage per State of Open

and Closed Claims

Part3

18


Excluded Claims

• Not an Applicable DCI State

• Medical-Only Claims

• Reinsurance Assumed Claims

• Claims Payable Under Federal Acts

• Noncompensable and Fraudulent Claims

• West Virginia Deliberate Intent (Mandolidis) Coverage

Excluded

Non-DCI Claims


Required Claims

• Not sampled

• Valued based on RTI date

• Anytime within 138 months of RTI date

• If reclassified to another benefit type, continue to report

Required

All Death and Permanent

Total Disabilities

19


Death or Permanent Total Disability

2012 2013 2014 2015 2016 2017

Example: Open claim that was not sampled in original reporting becomes a Permanent Total Disability (PTD)

Reported to Insurer 7/2012

018Value

1/2014

Due by 4/2014

030Value 1/2015

Due by 4/2015

042Value

1/2016

Due by 4/2016

054Value

1/2017

Due by 4/2017

Subsequent valuation level through 138

Claim #1234

Perm Total

Dec 2014

Claim #1234

Temporary


Sampled Claims

• Based on State Sample Ratio Table

• Random Sample:

• Recommend assigning three-digit numbers

• Each of the 1,000 possible numbers is equally likely (probability = 0.001)

• Can be assigned/used more than one time

Sampled

Percentage per State of Open

and Closed Claims

20


Sampling Ratios

State Sample Ratios for DCI Reporting

Code Jurisdiction State Open Claims

ClosedClaims

54 Alaska 100% 5%

08 District of Columbia 100% 9%

18 Maine 100% 5%

28 New Hampshire 100% 4%

38 Rhode Island 100% 3%

40 South Dakota 100% 8%

42 Texas 100% 66%

44 Vermont 100% 7%

Carriers are to report applicable open and closed claim sample ratios for each state. Open claims have a higher percentage ratio than closed claims.

State Sample Ratios for DCI Reporting

Code Jurisdiction State Open Claims

Closed Claims

09 Florida 12% 2%

12 Illinois 8% 1%

20 Massachusetts 14% 1%

24 Missouri 14% 1%

29 New Jersey 14% 1%

31 New York 6% 1%

32 North Carolina 19% 2%

37 Pennsylvania 11% 1%


Sampling Dos and Don’ts

If you sample correctly, the number of claims submitted each month per state will vary.

Not Used For:Verify the sample rates (1% vs. 10%)

Only report claims that the random sampling method chooses for you

Expect sampling to select claims for each state each month

Try to compute the number of claims to send each month and send that number of claims

Don’tDo

21


Claim Selection Process Recap

1• Select Jurisdiction State and Reported to Insurer Month

2• Exclude non-DCI claims

3• Select required claims

4• Assign random numbers

5• Apply sampling ratios



DCI claims are due to NCCI by the 21st month from the RTI date

All Death and Permanent Total Disabilities are required to be included in each month’s submission

You should try to compute the number of claims to send each month and send that number of claims

22


Elements and Report Types


DCI Report Types

Original

ReplacementSubsequent

23


Original Reports

• Valued 18 months after Reported to Insurer (RTI) Date

• All Death and Permanent Total Disability

• Eligible open and closed claims selected in the random sampling process


Original

Texas: Reports valued six months after RTI Date


Subsequent Reports

• Provide changes due to development of the claim

• Valued every 12 months after initial report

• Must match a claim on NCCI’s DCI database (based on key fields) unless:• Reporting a Death or Permanent Total claim

that has not been previously reported

Original


24


Subsequent Reports

Valued at 138th month

Reclassified

Closed

Subsequent

• Report at next loss valuation period

• Report all data valued as of the subsequent loss valuation

• No further reporting unless claim reopens or claim values change


Replacement Reports

Used For: Not Used For:Correcting nonrejected claims at any valuation level

Correcting rejected claims

Changing key field information Loss valuation updates due to normal development

Original

Subsequent ReplacementReport “R” in the Replacement

Report Code field

25


Replacement Reports

• Non-key field—each valuation level that contains the incorrect value

• Key field—most recently reported valuation level

Reminder: This is a complete replacement; ALL revised and unchanged data must be reported.

Replaces previously reported value for each valuation replaced

Replaces previously reported value for ALL valuation levels


Key Field Changes

Data Reporting Element

Carrier Code Previous Carrier Code

Policy Number Previous Policy Number

Policy Effective Date Previous Policy Effective Date

Reported to Insurer Date Previous Reported to Insurer Date

Claim Number Previous Claim Number

26


Claim Deletion

• Deleting of claim can only be done through the Detailed Claim Information tool

• Conditions when to delete claims:

• Noncompensable or fraudulent claims

Note: Deletion of a claim at any valuation will delete all valuations.


General Claim Information

55 Unique Elements

Key fields must match across valuations and other data types.

27


Claimant and Employer Information


Claim Expense and Payment Information

Lump-Sum Benefits Indemnity Benefits

28


Benefit Type Array: • Benefit Type Code• Benefit Amount Paid

• Weekly Benefit Amount

Lump-Sum Array:• Benefits Covered by Lump-

Sum Code• Lump-Sum Payment Amount

Multiple Benefits Reported


Data Dictionary

• Organized alphabetically• Includes data element descriptions, format, allowable

content, code tables, relationships, and reporting rules

Part6

29


Texas-Only Elements

• Employer FEIN

• Employee SSN

• Hospital Costs Amount Paid

• Total Payments to Physicians

• Date of First Payment

• Zip Code of Injury Site

Texas-only elements are at the end of the record layout. If you’re not reporting for Texas, you don’t need to report

the additional elements.

Medical Extinguishment Indicator—Not Applicable

6 Unique Texas Elements


Recap: True or False

If a DCI claim that has already been reported to NCCI becomes noncompensable or fraudulent, it should be deleted from DCA

To correct a DCI claim, just submit a subsequent report with the corrected information

You can report up to six different benefit type codes for lump-sum payments

30


Editing


Editing Flow

NCCICorrect the issue and resubmit

31


Editing

• Checks the validity, accuracy, and completeness of the data

• Ensures that the data submitted is consistent with reporting requirements and meets quality standards

• Identifies errors so that data providers can replace the data and/or take any other corrective action necessary

• Can receive more than one edit

Part7


Edit Types

Submission

Field

Logical

Relational Edits

32


Submission Edits

DCI File Submitted via DTVI

Step 1: Is the file name valid? If yes, go to step 2.

If No, send “Invalid File Name” email to sender

Step 2: Is the user authorized?If yes, go to step 3

If No, send “Unapproved Data” email to sender

Step 3: Does the file have the proper PGP encryption key (if encrypted)?

If the file does, go to step 4

If file is incorrect, send “Invalid Encryption Key” email to sender.

Step 4: Does the file have the proper record length or contain NULL characters?

If the file does, go to step 5

If file is incorrect, send “Invalid Data” email to sender.

Step 5: File moves to applicationfor further editing and backup file is created

Send “Successful Transmission”email to sender


Submission EditsFrom: [email protected] [mailto:[email protected]] Sent: Thursday, October 16, 2014 9:35 AM To: Mitch Cohen Subject: 99998 Record Type Code Must Be Valid Per Table Dear Mitch Cohen: NCCI would like to inform you that the following file submission was not processed: Mailbox: 7654321 File Name: v2dci.deptest_010801.txt Name: Mitch Cohen Account ID: 99998 10/16/2014 The entire submission was rejected for the following error(s): Record Type Code Must Be Valid Per Table Found invalid record type(s) Please review the file submission as well as the information in your system to determine the necessary corrective action. Once the file is corrected you may resubmit the file for processing. You are receiving this e-mail as a data customer of NCCI. Please do not respond to this system-generated e-mail. If you have questions or feel that you have received this e-mail in error, please contact Customer Service.

BLANK

33


Data Grades

EditClass

Data Grade Description

Corrective Action Required

Error Free

0 The DCI report is free of errors. (This error class and data grade are applicable and viewable only when using the DCI online tool.)

None.

Default 3 A data element was reported incorrectly and NCCI substituted an assumed correct default value for this data element.

None unless defaultvalue is incorrect.

Reject 9 A critical data element or condition needed for loading and mapping the data was reported incorrectly and is invalid. The DCI report was rejected, is not captured on the production database, and is not used in NCCI’s products and services.

A resubmission of the report is required.

Edit Classes determine how data is processed.

Data Grades describe the level of severity.


DCI Edit Matrices

34


DCI Edit Matrices

DCI Edit Matrix—All Edits in Production

DCI Edit Matrix—Future Edit Enhancements


DCI Production Edit Matrix

Record Type

Edit Number

Data Grade

Data Field Edit Message ReportType

EditType

ApplicableStates

ExcludedStates

Effective Date Edit Change

10092-02 9 Incurred Indemnity Amount Total

Incurred Indemnity Amount Total must equal the sum of:Benefit Amt Pd,Indemnity Lump Sum Amt,Claimant Legal Amt, andany Voc Rehab Amtwhen: Claim Status Cd equals 1,Type of Recovery Cd equals 01, andRecovery Reimbursement Amt equals zero

Original,Subsequent,Replacement

L All others FL, MI 03/11/11

10/01/10

Updated Edit Message to remove redundancy between Data Field and Edit Message.

Added edit.

10108-01 9 Jurisdiction State Code

Must be valid per table. Original,Subsequent,Replacement

F All 10/01/10 Added edit

10421-02 9 Preinjury/Average Weekly Wage Amount

Must be greater than 0. Original,Subsequent,Replacement

F All 04/10/14 Added edit

10434-04 9 Weekly Benefit Amount

Weekly Benefit Amount reported exceeds the maximum benefit for reported Jurisdiction State Code.


L All 10/01/10 Added edit

10434-05 9 Weekly Benefit Amount

Weekly Benefit Amount reported is less than the minimum benefit for reported Jurisdiction State Code.


L All 10/01/10 Added edit

19900-01 9 MiscellaneousLink Edits

A subsequent report must have a matching claim for a prior valuation level when Benefit Type Code is not equal to 01 or 02.

Note-Matching key fields are: Policy Number Policy Effective DateCarrier Code Claim Number Reported to Insurer Date

Subsequent R All TX 03/31/11

10/01/10

Added TX to Excluded States.

Added edit.

35


Field Edit

• Edit number 0108-01 looks at the Jurisdiction State Code

• Must be valid per table

• Most often the field is: • Zero-filled• Blank-filled• Alpha-filled


Edit Discussion

36


Logical Edits


Edit Discussion

0434 series are logical edits that compare the Benefit Type Code, Amount Paid, and Weekly Benefit Amount fields.• Must be greater than zero when Benefit Type Code is not

equal to a death or employers liability benefits• Weekly Benefit Amount reported exceeds the maximum

benefit for reported Jurisdiction State Code• Weekly Benefit Amount reported is less than the

minimum benefit for reported Jurisdiction State Code• Weekly Benefit Amount and Benefit Amount Paid were

used to calculate a duration that exceeds the period of time for the reported Valuation Level

37


Logical EditsWhen reporting the Weekly Benefit Amount:• Submit data as of report valuation• All elements of the array are edited

Benefit Array

Benefit Type Code

Benefit Amount

PaidWeekly Benefit Amount


Weekly Benefit Amount

Example:

$50


018@Valuation

= $4,180

Maximum Benefit Paid

38



Example:

$50


018@Valuation

= $4,180


Benefit Amount Paid

$5,000

Carrier reported values



Example:

$50 018@Valuation

= $4,180


Benefit Amount Paid

$5,000

Edit Number Edit Message

0434-02 The Weekly Benefit Amount and Benefit Amount Paid were used to calculate a duration that exceeds the period of time for the reported Valuation Level.

Carrier reported values

39


Edit Number Data Field Edit Message0434-02 Weekly Benefit

AmountThe Weekly Benefit Amount and Benefit Amount Paid were used to calculate a duration that exceeds the period of time for the reported Valuation Level.


Benefit Paid Amount is too high ($5,000 vs. $500)

Weekly Benefit Amount is too low ($50 vs. $150)

Benefit Type may have been reported incorrectly (TP vs. TT)

Lump-sum payment placed in the wrong array

REASONS


Relational Edits

Also known as Miscellaneous Link Edits, they compare the data in a specific field on the report with another data field:• Contained in the same report submission• Already stored on NCCI’s database • Both

Prevent the duplication of claims and correctly link subsequent and replacement reports

40


Relational Edits9900 series of edits are relational edits that compare the following:• Subsequent reports

• Must have a matching claim for a prior valuation level• Must not already reside on the DCI database• Must be submitted in proper sequence

• Key Field Changes must not match a claim on the DCI database based on revised key fields

• Replacement reports must have a matching claim for the same valuation level within the submission or on DCI database

• Multiple changes for a DCI report, with the same Valuation Level and Replacement Report codes, are present within the submission file

Note: Gaps in sequence are permitted for reopened claims whenprior reports are closed or medical only.



A claim can receive more than one reject edit

When a claim receives a reject (Data Grade 9) it is stored on the database

The DCI Reporting Guidebook provides the details of each DCI edit

Relational edits only look at data already stored on NCCI’s database

41


Reports


Reports

• Formats: CSV, PDF, XLS

• Notification via email

• Submission Results returned to submitter

• All others to the DCI data reporting contact

• Also available through the Detailed Claim Information tool

• Data Reports Web page at ncci.com

Part8

42


Available Reports

NCCI-Generated Reports Report Frequency

DCI Submission Results Reports Upon Receipt of DCI File

DCI Reject Follow-Up Report Monthly

DCI Expected Subsequents Report Monthly

DCI Overdue Subsequents Report Monthly


Submission Results Report

• Details of claims submitted, including rejects (Data Grade 9) and default errors (Data Grade 3)

• Generated with each electronic submission

• Submission Results returned to submitter via email

43


Reject Follow-Up Report

• Details of claims with one or more rejects (Data Grade 9)

• Remains on the report until corrected or is removed from staging

• Emailed to the DCI data reporting contact


Expected Subsequents Report

• Details subsequent valuation claims expected in the next 60 days

• Generated two months prior to its valuation month (five months prior to due date)


44


Overdue Subsequents Report

• Details subsequent valuation not received three months after valuation month

• Overdue 1–12 months, summary and detail

• Overdue 13 or more months, counts only



Customer-Generated Reports

• Provides a customized version of the information found on NCCI-generated reports

• Based on user criteria • Available upon customer request• Provides the most current view

Customer-Generated Reports

DCI Reject Report

DCI Expected Subsequents Report

DCI Overdue Subsequents Report

DCI Saved Claims Report

DCI Saved Claims Report:

Provides a listing of all claims entered and saved within the last 24 hours in the Detailed

Claim Information tool but not yet submitted

45


Compliance Programs


Compliance Programs

• Goal• Measure data provider

expected DCI submissions• Provide debits to encourage

timely submissions

• Data Quality Incentive Program (DQIP)

• Carrier Data Quality Report Program (Report Card)

46


DE

Alaska Hawaii

WA

OR

WY

CA

MT

ID

NVUT

AZ

CO

NM

TX

OK

KS

NE

SD

ND MN

IA

MO

AR

LA

MS

TN

AL GA

FL

WI

IL IN

MI

PA

KY

WV

OH

NY

VA

NC

SC

MD

NJ

CT

ME

VTNH MA

RI

DCI Compliance States Non-Participating

Compliance States Map


Data Quality Incentive Program

DQIP for DCI evaluates:

• 018–138 month DCI valuations• Does not evaluate Texas 6-month valuations

• Applicable compliance states only

• Based on timeliness

47


Data Quality Incentive Program

• Two debit categories: • 18 Month Valuations Past Due• >18 Month Valuations Past Due

• Debits apply to the overall data quality incentive factor used to modify the data collection and statistical agent fees

Refer to the Data Quality Web pageon ncci.com.


Data Manager Dashboard

48


Data Manager Dashboard


Carrier Data Quality Report Program

The Report Card evaluates the overall annual reporting performance.

99990NCCI Holdings

49


Carrier Report Card

Each category is graded separately and combined for one overall grade.

• Volume eligibility:

• 18 Month Valuations—40 expected

• >18 Month Validations—20 expected

• Number of valuations received on time is compared to the number expected for all states combined


Recap: True or False

NCCI mails out the monthly reports via hard copy

Overdue Subsequents Report details subsequent valuations not received three months after valuation month

DQIP does not evaluate Texas 18-month valuations

Carrier Data Quality Report Program (Report Card) is part of NCCI’s compliance program

50


Supplemental Information

Presenter Biographies

Christopher Mercer manages NCCI’s Medical Data and Detailed Claim Information Validation Teams. Chris possesses more than 18 years of experience in the insurance industry, predominantly in the workers compensation field. He has served as a manager in NCCI’s Data Resources Division for more than 12 years, which includes time managing the Financial Data Validation and Unit Data Validation Teams. Prior to that, he spent six years working for an insurance carrier, auditing and reporting data to NCCI as well as being responsible for carrier compliance.

Mitch Cohen has been with NCCI for 16 years and currently works in the Data Collection Department on the Customer Support Team of Data Resources. He works with data providers to resolve their Unit and DCI data reporting issues. Mitch was with the Customer Service Department prior to joining Data Resources.

Documents

Basics of Detailed Claim Information (DCI) Reporting ...Presenter Biographies Christopher Mercer manages NCCI’s Medical Data and Detailed Claim Information Validation