EDI LIBC-495 (Notice of Compensation Payable – BWC)
EDI LIBC-495 verifies if the Claim Administrator has implemented the changes that would result in the generation of the Notice of Compensation Payable (LIBC-495) based on the following EDI transaction/maintenance type codes:
- SROI IP
- SROI PY
- SROI AP
- SROI RB
- SROI 02
- SROI CA
- SROI PD
SROI IP
1. Claim Admin submits a FROI 00 to create a new test claim.
2. Claim Admin uses the claim created in Step 1 to submit an IP transaction with Agreement to Compensate Code (DN0075) = ‘L’ and making sure to populate new Mandatory Conditional Data Elements.
SROI PY
1. Claim Admin submits a FROI 00 to create a new test claim.
2. Claim Admin uses the claim created in Step 1 to submit a PY transaction with Agreement to Compensate Code (DN0075) = ‘L’ and making sure to populate new Mandatory Conditional Data Elements.
SROI AP
1. Claim Admin submits a FROI 00 to create a new test claim.
2. Claim Admin uses the claim created in Step 1 to submit an AP transaction with Agreement to Compensate Code (DN0075) = ‘L’ and making sure to populate new Mandatory Conditional Data Elements.
SROI RB
1. Claim Admin submits a FROI 00 to create a new test claim.
2. Claim Admin uses the claim created in Step 1 to submit an IP transaction with Agreement to Compensate Code (DN0075) = ‘W’ and making sure to populate new Mandatory Conditional Data Elements.
3. Claim Admin uses claim from Step 1 to submit an SROI 04 transaction with Full Denial Reason Code (DN0198) ‘4.A.’
4. Claim Admin submits a SROI RB transaction with Agreement to Compensate code (DN0075) “L” to reinstate benefits and making sure to populate new Mandatory Conditional Data Elements.
SROI 02
1. Claim Admin submits a FROI 00 to create a new test claim.
2. Claim Admin uses the claim created in Step 1 to submit an IP transaction with Agreement to Compensate Code (DN0075) ‘L’.
3. Claim Admin uses claim from Step 1 to submit a SROI 02 with an amended Initial Date Disability Began.
SROI CA
1. Claim Admin submits a FROI 00 to create a new test claim.
2. Claim Admin uses the claim created in Step 1 to submit an IP transaction with Agreement to Compensate Code (DN0075) ‘L’.
3. Claim Admin uses claim from Step 1 to submit a SROI CA increasing the Average Wage (DN0286) and Calculated Weekly Compensation Amount (DN0134).
SROI PD
1. Claim Admin submits a FROI 00 to create a new test claim.
2. Claim Admin uses the claim created in Step 1 to submit a SROI PD with Agreement to Compensate code (DN0075) “L” and Claim Type Code (DN0074) ‘M’.
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