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At a Glance:
Records Required to be Reported

§ 124.105

Records Required to be Reported

(a) Insurance carriers must submit claim EDI records when the insurance carrier:

(1) takes action on or events occur in a claim as described in §124.2 of this title (concerning Insurance Carrier Notification Requirements);

(2) corrects division-identified errors in a previously accepted electronic record as provided in §124.104(b) of this title (concerning Reporting Requirements);

(3) corrects insurance carrier-identified errors in a previously accepted electronic record as provided in §124.2(b)(4) of this title;

(4) discovers that a claim EDI record should not have been submitted to the division, and the division had previously accepted the claim EDI record; or

(5) receives a request from the division for claim EDI records.

(b) Regardless of the application acknowledgment code returned in an acknowledgment, claim EDI records are not considered received by the division if the claim EDI record:

(1) contains data, which does not accurately reflect the code value or actions taken when the insurance carrier processed information or acted on the claim; or

(2) fails to contain a conditional data element and the mandatory trigger condition existed at the time the insurance carrier acted on the claim.

(c) Claim EDI records submitted in the test environment are not considered received and do not comply with the reporting requirements of this section.

(d) Claims with a date of injury on or after January 1, 1991, must be reported in accordance with the requirements of this chapter (concerning Insurance Carriers: Notices, Payments, and Reporting).

End of Document