Department of Labor: Njcribimpguide4 4a

NEW JERSEY
EDI IMPLEMENTATION GUIDE
For the reporting of
First (FROI) and Subsequent (SROI) Reports of Injury
March 15, 2002

COMPENSATION RATING & INSPECTION BUREAU
Table of Contents
Original Release and Revisions .................................................................................................................5
Foreword ......................................................................................................................................................6
EDI Legislation ...........................................................................................................................................6
EDI Implementation Assistance .................................................................................................................6
Required Implementation Date ..................................................................................................................7
Use of Data Received through EDI............................................................................................................7
Acknowledgements....................................................................................................................................8
New Jersey Statutes and Rules Authorizing EDI .....................................................................................9
Important New Jersey Terminology.........................................................................................................20
Organization of Information in this Manual ............................................................................................26
New Jersey Methods of Delivery..............................................................................................................28
Background of State EDI Reporting Standards......................................................................................29
Executive Summary: Managing an EDI Implementation .......................................................................30
Information and Help.................................................................................................................................32
NJCRIB/NJDWC Official Web Pages ......................................................................................................32
NJCRIB Staff Phone & E-Mail..................................................................................................................32
NJCRIB Vendor Help Line and E-mail .....................................................................................................32
NJDWC Contact Information for Business/Law/Regulations Issues and Questions ...............................32
IAIABC Web Page & Phone Number.......................................................................................................32
Frequently Asked Question Document on the NJCRIB Web Page .........................................................32
NCCRIB EDI Reporting Process..............................................................................................................33
Steps to Implement NJCRIB EDI ..............................................................................................................34
NJCRIB EDI Requirements......................................................................................................................34
Specific Changes from the Current Process............................................................................................34
Participant Specific Changes ...................................................................................................................34
Report and Data Requirements................................................................................................................36
First Report of Injury (FROI) ....................................................................................................................36
L&I 1 .....................................................................................................................................................37
WC-1 ....................................................................................................................................................38
WC-2 ....................................................................................................................................................39
First Report of Injury (FROI) - Form IA-1 .............................................................................................40
First Report of Injury (FROI) - Form IA-1 OSHA ..................................................................................41
First Report of Injury (FROI) - Flat File Data Element List ...................................................................42
FROI Crosswalk Table – L&I 1, WC-1, & WC-2 to IAIABC IA-1 and Flat File .....................................44
Subsequent Report of Injury (SROI) ........................................................................................................48
WC-3 ....................................................................................................................................................49
WC-3 (continued) .................................................................................................................................50
New Jersey Benefit Status Letter .........................................................................................................51
Subsequent Report of Injury (SROI) - Flat File Data Element List .......................................................53
SROI Crosswalk Table - NJ Forms to NJ Benefit Status Letter and IAIABC Flat File .........................55
EDI Reports and Related Events..............................................................................................................61
FROI Requirements Table .......................................................................................................................62
SROI Requirements Table.......................................................................................................................65
NJCRIB FROI & SROI Event Tables .......................................................................................................67
Approved EDI Formats..............................................................................................................................68
NJCRIB Data Edits.....................................................................................................................................68
New Jersey Edit Matrix Table ..................................................................................................................69
Conditional Data Elements/Edits..............................................................................................................76
NJ CRIB EDI Implementation Guide Page 2 March 15, 2002

Acknowledgement and Correction Process .............................................................................................78
Transaction Sequence Requirements .....................................................................................................79
First Reports ............................................................................................................................................79
Subsequent Reports ................................................................................................................................79
Reporting Process Functions and Options ............................................................................................81
Manage State Reporting Requirements...................................................................................................81
Capture State Report Data.......................................................................................................................81
Data Entry Products .............................................................................................................................82
Data Content and Quality Editing Products ..........................................................................................82
Translate Data into or from IAIABC or ANSI formats...............................................................................82
Translator Products ..............................................................................................................................82
Manage Communications/Transmissions................................................................................................83
Communications Management Products .............................................................................................83
VANs ....................................................................................................................................................83
E-Mail Address .....................................................................................................................................84
Manage Acknowledgements, Replacement Reports, and Corrections ...................................................84
Manage Acknowledgements, Replacement Reports, and Corrections Products ................................84
Submitting Options to Consider ...............................................................................................................84
Workers Compensation EDI Reporting Products.................................................................................85
Stand Alone and Server-Based Workers Compensation EDI Reporting Products ..............................85
Web-based Data Entry & EDI Reporting Services ...............................................................................85
Claim EDI Reporting Services..............................................................................................................85
In-house Vs. Vendor Products and Services........................................................................................86
What can an Experienced EDI Vendor or Service Provider do for you?..............................................86
NJCRIB EDI Trading Partner Process .....................................................................................................88
1. Contact the IAIABC/Purchase the IAIABC EDI Release I Implementation Guide ............................88
2. Appoint an EDI Coordinator ..............................................................................................................88
3. Review NJ EDI Data Requirements and Claim Events that Require Reporting ...............................89
4. Examine your NJ WC Business Processes and Determine how NJ EDI Requirements Fit with
Them ........................................................................................................................................................89
5. Complete and Return the NJ EDI Trading Partner Agreement ........................................................89
NJCRIB EDI Project Agreement Sample .............................................................................................90
Trading Partner Agreement.................................................................................................................92
6. Complete and Return the Sender’s Trading Partner Profile .............................................................94
New Jersey Trading Partner Profile Application and Confirmation Form .............................................95
NJCRIB Trading Partner Information ...................................................................................................96
Instructions for Completing the New Jersey Trading Partner Profile Application and Confirmation
Form .....................................................................................................................................................97
NJCRIB Trading Partner Profile .........................................................................................................100
7. Schedule Changes to your Internal Business Processes and Systems .........................................102
8. Contact the NJCRIB EDI Test Coordinator to Review Schedule Testing .......................................102
Exemptions from Testing ...................................................................................................................102
Test Status Advisory...........................................................................................................................102
9. Schedule Training and Implementation for your Staff ....................................................................103
NJCRIB Test and Production Process ..................................................................................................104
Purpose..................................................................................................................................................104
NJCRIB Test Schedule – Test Plan Development.................................................................................104
Test Plan Procedures ............................................................................................................................105
Test Overview for WEB Users ...............................................................................................................105
Test Overview for VAN Mailbox Users...................................................................................................106
Step 1: Pretest Requirements ............................................................................................................106
Step 2: Technical Capability Test File ................................................................................................106
Step 3: Business Content Test File ....................................................................................................107
Step 4: NJ Test Completion (First Report of Injury) ...........................................................................109
Step 5: Business Content Test File (Subsequent Reports of Injury) ..................................................109

Step 6: NJ Test Completion (Subsequent Report of Injury) ...............................................................111
Ongoing Monitoring of Production Status ..............................................................................................111
Communication Requirements ..............................................................................................................112
New Jersey Policy for the Addition of External Connections..............................................................112
Network Requirements.......................................................................................................................113
Application Software Requirements ...................................................................................................113
Processing Requirements ..................................................................................................................114
Restrictions.........................................................................................................................................114
Appendices ..............................................................................................................................................115
Appendix 1 - Transaction Examples ......................................................................................................115
First Report of Injury – Scenario.........................................................................................................115
IAIABC Flat Files ................................................................................................................................115
Acknowledgement to First Report of Injury Scenario .........................................................................118
Subsequent Report of Injury (NJCRIB “Final” or SA Report) Scenario ..............................................119

Original Release and Revisions
The New Jersey EDI Implementation Guide was originally released on March 15, 2002.
Please report any errors for correction to NJCRIB. Contact MIS Manager, NJCRIB 60 Park Street,
Newark, NH 07102, Tel # 973-622-6014 Ext. 275.
Revision Date: Summary of Changes:
None to date

Foreword
EDI Legislation
This New Jersey Implementation Guide (Guide) has been compiled by the New Jersey Division of
Workers’ Compensation - Department of Labor (NJDWC) and the New Jersey Compensation Rating and
Inspection Bureau - Department of Banking and Insurance (NJCRIB). The Guide provides information
necessary to implement legislation signed by the Governor on January 5, 2002. Specifically, the Workers’
Compensation Law - N.J.S.A. 34:15-96 through 99 has been amended to alter the method of submitting
First Reports of Injury (FROI) and Subsequent Reports of Injury (SROI).
Prior to the new legislation, New Jersey employers were required to report work-related injury or
occupational disease information to their insurance carrier or third party administrator and to the NJDWC
using FROI paper forms L&I-1 and WC-1. Additionally, insurance carriers or third-party claim
administrators (TPA) were also required to report related information to NJDWC via SROI forms WC-2
and WC-3. State workers were required to file form RM-2 to report their claim to their employer and the
DWC.
Under the new legislation, employers are required to provide FROI and SROI information only to their
insurance carrier or third party administrator (TPA). The carrier or TPA is required to submit FROI and
SROI information in electronic format to NJCRIB using the International Association of Industrial Accident
Boards and Commission’s (IAIABC) Release 1 Electronic Data Interchange (EDI) standards. Additionally
the insurance carrier or TPA is required to send a copy of the FROI to the employer using either the
electronic format or on the IA-1 paper report form. Additionally, the insurance carrier or TPA is required to
send the information on the SROI to the employee using the New Jersey Benefit Status Letter. Similarly,
authorized self-insureds and statutory noninsureds not using TPAs also will report directly to NJCRIB in
the IAIABC Release 1 EDI format.
The date for the transition to EDI submission of FROI and SROI reports will be based on the claim’s date
of injury that is July 5, 2002. The legislation, signed by the Governor on January 5, 2002, requires
implementation six months following its enactment. Reports required on injuries and occupational disease
claims occurring prior to July 5, 2002, must continue to be reported in accordance with the provisions of
the statute prior to the changes implemented on July 5, 2002.
The paper and electronic formats established by the IAIABC have also been adopted. Accordingly, the
present New Jersey L&I-1, RM-2, WC-1, WC-2, and WC-3 paper forms will be replaced by the IAIABC IA-
1 and the New Jersey Benefit Status Letter forms. No Paper submissions will be accepted by NJDWC
or NJCRIB for injuries or occupational disease claims occurring on or after July 5, 2002.
EDI Implementation Assistance
This Guide, when used in conjunction with the IAIABC Release 1 EDI Implementation Guide, provides the
business and technical information to meet NJCRIB EDI submission requirements and includes the data
and code requirements for EDI submissions to NJCRIB and the paper counterparts to employers and
injured workers.

EDI compentency and business data quality content testing is required of each NJCRIB insurance carrier
or TPA (Trading Partner) per the NJCRIB Scheduled Test Plan prior to the implementation of production
EDI reporting. Approval must be secured from NJCRIB at the end of the testing period and prior to
submission of any production EDI transactions. Upon implementation of EDI production transmission,
paper filing from employers and carriers will no longer be required. After July 5, 2002, any paper
submissions will be deemed noncompliant with the statute. Any carrier or self-insured employer who is not
reporting FROI or SROI transactions electronically will be deemed noncompliant with the statute.
Electronic submissions of the FROI and SROI reports are those sent electronically either through an in-
house facility, or through an experienced EDI vendor. An experienced EDI vendor is one who is
experienced in the IAIABC Release 1 EDI format and who has been sending electronic submission to
other states. Please see the “Information and Help” section of this Guide and the IAIABC web site
(www.iaiabc.org) for more details.
Required Implementation Date
As indicated above, the required implementation date is July 5, 2002. However, there are tasks that must
be accomplished during the six-month period from the signing of the legislation to the required
implementation date.
During the six-month period immediately following enactment of legislation, carriers, authorized self-
insureds, statutory noninsureds, and TPAs not yet approved for EDI submissions may file either the New
Jersey paper forms or the IAIABC IA-1, included in this guide with NJDWC. No paper forms will be
accepted by the NJDWC for accidents occurring on or after July 5, 2002 --all filings for injuries and
occupational disease claims must be made via the IAIABC Release 1 electronic formats. Note also that
financial penalties may be associated with paper filings to NJCRIB or NJDWC on claims occurring on or
after July 5, 2002 and which are beyond the required EDI filing date of July 5, 2002.
There are two exceptions to the July 5, 2002 required implementation date:
1. Injuries/occupational disease claims with a Date of Injury prior to July 5, 2002 continue to be
reported in accordance to previous NJDWC Reporting requirements. EDI submissions must be
made on all injuries or occupational disease claims occurring on or after July 5, 2002. However,
early EDI implementation may begin once the EDI trading partner has achieved “production”
status at the conclusion of its testing.
2. Injuries/occupational disease claims occurring on or after July 5, 2002 may be exempted from EDI
submission if the New Jersey Trading Partner has requested and been granted a variance. Those
Trading Partners granted a variance must continue to report via the New Jersey approved paper
forms under the terms of the variance to the New Jersey Division of Workers’ Compensation.
Use of Data Received through EDI
Data received through the New Jersey EDI Reporting is available only to NJCRIB and NJDWC as required
by statute. The NJCRIB EDI vendor will assure the data security and confidentiality of the EDI process for
the data received by and processed by the vendor.

Acknowledgements
NJDWC and NJCRIB wish to thank all individuals and organizations including the IAIABC, Insurers, Self
Insurance Association, NJ Public Entity Fund Administrators, and Third Party Administrators for their input
and cooperation.

New Jersey Statutes and Rules Authorizing
EDI

Important New Jersey Terminology
The following definitions apply to the New Jersey documents and EDI processes described in this
Implementation Guide.
ADMINISTRATOR
Synonymous with Claim Administrator.
ANSI ASC X12
American Standards National Institute, Accredited Standards Committee, X12 - is an organization that
develops Electronic Data Interchange (EDI) communication standards. The “X” represents
“Communications” and “X12” is the twelfth Communication Standards Committee under ASC. This
organization is also referred to as “ANSI X12,” “ASC X12” or just “X12” Also, see “X12N.”
AUTHORIZATION PROCESS
The initial step taken by a “reporter” to become a trading partner with the NJCRIB – the completion of
the Trading Partner Agreement.
BATCH
A set of records containing one IAIABC Header record, one or more FROI or SROI transactions, and
one Trailer record, ANSI equivalent. Any error in the Header record or the Trailer record will cause the
rejection of the entire Batch without further transaction level edits being applied. A batch may not mix
the 148 (FROI) and the A49 (SROI) transaction types together.
BUSINESS COMPETENCE
A term used to describe whether the data content meets the quality standards of the NJCRIB.
BUSINESS RULES
The business requirements that dictate when a report is created, edited, and when and how
transmitted.
CARRIER
An Insurance Company licensed to write Workers’ Compensation and Employer’s Liability Insurance
in New Jersey and a member of NJCRIB.

CLAIM ADMINISTRATOR
The organization that services workers’ compensation claims according to jurisdiction rules. An
Administrator may be an Insurer, a Third Party Administrator, an Independent Adjuster, a Self-
administered Self-insured Employer, or Statutory Noninsured.
DATA ELEMENT
A single piece of defined information contained within a transaction (FROI or SROI). Each Data
Element is assigned a reference number (DN - Data Number) and includes a definition and format
(length and data type) and may if it is a code list acceptable values or reference the code source (for
example, Employer FEIN is 15 AN).
DISA
Data Interchange Standards Association - is the Secretariat of X12. DISA manages the EDI standards
database, arranges standards development meetings, and provides educational conferences and
seminars.
EDI
(EDI) is the computer-to-computer exchange of data or information in a standardized format. In

workers’ compensation. EDI refers to the electronic transmission of claims information from Claims
Administrators (insurers, self-administered self-insured employers, and third party administrators) to a
State Workers’ Compensation Agency.
EDITED DATA
A term used to describe the information on a transaction after it has been processed through the
NJCRIB system edits and found to contain valid data.
ELECTRONIC FORMAT
A term used to refer to IAIABC EDI Release 1 format and standards.
ENVIRONMENT
The boundary and conditions under which an application runs or in which files are manipulated or
processed.
EVENT
A specific business occurrence, such as the occurrence of an accident, satisfying the waiting period,
the initial payment on a claim, suspension, or the reinstatement of a benefit, etc. Such events when
entered into a computer system may be defined as a trigger for a jurisdiction-required report.
EXPERIENCED EDI VENDORS

EDI Vendors who are knowledgable of IAIABC EDI Release 1 standards, and provide services such
as EDI report submission products, translation, communications management, report backup, data
security, and network servicing (NSP) including high speed transmission lines. Some EDI vendors
also provide web-based products. All experienced EDI vendors have demonstrated EDI competence
in several IAIABC EDI states.
FROI
First Report of Injury – a group of transactions that occur at the early stages of claim processing that
typically report the entities involved, and describes the accident and resulting injuries.
IAIABC
International Association of Industrial Accident Boards and Commissions – an organization, whose

members are industrial accident, workers’ compensation, or other governmental bodies as well as
associate members comprised of other industry-related organizations and individuals.
IG
An abbreviation used to refer to an Implementation Guide.
MTC
Maintenance Transaction Code – A Code that identifies the purpose of a transaction. The MTC
(DN#2) is included in all EDI transactions. For example: Original FROI (00), Semi-Annual (SA). The
Semi-Annual Report is the last (final) report due on an open or closed claim.
NJCRIB
New Jersey Department of Banking and Insurance-Compensation Rating & Inspection Bureau, the
direct recipient of all EDI claim transmissions on behalf of NJDWC.
NJDWC
New Jersey Division of Workers’ Compensation, the ultimate recipient of all FROI & SROI information.
Also, the direct recipient of any hard-copy claim forms prior to the EDI mandate of July 5, 2002.
PRODUCTION (STATUS)
A designation that a Trading Partner has completed all EDI implementation testing satisfactorily as
determined by the NJCRIB EDI Test Coordinator, and who may submit electronically if approved prior
to July 5, 2002 and must report all claims electronically from July 5, 2002 forward.

RAW DATA
Refers to the transaction and its contents as it is received from a sender by the NJCRIB and before
the data is subjected to the NJCRIB EDI System’s automated edits.
RECEIVER
See NJCRIB.
REPORTER
The entity required by law to file or may be allowed by law or regulation to file for itself or on behalf of
customers or clients. In New Jersey, this is the Trading Partner.
SELF INSURED
An employer authorized by the Commissioner of Banking & Insurance to self-insure its obligations
under the New Jersey Law (N.J.S.A. 34-15-77).
SENDER
An entity that forwards the Trading Partner’s information in the IAIABC EDI Release 1 format to and
receives EDI acknowledgments from NJCRIB. This entity is required to complete the Trading Partner
Profile.
SROI
Subsequent Report of Injury – a group of transactions that report claim processing changes to, or
current totals of benefits paid on a claim.
STATUTORY NON-INSURED
Statuatory Non-Insured employers are public government entities (i.e., the state, county, municipality,
or school district). They are not required to purchase workers’ compensation insurance, but they do
have to make provisions to cover any costs that could arise from workers’ compensation claims filed
against them.
TECHNICAL COMPETENCE
A term that refers to both the ability to communicate electronically and that the file structure used is
appropriate.

TEST PERIOD
The initial environment or phase in which the trading partner/sender/reporter sends a series of
transactions that are analyzed for both the technical and business content.
TEST PLAN
A plan developed by the NJCRIB EDI Test Coordinator and the Sender’s EDI Coordinator outlining the
events, the time frame, and the responsibilities of each party for testing and evaluating data sent in the
Test environment.
TPA
A Third Party Administrator that provides the claim administration services on behalf of Carriers, Self-
insureds or Statutory Noninsureds.
TRADING PARTNER
A Carrier, Self-Administered, Statutory Noninsured, or TPA responsible for providing the claim
handling service for claims.
TRANSLATOR
Software that uses data conversion mapping rules to convert data from one format to another.
Normally, for EDI processing, this term refers to a product the converts data between proprietary (not
a national or industry standard) formats and X12 format. Refer to the Vendor section of this
Implementation Guide for further information.
TRANSACTION
In this guide, a Transaction refers to one detail record (example FROI or SROI) and contains data
elements as defined in the IAIABC record layouts, which are found in the IAIABC EDI Release I
Implementation Guide. See MTC also listed in this Glossary.
TRANSACTION TYPE
Explains the purpose of a transaction. For example: Original FROI (00), Semi-Annual (SA). See Event
and MTC listed in this Glossary.
TRANSMISSION FILE
One or more batches shipped together from the sender to the receiver.

VAN
A Value Added Network, VAN, is an organization that facilitates the exchange of data between trading
partners by performing some or all of the following services: extended hours of operation (often 24 x
7), a mailbox from which EDI transactions may be sent or received, communication functions to
monitor and assure successful data transfer, data recovery, and data security, etc.
X12N
X12 Insurance Subcommittee - is the X12 subcommittee that develops EDI standards for the
insurance industry.

Organization of Information in this Manual
This NJCRIB EDI Implementation Guide is being presented to you in a sequence we anticipate will match
a claim administrator’s interests and managerial responsibilities. The following synopsis of its sections
may be of assistance.
The Background of State EDI Reporting Standards (page 28) is provided to convey that state EDI
reporting originated as a claim administrator effort and that continues today with states and claim
administrators working together at the IAIABC. The goals are to:
• Simplify state reporting requirements through standardization,
• Assist states to manage their Workers’ Compensation Systems, and
• Reduce state reporting costs.
The Executive Summary: Managing an EDI Implementation (page 30) is provided to draw attention to the
various implementation tasks and options to consider.
Information and Help (page 32) is provided as a source for New Jersey state assistance, NJ’s vendor’s
assistance, access to current information, related projects and topics, as well as other vendor and
consultant services and options.
The Steps to Implement NJCRIB EDI (page 34) refer to Specific Changes from the Current Process (NJ
DWC process) (page 34) providing a base from which to understand the new requirements.
The Report and Data Requirements (page 36) are presented in several stages:
1. NJ DWC forms with IAIABC data number notations indicate current data used in electronic
reporting.
2. IAIABC paper forms and electronic data lists describe the First Report of Injury (FROI) and
Subsequent (SROI) data requirements.
3. Cross-references for FROIs and SROIs provide an analysis of the requirements and relate the
previous reporting methods to the new electronic reporting requirements.
This section identifies several data definitions that must be considered.
An introduction to EDI Reports and Related Events (page 61) identifies situations in which the NJCRIB
EDI reports are due. A table of NJCRIB events is provided.
The Approved EDI Formats (page 68) section describes the technical formats authorized by NJCRIB in
business terms. (Technical data for the formats is provided in the IAIABC Release 1 Implementation
Guide and again in the appendix of this Guide.)
Data Quality is a key philosophy of all EDI systems. EDI is an interactive relationship between your
company and NJCRIB. Data you submit must pass NJCRIB Edits. The NJCRIB EDI system will
acknowledge each Report (transaction) you submit. Transactions that fail must be resent. Data Errors
must be corrected. The NJCRIB Data Edits (page 68) provide NJCRIB edit rules and an overview of how
this process works. The Transaction Sequence Requirements (page 79) section expresses the order in
which a claim administrator will submit reports to NJCRIB and the business events to which they
correspond. Therefore, reports and transactions must be in the correct order of business events.
Educational information to bridge claim administrator knowledge and EDI processes is provided
throughout the guide.
The Reporting Process and Functions & Options (page 81) section lists a combination of in-house and
vendor EDI solutions. It includes several basic tips that will assist you to make the proper decisions for
your company.

The NJCRIB EDI Trading Partner Process (page 88) section walks you through completing a Trading
Partner Agreement and a Trading Partner Profile. The Trading Partner Agreement documents report and
data requirements the NJCRIB EDI system will expect from you. The Trading Partner Profile relays
information that is used by NJCRIB and your system (or if you elect to use one to send your information,
the vendor’s system) to communicate electronically with each other. Therefore, your reporting option
choices will determine some of the information on the Trading Partner Profile; option selections must first
be selected.
The Test and Production Process (page 104) describes the procedure you will use in proving your
technical capability, the quality of your data, and thereby, the elimination of paper reporting. You will be
deemed out of compliance with the statutory requirements if the quality of your data in your EDI
submissions falls below NJCRIB’s data quality requirements even after you reach “production” status
following your testing.

New Jersey Methods of Delivery

Background of State EDI Reporting Standards
A specific set of standards for workers’ compensation reporting formats is now available. New Jersey
Division of Workers Compensation (NJDWC) and New Jersey Compensation Rating & Inspection Bureau
(NJCRIB) also share their objectives. Development of the standards began in 1989 when a group of
national Claim Administrators worked with the North Carolina Workers’ Compensation agency to develop
the first state-accepted electronic Report of Injury. Their objective was to reduce state reporting
administrative processes and costs. Their project was successful and provided almost immediate benefit
to both the claim administrators and North Carolina.
Based on the success of the North Carolina project, the participants set out to duplicate the process in
other states. Many changes to the North Carolina model were needed. State reporting had to be
considered in the broadest terms instead of by state or locality. The group continued to meet under the
International Association of Industrial Accident Boards and Commissions (IAIABC) umbrella unofficially to
satisfy antitrust requirements.
This group identified several major categories of Claim Administrator and Employer Reports and when
state-required reports were to be submitted, it identified which data was required. This allowed creation of
a data element dictionary and a reporting event table that could be used by any state and which was
based on the claim administrator claim handling process. The developers used existing and widely used
data standards to leverage system enhancements implemented by many claim administrators and state
administrators. As a result, the group reduced numerous data elements and reporting situations into a
more concise data list and a manageable set of reporting conditions that would meet the needs of most
states.
The initial process took several years to accomplish. Its success is attributable to the state and claim
administrator participants who painstakingly and patiently reviewed state requirements and claim
administrator processes that benefited both parties. Their work continues today to expand the use of
these EDI standards. As state participation grew, these copyrighted standards are now available from the
IAIABC. Contact the IAIABC at (608) 277-1479 or visit their web site at http://www.iaiabc.org to acquire a
copy of the standards, which may be downloaded from their site at no cost to you.

Executive Summary: Managing an EDI
Implementation
If you are a Claim Administrator who has not been involved in fulfilling state Workers’ Compensation
electronic reporting requirements before, it may all seem foreign and totally technical to you. In reality,
EDI, while it is all about business, does have two sides. It’s about using data that originates in your claim
handling processes to meet jurisdictional reporting requirements. Ideally, it shifts report generation from a
manual process to an automated or software-assisted process. Therefore, your initial task is to assess the
requirements, compare them to your manual and automated processes, and determine your best
business solution. EDI does have a considerable technical or “Information Systems” component, but it is
based on your business associations and business processes.
The technical side of EDI has three major components.
1. Your computer-based claim processing system where claim data is stored.
2. An EDI management system or a component that contains jurisdiction requirements:
a. the required report types,
b. when they are required,
c. when they are due,
d. their data requirements,
e. required edits,
f. the states response to each report.
3. A system that manages the exchange of reports between your organization, states, your clients,
etc.
Due to the differences between Claim Administrator claim handling processes and their computer
systems, each administrator may have very different capabilities. Each must assess the best way to
modify their claim handling process and determine how to implement the three technical EDI components.
The solution may be to use your own technical staff to build the technical components, use a bridge or
vendor system, or, if your volume is low, to subscribe to the NJCRIB web-based or Internet solution. Some
may conclude that a mixture of in-house development and vendor products and services work best for
them – others will conclude a different solution works best for them depending on the services available to
you, the technology you already use, and cost constraints.
The following is a possible list of tasks to perform. The list is not intended to be all-inclusive or be in the
optimal order. Its primary goal is to raise your awareness to allow your own managerial skills and insight to
take over.
1. Determine if your company is subject to the NJCRIB requirements and the mandate
implementation date of July 5, 2002.
2. Acquire a copy of the “IAIABC Release 1 EDI Implementation Guide” from the IAIABC.
3. Develop a basic understanding of EDI and NJCRIB reporting requirements.
4. Scan the Information and Help (page 32) section.
5. Read the Steps to Implement NJCRIB EDI Requirements (page 34) to know what will be required
of your claims process and electronic reports to NJCRIB.
6. Perform a high-level comparison of NJCRIB requirements against your current claim computer
system capabilities.
7. Read the Report Process Functions & Options of Claim Administrator and vendor EDI products
and services options to consider.

8. Based on your high-level assessment of existing capabilities and EDI requirements, conceptualize
how your organization might implement the various options and which solution might be the most
appropriate.
9. Use your organization project development process to initiate a formal project proposal involving
business and technical departments using the detailed NJCRIB business requirements. Be sure
to scope the project to include anticipated related EDI projects.
10. Use the information resources to expand your knowledge of state EDI reporting.
11. Use industry meetings and other business contacts to identify claim administrators that have
participated in the development of the standards or have successfully implemented EDI in other
states. Inquire about how they implemented EDI and what they would do differently now. What
were their experiences building EDI solutions or with vendor products or services?
12. Determine your scheduled New Jersey Test Date. Refer to the NJCRIB Test Schedule on the web
site.
13. Complete and submit your Trading Partner Agreement form and your Trading Partner Profile to
the NJCRIB EDI Test Coordinator at least two weeks prior to the first date of your scheduled Test
Period.
14. Monitor the NJCRIB official web site for new information and requirements changes. Attend
training sessions.
15. Implement your EDI solutions and document all processes.
16. Train Claim and Technical personnel for their roles and duties.
17. Prepare and begin submission of Test processes with NJCRIB on the first date of your assigned
Test Period.
18. Begin submission of Production Transactions on the approved Production date and no later than
July 5, 2002.
19. Monitor and update processes and train staff accordingly as any process issues occur.
20. Continue to check the NJCRIB web site periodically and participate in any NJCRIB EDI initiatives
that may develop.
21. Pass your experiences along to help those who follow your organization into EDI.

Information and Help
NJCRIB/NJDWC Official Web Pages www.NJCRIB.com

www.dwc.dol.state.nj.us
NJCRIB Staff Phone & E-Mail Technical Contact:

phone: (800) 240-0088
e-mail: njedi@hnc.com
fax: (949) 655-3375
NJCRIB Vendor Help Line and E-mail e-mail: njedi@hnc.com or

phone (800) 240-0088
fax (949) 655-3375
NJDWC Contact Information for Division of Workers’ Compensation

Attn: EDI Coordinator
P.O. Box 381
Business/Law/Regulations Issues Trenton, NJ 08625-0381
e-mail dwcedi@dol.state.nj.us
and Questions phone number: (609) 292-2515
IAIABC Web Page & Phone Number Web Site address:

www.iaiabc.org/html/impguide.htm
phone number: (608) 277-1479 (Madison,
WI)
Frequently Asked Question www.njcrib.com

Document on the NJCRIB Web Page

NCCRIB EDI Reporting Process

Steps to Implement NJCRIB EDI
NJCRIB EDI Requirements
The objectives of this section are:

1. To convey the NJCRIB EDI Reporting requirements as clearly as possible.
2. To prepare you to assess your organization’s capabilities and determine the best way for your
organization to meet NJCRIB requirements.
Specific Changes from the Current Process
This section summarizes the more significant changes so that you may better understand the transitional
process.
Format: Changes from New Jersey state paper forms to national standard electronic
formats.
Data Content: Is predominantly the same as existing NJDWC requirements but expressed
using IAIABC terminology and definitions so that it is consistent with national
standards.
Methodology: Requirements are stated in specific terms that allow computer processing so that
New Jersey employers and administrators may replace their manual reporting
process with an automated process.
Effective: EDI submissions of IAIABC FROI and SROI reports in Flat or ANSI formats will
be required six months (July 5, 2002) following the enactment date of the
legislation (January 5, 2002). OSHA requirements remain.
Participant Specific Changes
Current: New Jersey employers are responsible to report via paper forms, L&I-1, and WC-
1 to their insurance carrier or third party administrator and to the NJDWC.
New: Employers will report FROI or SROI information only to the Insurer or TPA using
any agreed upon format.
Differences: Employer:
1. Stops reporting to NJDWC.
2. Continues to report to the Insurer or TPA.
3. Is not required to use the L&I-1 and WC-1.
4. May use any agreed upon format, such as telephone, IAIABC flat, ANSI,
or paper formats to communicate with the Insurer or TPA.

Current: Insurers and TPAs are responsible to report via paper forms WC-2 and WC-3 to
NJDWC.
New: Insurers and TPAs are responsible to report via IAIABC electronic flat or ANSI
formats to NJCRIB, and to the employer in electronic or paper FROI or SROI
format, and to the employee in SROI paper format using the New Jersey Benefit
Status Letter.
Differences: Insurer/TPA:
1. Stops reporting to NJDWC using the WC-2 and WC-3 forms.
2. Begins reporting to NJCRIB using IAIABC FROI or SROI in flat or ANSI
formats.
3. Copies FROI to the Employer using IAIABC flat, ANSI, or paper formats.
4. Copies SROI to the employee using New Jersey Benefit Status Letter
paper format.
Current: Self-Insureds and Noninsureds responsible to report via paper forms L&I-1 and
WC-1, and WC-2 and WC-3 to NJDWC.
New: Self-Insureds and Non-Insureds are responsible to report via IAIABC electronic
flat or ANSI formats to NJCRIB, and to the employee in paper format using the
New Jersey Benefit Status Letter.
Differences: Self-Insureds and Noninsureds:
1. Stops reporting to NJDWC and using the paper forms L&I-1 and WC-1,
and WC-2 and WC-3.
2. Begins reporting to NJCRIB using IAIABC FROI or SROI in flat or ANSI
formats.
3. Copies SROI to the employee in paper IA-2 or New Jersey Benefit Status
Letter format.
Current: NJDWC receives reports in paper format.
New: NJCRIB receives reports electronically and edits them for data content and
quality before being moved into NJCRIB computer system and then to the
NJDWC. An Acknowledgement that the report was either accepted, rejected,
and/or contained data errors is sent to the submitter. The submitter must either
replace any rejected reports or submit corrections to data errors.
Differences: Insurer, TPA, Self-Insured, and Noninsured
1. Must submit NJCRIB reports electronically and monitor them for data
content and quality.
2. Must replace rejected reports.
3. Must correct data errors.
4. Are placed in an out-of-compliance mode if data quality falls below the
required data quality level.
5. Are monitored for compliance. Failure to achieve and maintain EDI
performance requirements may subject the carrier to subsequent EDI
audits until EDI standards are achieved with possible penalty exposure.

Report and Data Requirements
The existing New Jersey L&I-1, RM-2, WC-1, WC-2, and WC-3 forms have been enclosed with
modifications to show the new reporting data requirements. Each Data Element that is included in the new
requirements is identified on each New Jersey report form by its Data Number (DN#). A DN# is a
reference to an Industry Standard, IAIABC Data Element. Definitions for these elements can be found in
the IAIABC E.D.I. Release 1 Implementation Guide. A DN# in “Blue” identifies First Report (FROI) data
elements. A DN# in “Red” identifies Subsequent Report (FROI) data elements.
Not all existing data elements are included in the EDI Reports; therefore, certain data elements will not
have a DN#. In some situations, existing and new data requirements have similar intent/usage but are not
the same. These are labeled “MOD” for modified. The new requirements include data not present on the
existing New Jersey Forms. Many of these tend to be standard use identifiers required for automated
processing. Others are typical of common employer and claim administrator bureau and occupational
reporting. The additional data element requirements are provided in two separate FROI and SROI data
element lists. The FROI and SROI information required in New Jersey lists relate the data to the New
Jersey form source if any, and to the IAIABC Paper and Electronic Reports. Those reports are also
provided.
First Report of Injury (FROI)
The forms and lists for First Reports of Injury are on the following pages.

L&I 1
DN28 DN29 DN30

DN7 DN82
DN24 DN31
DN16
DN25
DN18
DN19, DN20, DN21, DN22, DN23
DN44, DN43, DN45 DN42 DN53

DN52
DN46, DN47, DN48, DN49, DN50 DN60
DN62, DN63
DN51 DN64
DN33, DN34
DN38
DN35, DN36
DN57 DN65 DN68

WC-1
DN4
DN43, DN44, DN45

DN46, DN47, DN48, DN49, DN50
DN60 DN53
----------DN54--------- DN42
DN55
DN18
DN19, DN20, DN21, DN22, DN23
---------DN31------- DN32 DN57
DN16 DN68
DN62
DN62
DN62

WC-2
DN4
DN44, DN43, DN45

DN46, DN47, DN48, DN49, DN50 DN53
DN60
DN42
----------DN54------------ DN55
DN18
DN19, DN20, DN21, DN22, DN23 DN57
-------DN31------- DN32
DN16 DN68
DN62
DN62
DN62

First Report of Injury (FROI) - Form IA-1
DN15 DN2
DN18
DN19, DN20, DN21, DN22, DN23
DN4 DN5
DN26
DN27
DN33, DN34
DN7, DN9
DN7 DN29 DN30 DN10, DN11, DN12, DN13, DN14
DN6 DN28 DN8
DN43, DN44, DN45

DN52 DN42 DN61
DN53 DN54
DN46, DN47, DN48, DN49, DN50 DN60
DN58
DN51 DN55 DN59
DN66
DN62 DN63 DN64 DN67
DN31 DN65 DN40 DN56

DN32
DN34 DN37 DN36
DN38
DN38 DN38
DN38
DN37
DN68 DN57
DN39
DN41 DN3

First Report of Injury (FROI) - Form IA-1 OSHA
DN15 DN2
DN18
DN19, DN20, DN21, DN22, DN23 DN4 DN5
DN26
DN27
DN33
DN34
DN7 DN29 DN30 DN7, DN9

DN10, DN11, DN12, DN13, DN14
DN6 DN28 DN8
DN43, DN44, DN45 DN52 DN42 DN61

DN53 DN54 DN60
DN46, DN47, DN48, DN49, DN50
DN58
DN51 DN55 DN59

DN66
DN62 DN63 DN64 DN67
DN31 DN32 DN65 DN40 DN56
DN34 DN37 DN36
DN38 DN38
DN38 DN38
DN38
DN37
DN68 DN57
DN39
DN41 DN3

First Report of Injury (FROI) - Flat File Data Element List
First Report of Injury Requirements

Groupings
No Data Name Edits
Transaction
1 Transaction Set Id Must Be 148, A49, HD1 or TR1
2 Maintenance Type Code Must Be 00, 04, 01, 02, CO, or AU
3 Maintenance Type Code Date Must Be a Valid Date CCYYMMDD
Jurisdiction
4 Jurisdiction Must be "NJ"
5 Agency Claim Number
Claim Admin.
6 Insurer FEIN
7 Insurer Name
8 TPA FEIN Mandatory if TPA is reporting
9 TPA Name Mandatory if TPA is reporting
10 Claim Admin. Address Line 1
11 Claim Admin. Address Line 2
12 Claim Admin. City
13 Claim Admin. State
14 Claim Admin. Postal Zip
15 Claim Admin. Claim Number
Insured
16 Employer FEIN
17 Insured Name
18 Employer Name
19 Employer Address Line 1
20 Employer Address Line 2
21 Employer City
22 Employer State
23 Employer Postal Code
24 Self Insured Indicator
25 Industry Code
26 Insured Report Number
27 Insured Location Number
Policy
(Policy Fields are only Mandatory for Insured Employers)
28 Policy Number O IF Self-Insured, Else M If WC Policy.
29 Policy Effective Date O IF Self-Insured, Else M and then Must Be a
Valid Date CCYYMMDD, and Must Be < or =
Date of Injury.
30 Policy Expiration Date O IF Self Insured, Else M and then Must Be a
Valid Date CCYYMMDD and Must Be > or =
Date of Injury.
Accident
31 Date of Injury Must be< or = Date Reported to Employer and
Must Be a Valid Date CCYYMMDD.
32 Time of Injury
33 Postal Code of Injury Site

First Report of Injury Requirements
34 Employers Premise Indicator
35 Nature of Injury Code
36 Part of Body Injured Code
37 Cause of Injury Code
38 Accident Description / Cause
39 Initial Treatment Code
40 Date Reported to Employer Must Be a Valid Date CCYYMMDD
And Must Be > or = Date of Injury.
41 Date Reported to Claims Admin. Must Be a Valid Date CCYYMMDD
Employee
42 Social Security Number
43 Employee Last Name
44 Employee First Name
45 Employee Middle Initial
46 Employee Address Line 1
47 Employee Address Line 2
48 Employee City
49 Employee State
50 Employee Postal Code
51 Employee Phone
52 Employee Date of Birth
53 Gender Code
54 Marital Status Code M If death claim, else N/A.
55 Number of Dependents Must Be Numeric and M If death claim,
else N/A.
56 Date Disability Began Must Be a Valid Date CCYYMMDD and
M if unable to perform regular work, Else N/A.
57 Employee Date of Death M If death claim, Else N/A.
If Applicable it Must Be a Valid Date
CCYYMMDD and Must be > or = Date of Injury.
Employment
58 Employment Status Code
59 Class Code
60 Occupation Description
61 Date of Hire Must Be a Valid Date CCYYMMDD
62 Wage
63 Wage Period
64 Number of Days Worked Must Be Numeric
65 Date Last Day Worked M If Loss OF Time From Work and
Must Be a Valid Date CCYYMMDD, Else N/A.
66 Full Wages Pd for Dte of Inj
Indicator.
67 Salary Continued Indicator
68 Date of Return To Work Must Be a Valid Date CCYYMMDD
M if employee able to return to regular duties,
Else N/A.

FROI Crosswalk Table – L&I 1, WC-1, & WC-2 to IAIABC IA-1 and Flat File
Employer’s NJ L&I-1 Form IAIABC 1A-1 Form EDI FROI Elements

L&I-1, WC-1, and WC-2 Forms Jurisdiction DN 4 – mandatory
No Agency Claim No. DN 5 – conditional
1. Carrier’s name Yes DN 7 – mandatory
1. If self-insured indicate “self-insured” Self-Insured Indicator DN 24 – mandatory
1. Carrier’s address Carrier’s address DN 10 – 12-14 mandatory
DN 11 – conditional
No Claim Administrator DN 10 – 12-14 mandatory
address
1A. Policy number Yes DN 28 – conditional
1B. Policy effective date Yes DN 29 – conditional
1B. Policy expiration date Yes DN 30 – conditional
2. Date of injury or illness Yes DN 31 – mandatory
2. Time of day Yes DN 32 – mandatory
No Insurer’s FEIN DN 6 – mandatory
No Claim Adm. Claim No. DN 15 – mandatory
No TPA's FEIN DN 8 – conditional
No TPA's Name DN 9 – conditional
No Insured name (Parent DN 17 – optional

Organization)
3. Employer name Yes DN 18 – mandatory
7. Employer address Yes DN 19, 21-23 mandatory
DN 20 - conditional
8. Employer telephone number Yes No (not needed)
4. Employer FEIN number Yes DN 16 – mandatory
5. SIC number Yes DN 25 – mandatory
No Insured Report No. DN 26 – conditional
No Insured Location No. DN 27 – conditional

6. Number of employees in firm No No (not needed)
9. Nature of business No No (not needed)
7. Location if different from mailing Yes No (not needed)
address
10. Employee name Yes DN 43 – 44 mandatory
No Employee Middle Initial DN 45 – conditional

15. Employee home address Yes DN 46, 48–50 mandatory
18. Employee telephone number Yes DN 51 – conditional
11. Social Security Number Yes DN 42 – mandatory
12. Date of birth Yes DN 52 – mandatory
13. Age No No (not needed)
14. Sex Yes DN 53 – mandatory
No Employment Status DN 58 – conditional
16. Occupation (Job title) Yes DN 60 – mandatory
No Date of Hire DN 61 – conditional
No Class Code DN 59 – conditional

19. Wages Yes DN 62 – 63 mandatory
20. Number of hours worked per day Number of days worked per DN 64 – mandatory
week
17. Department where employed No No (not needed)
See WC-1.7 Number of dependents DN 55 – conditional
See WC-1.5 Marital status DN 54 – conditional
No Salary continued indicator DN 67 – mandatory

21. Location where accident occurred Postal code of injury site DN 33 – conditional
No Employer premise indicator DN 34 – mandatory
22. What was employee doing (cause) Specific activity or work DN 38 – mandatory
process that employee is
engaged in
23. Object or substance machine or tool All equip. material or No (not needed)
that directly injured employee chems. used at acc.
How injury occurred object
or substance that injured
employee
No Cause of injury code DN 37 – mandatory
(cause)
24. Nature of injury and part of body Type of injury/illness code DN 35 – mandatory
(nature)
No Part of body code (part) DN 36 – mandatory
No Date disability began DN 56 – conditional

25. Did employee die? If yes, give date of Yes DN 57 – conditional
death
26. Unable to work day after (Last day Yes DN 65 – conditional

worked)
27. Returned to work Yes DN 68 – conditional
28. Treating doctor Yes No (not needed)
29. Treating doctor’s address Yes No (not needed)
30. Hospital Name Yes No (not needed)
31. Hospital Address Yes No (not needed)
No Date reported to claims DN 41 – mandatory

administrator
No Initial treatment code DN 39 – mandatory
No Date reported to employer DN 40 – mandatory
No Full-wages-pd.-for-date-of- DN 66 – conditional
inj. indicator
Completed by: (preparer name) Yes No (not needed)
Title of preparer: Yes No (not needed)
Signature of preparer: No No (not needed)
Date this form prepared: Yes No (not needed)
Employer’s NJ WC-1 Form

1. Name and address of employee
8. Name and address of employer
8. FEIN number of employer
2. Occupation of title
3. Age
4. Sex
5. Marital status Yes DN 54 – conditional
6. Social Security Number
7. Number of dependents Yes DN 55 – conditional
9. Date of accident
10. Did employee die? If yes, give date of
death
11. Did employee return to work
12. Date returned to work
13. Probable date returned to work No No (not needed)
14. Average earnings
15. Wages per day

16. Wages per hour
17. Was board and lodging furnished? No No (not needed)
18. Number of hours in regular work day
19. Number of days in regular work day
20. Amount of weekly wages
Date this form prepared:
Signature of preparer:
Title of preparer:
Carrier’s WC-2 Form
1-20 same as in WC-1
Date this form was prepared
Signature of preparer:
Title of preparer:
Signature of employee: No No (not needed)
Signature of witness: Witness name No (not needed)
No Compensation was or is to be paid No No (not needed)
NJDWC Guarantee payment of
compensation
No No (not needed)
Signature

Subsequent Report of Injury (SROI)
The forms and lists for First Reports of Injury are on the following pages.

WC-3
DN4
DN31 DN42
DN57
DN75
DN95, DN96
DN64 DN62
DN3
DN56 DN88 DN72
DN90
DN83, DN84
DN87 DN90 DN86 DN85
DN85 = 030/040 DN90 for DN85 = 030/040

DN86 for 030/040

WC-3 (continued)
DN4
DN31
DN42
DN3
DN86, DN95
DN97
DN87 DN90 DN86 for “010”
DN85, DN87
DN87 for “010”

DN93, code=300

New Jersey Benefit Status Letter
[Claim Administrator Letterhead]

[Claim Administrator Address]
DATE of NOTICE: [DATE]
DN44, DN43
TO:[NAME OF INJURED EMPLOYEE]
DN46, DN47
[ADDRESS]
DN48, DN49, DN50
[CITY, STATE, ZIP]
DN31
[DATE OF INJURY]
DN42
[EMPLOYEE SSN]
DN15
[CLAIM ADMINISTRATOR CLAIM #]
DN5
[JURISDICTION CLAIM #]
Dear [Injured Worker Name],

I am handling your claim for workers’ compensation benefits. In accordance with New Jersey law, I
am sending you a summary of your claim and benefits paid to date. The information contained in this
notice has been provided to the state in an electronic format. Only the boxes checked or information
provided applies to your workers’ compensation claim.
This notice is with reference to the following status of your workers’ compensation claim: (claim
administrator selects all applicable)
DN72
( ) You were released to return to work on [RTW or RRTW Date] .
DN70
( ) Your injury reached maximum medical improvement status on [MMI Date] .
( ) Your injury was assigned a permanent impairment rating as follows:
[Permanent Impairment Percent] DN 84 of the [Permanent Impairment Body Part] DN 83
( ) This workers’ compensation claim involves a fatality that occurred on [Date of Death]
DN57 and we [have/have not] been providing death benefits on this claim.
According to our records, your injury occurred while you were working for:
DN18
[NAME OF EMPLOYER]
DN19, DN20, DN21, DN22, DN23
[EMPLOYER’S ADDRESS]
DN62
At the time of the injury, your average weekly wage was [$0000000.00] . Items such as overtime,
lodging, uniforms, etc. [were/were not applicable] to the average weekly wage calculation, pursuant
to jurisdictional requirements. Based on your average weekly wage, your weekly benefit rate was
DN87
calculated at [$0000000.00] .

(We still feel that it would be best to completely eliminate the following paragraph. The explanation
here does not provide any relevant info to those receiving perm benefits. If it cannot be eliminated,
then we suggest the following changes.)
****If maximum medical improvement box was checked above, insert this paragraph:
Once maximum medical improvement has been reached, you are no longer eligible for temporary
disability benefits; but if you sustained a permanent disability, you may be entitled to permanent
benefits. The weekly benefit is defined by statute with a value based upon degree of impairment.
****The following paragraph will be used on all letters:

To date, we have provided the following workers’ compensation indemnity benefits for your injury:
Benefit Description Paid To Date From/Through Dates # Weeks# Days

DN85 (text descr instead of code#) DN 86 DN88/DN89 DN90 DN91
(*****insert printout of benefits paid by benefit type*****)
_______________________ ______________ ______________________ _____ _____

_______________________ ______________ ______________________ _____ _____
_______________________ ______________ ______________________ _____ _____
_______________________ ______________ ______________________ _____ _____
_______________________ ______________ ______________________ _____ _____
_______________________ ______________ ______________________ _____ _____
_______________________ ______________ ______________________ _____ _____
_______________________ ______________ ______________________ _____ _____
_______________________ ______________ ______________________ _____ _____
If you do not agree with the information contained in this letter, please contact me via one of
the methods below:
Adjuster’s Name:
Telephone #:
Fax #:
E-Mail Address:
You may write to the New Jersey Division of Workers’ Compensation at P.O. Box 381, Trenton,
NJ 08625-0381, dwcedi@dol.state.nj.us to request a review of your claim.

Subsequent Report of Injury (SROI) - Flat File Data Element List
Subsequent Report of Injury Requirements

Grouping
No Data Name Edits
Transaction
1 Transaction Set Id Must be 148, A49, AK1, HD1 or TR1.
2 Maintenance Type Code Must be SA, 04, 02, or CO.
3 Maintenance Type Code Date Must be a valid date CCYYMMDD.
Jurisdiction
4 Jurisdiction Must be "NJ.”
Claim Admin.
6 Insurer FEIN
8 TPA FEIN M if Third Party Administrator is reporting.
14 Claim Admin. Postal Zip
Employee
42 Social Security Number
55 Number Of Dependents M if Death Claim, else N/A. Must be a valid date
CCYYMMDD.
69 Pre-Existing Disability M if Pre-Existing, else N/A.
56 Date Disability Began M if unable to perform regular duties, else
N/A. Must be a valid date CCYYMMDD.
70 Date of Maximum Medical M if Max Med Improvement, else N/A.
Improvement Must be a valid date CCYYMMDD.
71 Return to Work Qualifier M if returned to work, else N/A. Must be
a valid date CCYYMMDD.
72 Date of Return/Release to M if returned to work, else N/A. Must be
Work a valid date CCYYMMDD.
57 Employee Date of Death M if Death Claim, else N/A. Must be a valid date
CCYYMMDD.
Wage
62 Wage
63 Wage Period
64 Number Of Days Worked M if Disability < a week, else N/A.
67 Salary Continued Indicator
Accident
31 Date Of Injury Must be a valid date CCYYMMDD.
15 Claim Administrator Claim
Number
5 Agency Claim Number
Claim Status
73 Claim Status Must be in Table - Valid Code.
74 Claim Type Must be in Table - Valid Code.
75 Agreement to Compensate Code
76 Date Of Representation M if has Legal Rep., else N/A. Must be a valid
date CYYMMDD.
Payments
77 Late Reason Code
Variable Segment Counters

78 Number of Permanent Impairments
79 Number of Payment/Adjustments

Subsequent Report of Injury Requirements
80 Number of Benefit Adjustments
81 Number of Paid to Date/Reduced Earnings/Recoveries
82 Number of Death Dependent/Payee Relationships
Variable Segments
Permanent Impairment Occurs M if 78 > 0, else N/A.
83 Permanent Impairment Body Must be in Table - Valid Code
Part Code
84 Permanent Impairment Must be valid percentage
Percent
Payment/Adjustments Occurs Number of Payment/Adjustment Times
85 Payment/Adjustment Code M if payment made, else N/A
86 Payment/Adjustment Paid To M if 79 > 0, else N/A.
Date
87 Payment/Adjustment Weekly M if 79 > 0, else N/A.
Amount
88 Payment/Adjustment Start M if 79 > 0, else N/A.
Date Must be a valid date; CCYYMMDD.
89 Payment/Adjustment End M if 79 > 0, else N/A.
Date Must be a valid date CCYYMMDD.
90 Payment/Adjustment Weeks M if 79 > 0, else N/A.
Paid
91 Payment/Adjustment Days M if 79 > 0, else N/A.
Paid
Benefit Adjustments Occurs Number of Benefit Adjustments Times
92 Benefit Adjustment Code M if payment made, else N/A.
93 Benefit Adjustment Weekly M if 80 > 0, else N/A.
Amount
94 Benefit Adjustment Start Date M if 80 > 0, else N/A.
Must be a valid date CCYYMMDD.
Paid To Date /Reduced Earnings /Recoveries occurs Paid To Date/Reduced Earnings
/Recoveries Times
95 Paid To Date / Reduced M if payment made, else N/A.
Earnings / Recoveries Code
96 Paid To Date / Reduced M if 81 > 0, else N/A.
Earnings / Recoveries Amount
Death Dependent/Payee Relationships Occurs Death Dependent/Payee Relationship
Times
97 Dependent/Payee M if fatal payment/adjustment type code
Relationship payment made, else N/A.

SROI Crosswalk Table - NJ Forms to NJ Benefit Status Letter and IAIABC
Flat File
SROI Information in New Jersey

NJ WC-3 Form New Jersey Benefit Status EDI-SROI
Presence of WC-3 Form Jurisdiction DN – 4 mandatory
1. Injured Worker’s name Employee’s name No (not needed)
1. Injured Worker’s Home address Employee Address Line 1 No (not needed)
Employee Address Line 2
Employee City
Employee State
Employee Postal Code
2. Age No No (not needed)
3a. Social Security No. Soc. Security Number DN – 42 mandatory
3. Date of accident Date of injury DN – 31 mandatory
4. Probable date of recovery No No (not needed)
No Report effective date (Date DN – 3 mandatory

of Notice)
5. Did injury cause death Date of death DN – 57 conditional
No No DN – 2 mandatory
6. Employer name Employer name No (not needed)
6. Employer address Employer’s address Line 1 No (not needed)
Employer’s Address Line 2
Employer City
Employer State
Employer Postal Code
6. Employer FEIN or NJTIN No No (not needed)
No No DN – 26 conditional
7. Agreement to compensate signature No DN – 75 mandatory
8. Did injury require medical aid No No (not needed)
9. Medical aid to be paid by employer or No No (not needed)
carrier
9a. Cost of medical aid rendered No DN – 95 conditional
by carrier or employer
With code = 350, 360 or
370 and with paid amount
in DN 96 per code
10. Output earning/daily average No No (not needed)

11. Output by day/wages per pay No No (not needed)
12. Output by hour/hourly rate No No (not needed)
13. Number of hours worked per day No No (not needed)
14. Number of days in a reg. work week No DN – 64 conditional
15. Amount of weekly wages Average Weekly Wage DN – 62 mandatory
No No No (not needed)
16. Were board and lodging furnished No No (not needed)
17. Name and Address of physician No No (not needed)
Date form prepared Date of Notice DN – 3 mandatory
18. Detailed X-ray findings No No (not needed)
19. Detailed diagnosis of physician No No
States get this directly from
provider & not carrier (34-
15-100)
20a. General X-ray findings No No (not needed)
20b. Total number of treatments No No (not needed)
20c. Date of discharge No No (not needed)
21. General diagnosis No No (not needed)
22. Is worker capable of doing same No No (not needed)
work
23. Date disability began From Date DN – 56 conditional
No Through Date DN – 69 conditional

Payments
No Payment Type DN – 85 conditional
No Amount Paid to Date DN – 86 conditional

24. Date payments began Paid from-date DN – 88 conditional
No Paid through-date DN – 89 conditional
No # Weeks paid DN – 90 conditional
No # Days paid DN – 91 conditional
Benefit Adjustments
Yes No DN – 92 conditional
Paid To Date
No
Actual = Code 600 – 624
Deemed + Code 650 – 674
600-675 Code
No No No (not needed)
Recoveries
Yes No DN–95 conditional

Code = 800-840
for DN 95 (800 - 840)

Claim Administration
1. Self Insurer or Carrier Name Insurer name (if Claim No (not needed)
Administrator)
No TPA name (if assigned) No (not needed)
No Claim Adm. Claim Number DN – 15 mandatory
No Claim Adm. Address DN – 14 mandatory

(Postal Zip Code)
Yes No DN – 73 mandatory
Yes No DN – 74 mandatory
25. Date injured returned to work Date returned to work DN – 72 conditional
Applicable to Formals only Agency Claim Number DN – 5 conditional
26. Total time unable to work No but can be calculated Can be calculated by (DN
weeks/months by 72 – DN 56)
(Date Return to work – date
from)
27. Did any perm. injury result from No ----------
accident
28. If yes describe fully, giving % of No DN – 83 conditional
member involved
DN – 84 conditional
29. Amount of weekly compensation No DN – 87 conditional
30. No. of weeks / amt. pd. for temp. Payment Type DN – 85 conditional
disability
# Weeks Paid (Code 050, 070)
Weeks $$
Amount Paid to Date DN – 90 conditional
31. Number of weeks to be paid for # Weeks Paid DN – 90 conditional
amputation
32. Number of weeks to be paid for other # Weeks Paid DN – 90 conditional
permanent injuries
33. Total amount of compensation for Payment Type DN – 85 conditional
permanent injuries
Amount Paid to Date (Code 030, 040, 530, 540)

34. Was there an informal hearing No No (not needed)
NJ WC-3A NJ Benefit Status Letter EDI SROI
Name of Employer Employer Name No (not needed)
Employer FEIN # or NJTIN No No (not needed)

40. Date of preparation Date of Notice DN – 3 mandatory
41. Cost of Employer or Carrier Payment Type DN – 85 conditional
# Weeks Paid (code 010 or 510)
42. Name each dependent No No (not needed)
Name No No (not needed)
Date of Birth No No (not needed)
Relationship to deceased No DN – 97 conditional

(based on code)
Physically or mentally deficient (Y or No DN – 97 conditional
N) Code = 7
No Date of MMI DN – 70 conditional
43. Amount of compensation paid prior Payment Type DN – 85 conditional
to death
# Weeks paid (Code other than 010, 510)
44. Specify dependents which are No DN – 97 (not needed)
physically or mentally deficient relationship value in first
position, if handicapped,
will equal “7”
Date of accident Date of injury DN – 31 (not needed)
Name of deceased employee Employee Name No (not needed)
Social Security Number Soc. Security Number DN – 42 (not needed)
Name of principal dependent No No (not needed)
Address No No (not needed)

45. Weekly comp rate paid to each No No (not needed)
dependent:
Rate: No No (not needed)

Weeks: No No (not needed)
Amount: No No (not needed)

46. Total compensation paid & to be Amount Paid to Date DN – 86 conditional
paid dependents
47. Total cost of burial paid by Paid to Date (PTD) Type DN – 95 conditional
employer/carrier
(Code = 300)
PTD Amount DN – 96 conditional
Agreement to compensate dependents – No No (not needed)
signature
Agreement to accept compensation by No No (not needed)
principal dependent – signature

EDI Reports and Related Events
The industry standards for State Reporting considered state oversight and compliance objectives and how
they are achieved in the claim administrator claim handling processes. As such, the standards relate state
EDI Reporting requirements to claim processing events. Each report or transaction, is labeled with a code
to identify the claim event it represents: Initial Payment, Change of Benefits, Denial, Suspensions, Partial
Suspensions, Reinstatements, Acquired Claim, etc. The Event codes have taken the American National
Standards Institute (ANSI) technical name of Maintenance Type Codes (MTC). Release 1 is comprised of
approximately 40 business events (MTCs). NJCRIB State Reporting only uses nine of the available MTCs:
1. Original First Report of Injury (00),
2. Denial (04),
3. Acquired (AU) for FROI Reports,
4. Change FROI (02)
5. Correction FROI (CO)
6. Semi-Annual (SA) SROI Report
7. Denial SROI (04)
8. Change SROI (02), and
9. Correction SROI (CO).
The data required to be reported is based on the business event. Date Requirements are often referred to
and expressed as MCOs: Mandatory, Conditional, or Optional. Conditional data elements require the
situation be specified when that data element is “Mandatory” or “Optional.” Mandatory indicates the data
element is required or else the transaction is incomplete and will be rejected. Mandatory data includes
data that is necessary to process the claim from a technical or business standpoint. A claim missing a
Claim Administrator Claim Number or Insurer FEIN will not allow the claim to be matched to the NJCRIB
database, or matched to the Insurer database or trading partner table. Missing Date of Injury, Nature of
Injury, or Part of Body codes may render statistical analysis invalid.
Two tables are provided to identify NJCRIB FROI MTC Report Data Requirements and SROI MTC Data
Requirements.
A third table, the NJCRIB Event Table, defines the business situation that will cause a Report (MTC) to be
required, such as, either an Original First Report of Injury or a Denial First Report of Injury (if claim is
being denied at the time it is being reported) must be submitted to NJCRIB FROI if:
• An accident or occupational exposure results in lost work days,
• Medical treatment or care by a medical provider other than first aid administered at the site of
accidence or occurrence.
At the time, the insurance carrier, third party administrator, self-insured employer, or statutory non-insured
employer has knowledge of one of the following events, a SROI must be reported. When the injured
employee has:
• Recovered so as to be able to return to work, or
• Reached maximum medical improvement (MMI), or
• Is deceased, or
• The claim is 26 weeks after the date of accident on a medical only claim.
Review the details of the NJCRIB Event table to determine which nine specified business events occur
and when a report is required.

FROI Requirements Table
Maintenance Type Code (MTC) values:

00 Original
04 Denial
01 Cancel
02 Change
CO Correction
AU Acquired Unallocated
Groupings
Elements MTCs
No Data Name Fmt. Beg End 00 04 01 02 CO AU Edits
Transaction
1 Transaction Set Id 3 A/N 1 3 M M M M M M Must Be 148, A49, AK1, HD1 or
TR1
2 Maint. Type Code 2 A/N 4 5 M M M M M M Must Be 00, 04, 01, 02, CO, or
AU
3 Maint. Type Code Date DATE 6 13 M M M M M M Must Be a Valid Date
CCYYMMDD
Jurisdiction
4 Jurisdiction 2 A/N 14 15 M M M M M M Must be "NJ"
5 Agency Claim Number 25 A/N 16 40 O C M M M C Mandatory if previously assigned
and available
Claim Admin.
6 Insurer FEIN 9 A/N 41 49 M M M M M M
7 Insurer Name 30A/N 50 79 M M M M M M
8 TPA FEIN 9 A/N 80 88 C C C C C C Mandatory if TPA is reporting
9 TPA Name 30 A/N 89 118 C C C C C C Mandatory if TPA is reporting
10 Claim Admin. Address Line 1 30 A/N 119 148 M M M M M M
11 Claim Admin. Address Line 2 30 A/N 149 178 O O O O O O
12 Claim Admin. City 15 A/N 179 193 M M M M M M
13 Claim Admin. State 2 A/N 194 195 M M M M M M
14 Claim Admin. Postal Zip 9 A/N 196 204 M M M M M M
15 Claim Admin. Claim Number 25 A/N 205 229 M M M M M M
Insured
16 Employer FEIN 9 A/N 230 238 M M M M M M
17 Insured Name 30 A/N 239 268 O O O O O O
18 Employer Name 30 A/N 269 298 M M M M M M
19 Employer Address Line 1 30 A/N 299 328 M M M M M M
20 Employer Address Line 2 30 A/N 329 358 O O O O O O
21 Employer City 15 A/N 359 373 M M M M M M
22 Employer State 2 A/N 374 375 M M M M M M
23 Employer Postal Code 9 A/N 376 384 M M M M M M
24 Self Insured Indicator 1 A/N 385 385 M M M M M M
25 SIC Code 6 A/N 386 391 M M M M M M
26 Insured Report Number 10 A/N 392 401 O O O O O O
27 Insured Location Number 15 A/N 402 416 O O O O O O
Policy
(Policy Fields are only Mandatory for Insured Employers)
28 Policy Number 30 A/N 417 446 C C C C C C O IF Self-Insured, Else M If WC
Policy.

Groupings
Elements MTCs
No Data Name Fmt. Beg End 00 04 01 02 CO AU Edits
29 Policy Effective DATE 447 454 C C C C C C O IF Self-Insured, Else M and
then Must Be a Valid Date
CCYYMMDD, and Must Be < or =
Date of Injury.
30 Policy Expiration DATE 455 462 C C C C C C O IF Self-Insured, Else M and
then Must Be a Valid Date
CCYYMMDD and Must Be > or =
Date of Injury.
Accident
31 Date of Injury DATE 463 470 M M M M M M Must be< or = Date Reported to
Employer and Must Be a Valid
Date CCYYMMDD.
32 Time of Injury HHMM 471 474 M M M M M M
33 Postal Code of Injury Site 9 A/N 475 483 M M O M M M
34 Employers Premise Indicator 1 A/N 484 484 M M O M M M
35 Nature of Injury Code 2 A/N 485 486 M M M M M M
36 Part of Body Injured Code 2 A/N 487 488 M M M M M M
37 Cause of Injury Code 2 A/N 489 490 M M M M M M
38 Accident Description / Cause 150 491 640 M M M M M M
A/N
39 Initial Treatment Code 2 A/N 641 642 M M O M M M
40 Date Reported to Employer DATE 643 650 M M M M M M Must Be a Valid Date
CCYYMMDD and Must Be > or =
Date of Injury.
41 Date Reported to Claims DATE 651 658 O O O O O O Must Be a Valid Date
Admin. CCYYMMDD
Employee
42 Social Security Number 9 A/N 659 667 M M M M M M
43 Employee Last Name 30 A/N 668 697 M M M M M M
44 Employee First Name 15 A/N 698 712 M M M M M M
45 Employee Middle Initial 1 A/N 713 713 O O O O O O
46 Employee Address Line 1 30 A/N 714 743 M M M M M M
47 Employee Address Line 2 30 A/N 744 773 O O O O O O
48 Employee City 15 A/N 774 788 M M M M M M
49 Employee State 2 A/N 789 790 M M M M M M
50 Employee Postal Code 9 A/N 791 799 M M M M M M
51 Employee Phone 10 A/N 800 809 O O O O O O
52 Employee Date of Birth DATE 810 817 M M M M M M
53 Gender Code 1 A/N 818 818 M M M M M M
54 Marital Status Code 1 A/N 819 819 C C C C C C M If death claim, else N/A.
55 Number of Dependents 2N 820 821 C C C C C C Must Be Numeric and M If death
claim, else N/A.
56 Date Disability Began DATE 822 829 C C C C C C Must Be a Valid Date
CCYYMMDD and M if unable to
perform regular work, Else N/A.
57 Employee Date of Death DATE 830 837 C C C C C C M If death claim, Else N/A. If
Applicable it Must Be a Valid
Date CCYYMMDD and Must be >
or = Date of Injury.
Employment
58 Employment Status Code 2 A/N 838 839 O O O O O O
59 Class Code 4 A/N 840 843 M M O M M M
60 Occupation Description 30 A/N 844 873 M M O M M M
61 Date of Hire DATE 874 881 O O O O O O Must Be a Valid Date
CCYYMMDD
62 Wage $9.2 882 892 M M M M M M

Groupings
Elements MTCs
No Data Name Fmt. Beg End 00 04 01 02 COAU Edits
63 Wage Period 2 A/N 893 894 M M M M M M
64 Number of Days Worked 1N 895 895 M M M M M M Must Be Numeric
65 Date Last Day Worked DATE 896 903 C C C C CC M If Loss OF Time From Work
and Must Be a Valid Date
CCYYMMDD, Else N/A.
66 Full Wages Pd for Dte of Inj 1 A/N 904 904 O O O O O O
Indicator.
67 Salary Continued Indicator 1 A/N 905 905 M M O M M M
68 Date of Return To Work DATE 906 913 C O O C C C Must Be a Valid Date
CCYYMMDD and M if employee
able to return to regular duties,
Else N/A.

SROI Requirements Table
Maintenance Type Code (MTC) values:

SA Semi-Annual
04 Denial
02 Change
CO Correction
Grouping MTCs Edits Occ.

No. SA 04 02 CO
Transaction
1 Transaction Set Id M M M M Must be 148, A49, AK1, HD1 or TR1. 1
2 Maint. Type Code M M M M Must be SA, 04, 02, or CO. 1
3 Maint. Type Code Date M M M M Must be a valid date CCYYMMDD. 1
Jurisdiction
4 Jurisdiction M M M M Must be "NJ.” 1
Claim Admin.
6 Insurer FEIN M M M M 1
8 TPA FEIN C C C C M if TPA is reporting. 1
14 Claim Admin. Postal Zip M M M M 1
Employee
42 Social Security Number M M M M 1
55 Number Of Dependents C C C C M if Death Claim, else N/A. Must be a valid date 1
CCYYMMDD.
69 Pre-Existing Disability C C C C M if Pre-Existing, else N/A. 1
56 Date Disability Began C C C C M if unable to perform regular duties, else N/A. 1
Must be a valid date CCYYMMDD.
70 Date of Maximum Medical C C C C M if Max Med Improvement, else N/A. Must be a 1
Improvement valid date CCYYMMDD.
71 Return to Work Qualifier C C C C M if returned to work, else N/A. Must be a valid 1
date CCYYMMDD.
72 Date of Return/Release to C C C C M if returned to work, else N/A. Must be a valid 1
Work date CCYYMMDD.
57 Employee Date of Death C C C C M if Death Claim, else N/A. Must be a valid date 1
CCYYMMDD.
Wage
62 Wage M M M M 1
63 Wage Period M M M M 1
64 Number Of Days Worked C C C C M if Disability < a week, else N/A. 1
67 Salary Continued Indicator M M M M 1
Accident
31 Date Of Injury M M M M Must be a valid date CCYYMMDD. 1
26 Insured Report Number O O O O 1
15 Claim Administrator Claim M M M M 1
Number
5 Agency Claim Number M M M M 1
Claim Status
73 Claim Status M O O O Must be in Table - Valid Code. 1
74 Claim Type M O O O Must be in Table - Valid Code. 1
75 Agreement to Compensate M M M M 1
Code
76 Date Of Representation C C C C M if has Legal Rep., else N/A. Must be a valid 1
date CCYYMMDD.
Payments
77 Late Reason Code C C C C 1
Variable Segment Counters

Grouping MTCs Edits Occ.
No. SA 04 02 CO
78 Number of Permanent M M M M 1
Impairments
79 Number of M M M M 1
Payment/Adjustments
80 Number of Benefit M M M M 1
Adjustments
81 Number of Paid to M M M M 1
Date/Reduced
Earnings/Recoveries
82 Number of Death M M M M 1
Dependant/Payee
Relationships
Variable Segments
M if 78 > 0, else N/A. 6
83 Permanent Impairment C C C C Must be in Table - Valid Code 1
Body Part Code
84 Permanent Impairment C C C C Must be valid percentage 1
Percent
10
85 Payment/Adjustment Code C C C C M if payment made, else N/A 1
86 Payment/Adjustment Paid C C C C M if 79 > 0, else N/A. 1
To Date
87 Payment/Adjustment C C C C M if 79 > 0, else N/A. 1
Weekly Amount
88 Payment/Adjustment Start C C C C M if 79 > 0, else N/A. Must be a valid date 1
Date CCYYMMDD.
89 Payment/Adjustment End C C C C M if 79 > 0, else N/A. Must be a valid date 1
Date CCYYMMDD.
90 Payment/Adjustment Weeks C C C C M if 79 > 0, else N/A. 1
Paid
91 Payment/Adjustment Days C C C C M if 79 > 0, else N/A. 1
Paid
92 Benefit Adjustment Code C C C C M if payment made, else N/A. 1

93 Benefit Adjustment Weekly C C C C M if 80 > 0, else N/A. 1
Amount
94 Benefit Adjustment Start C C C C M if 80 > 0, else N/A. Must be a valid date 1
Date CCYYMMDD.
95 Paid To Date / Reduced C C C C M if payment made, else N/A. 1

Earnings / Recoveries Code
96 Paid To Date / Reduced C C C C M if 81 > 0, else N/A. 1
Earnings / Recoveries
Amount
97 Dependent/Payee C C C C M if payment made, else N/A. 1

Relationship

NJCRIB FROI & SROI Event Tables
NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU

FIRST AND SUBSEQUENT REPORTS OF INJURY EVENT TABLE
MTC MTC Description Report Trigger
00 Original First Report of Due 21 days from Receipt of Claim.

Injury
Due Immediately at Time Jurisdiction Change noted by Claim
01 Cancel First Report of injury Administrator.
Due Immediately at the time any data element previously
02 Change First Report of reported is updated in Claim Administrator’s system.
Injury
Due 21 days from Receipt of Claim if sending as a first report.
Due Immediately at the time the Claim Administrator denies the
04 Denial First Report of Injury claim. Send the FROI 04 if sending as a follow up to “00,
Original First Report of Injury” or “AU” Acquired Claim First
Report and no SROI report has been sent.
CO Correction First Report of Due the day following receipt of the AK1 Acknowledgement of a
Injury prior FROI with a status of “TE.”
AU Acquired Claim, First Due within 21 days of date current claim administrator assumed
Report of Injury of claim handling responsibilities.
SA Semi-Annual Subsequent One Semi-Annual report is due within six months after the day of
Report of Injury the date when the claimant has returned to work, reached MMI,
or is deceased. For medical only claims, due within 6 months
following the date of accident. No further SA report is due.
04 Denial Subsequent Report Due immediately at the time the Claim Administrator denies the
of Injury claim. Send SROI 04 if any other SROI has been sent
previously.
02 Change Subsequent Report Due immediately at the time any SROI data element previously
of Injury sent on the SA, 04 SROI, or CO SROI is updated in the Claim
Administrator’s system.
CO Correction to Subsequent Due the day following receipt of the AK1 Acknowledgement to a
Report of Injury prior SROI with a status of TE.

Approved EDI Formats
NJCRIB approves the use of IAIABC or ANSI technical formats. Both use the IAIABC data standards for
State Reporting. These formats were chosen to standardize, simplify, and reduce the costs of exchanging
data. Each meets the requirements of state reporting but also possesses characteristics that may make
one format more suitable to your needs.
The IAIABC format is a flat file format. Each IAIABC format data element is identified by its physical
position in the file. All data must be included. Missing or partially filled fields must be filled by blanks or
zeros as per the data type it represents. The Release 1 Flat File Format is relatively simple and the
technology is well known and suited for in-house development. Some translators process IAIABC Flat
Files. Release 1 includes five flat files: First Report (FROI), Subsequent Report (SROI),
Acknowledgement (AK1), and Header (HD1) and Trailer (TR1) files.
The ANSI format is a coded format. Each ANSI format data element is identified by a code and sequence
scheme. This scheme does not require State Optional data to be omitted. Field delimiters eliminate the
need to zero or blank fill a field to flat file field lengths. The ANSI format was developed to meet OSHA,
BLS, Drs. Reports, and also contains data typically exchanged between a claim administrator and
policy/contract holders. The ANSI format provides for hierarchical representation of the data and is
therefore is fitted for and economical for transmitting huge amounts of claims. Because of its complexity,
most organizations purchase a commercial translator and simply, using translator tools, map their data
names to the standard reports. The ANSI Format uses two transactions: 148 Report of Injury or Illness,
and 824 Acknowledgement. These transactions include Header and Trailer conventions. ANSI
transmission capabilities include grouping and additional addressing functionality. ANSI transactions are
mandated for Health Care Insurance under the HIPAA Act.
The IAIABC and ANSI Format is detailed in the IAIABC Release 1 EDI Implementation Guide.
An updated ANSI Format and examples are available in the appendix of this Guide.
NJCRIB Data Edits

The industry state reporting standards include a process that enables a claim administrator to relate a
generic edit to data used in any state report. Two charts are provided. The first identifies edits applied to
NJCRIB FROI and SROI reports. The second identifies edits applied to Header and Trailer transactions.
All Reports submitted to NJCRIB are edited against the appropriate chart.

NJ CRIB EDI Implementation Guide
New Jersey Edit Matrix Table

IAIABC
DN
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Claim Admin. Claim Number
Claim Admin. Postal Zip
Claim Admin. State
Claim Admin. City
Claim Admin. Address Line 2
Claim Admin. Address Line 1
TPA Name
TPA FEIN
Insurer Name
Insurer FEIN
Agency Claim Number
Jurisdiction
Maint. Type Code Date
Maint. Type Code
Transaction Set ID
IAIABC Data Element Name

First Report Transaction
Trigger = Within 21 days
Error Messages
Mandatory Field Not Present
TRC
TRC
TRC
001
TR
TR
TR
TR
TR
TR
TR
TR
TR
TR
TR
Page 69
018 028 029 Number of Days Worked must be 0-7

Must be Numeric 0 - 9
TR
TR
TR
Must be a valid date (CCYYMMDD)

TR
Must be A-Z, 0-9 or spaces

TRC
030
TE
TE
TE
TE
TE
TE
TE
Must be a vaild time (HHMM)

031 033 034 035
Must be <= Date of Injury

Must be >=Date of Injury
TR
Must be >= Date Disability Began

Must be <= Maintenance Type Code
037
Date
Must be => Start Date
038 039 040 041 042 050 053 055 057
No Match on NJCRIB Database

TR
TR
TR TR
All Digits Cannot be the Same

TR
March 15, 2002
Must be <= Current Date

TR
Not Statutorily Valid

TR
No Matching Subsequent Rpt (A49)

No Matching FROI (148)
TR
TR
Must be <= Date of Hire

Duplicate Transmisson / Transaction
TR TR
TR TR
TR TR
TR TR
Code / ID Invalid
TRC
058
TR
Value not consistant with previous rpt

059 066 067 068 100
TE
Invalid Record Count

Must Be >= Policy Effective Date
Must be <= Policy Expiration date
No Leading or Embedded Spaces
TR
TR
TR
Error Messages

Number of Days Worked must be 0-7






Code / ID Invalid
Date
IAIABC IAIABC Data Element Name 001 018 028 029 030 031 033 034 035 037 038 039 040 041 042 050 053 055 057 058 059 066 067 068 100
DN
16 Employer FEIN TR TR TR
17 Insured Name TE
18 Employer Name TR TE
19 Employer Address Line 1 TR TE
20 Employer Address Line 2 TE
21 Employer City TR TE
22 Employer State TR TR
23 Employer Postal Code TR TR TRC TRC
24 Self Insured Indicator TR TR
25 SIC Code TR TE
26 Insured Report Number TE
27 Insured Location Number TE
28 Policy Number TRC TE TR
29 Policy Effective TRC TR TE TE TR TR
30 Policy Expiration TRC TR TE TR
31 Date of Injury TR TR TR TR TE TE TE
32 Time of Injury TR TR
33 Postal Code of Injury Site TR TR TRC TRC
34 Employers Premise Indicator TR TR
35 Nature of Injury Code TR TR
36 Part of Body Injured Code TR TR
37 Cause of Injury Code TR TR

Error Messages







Code / ID Invalid
Date
DN
38 Accident Description / Cause TR
39 Initial Treatment Code TR TE
40 Date Reported to Employer TR TR TR TR TR
41 Date Reported to Claims Admin. TE TE TE TE
42 Social Security Number TR TR TR TR TE
43 Employee Last Name TR TE
44 Employee First Name TR TE
45 Employee Middle Initial TE
46 Employee Address Line 1 TR TE
47 Employee Address Line 2 TE
48 Employee City TR TE
49 Employee State TR TR
50 Employee Postal Code TR TR TRC TRC
51 Employee Phone TE TRC
52 Employee Date of Birth TR TR TE TR TE TE
53 Gender Code TR TR
54 Marital Status Code TRC TE TE
55 Number of Dependents TRC TR
56 Date Disability Began TR TE TE TE
57 Employee Date of Death TR TR TE TE
58 Employment Status Code TE
59 Class Code TR TE

Error Messages







Code / ID Invalid
Date
DN
60 Occupation Description TR TE
61 Date of Hire TE TE TE
62 Wage TR TR
63 Wage Period TR TR
64 Number of Days Worked TRC TR TR
65 Date Last Day Worked TRC TR TE TE TE
66 Full Wages Pd for Dt of Injury Ind. TE
67 Salary Continued Indicator TR TR
68 Date of Return To Work TE TE TE TR
Subsequent Report Transaction
1 Transaction Set ID TR TR TR
2 Maint. Type Code TR TR TR TR TR TR
3 Maint. Type Code Date TR TR TR
4 Jurisdiction TR TR TR
6 Insurer FEIN TR TR TR TR
8 TPA FEIN TRC TR TR TR
14 Claim Admin. Postal Zip TR TR TRC TRC
42 Social Security Number TR TR TR TR TR TE
55 Number Of Dependents TRC TR
69 Pre-Existing Disability TR
56 Date Disability Began TRC TR TR TR TR
70 Date of Maximum Medical Improvement TR TR TR TR

Error Messages







Code / ID Invalid
Date
DN
71 Return to Work Qualifier TRC TE
72 Date of Return/Release to Work TRC TR TR TR TR TR
57 Employee Date of Death TRC TR TR TR TR
62 Wage TR TR
63 Wage Period TR TE
64 Number Of Days Worked TR TR TE
67 Salary Continued Indicator TR TR
31 Date Of Injury TR TR TR TR TR TE TE
26 Insured Report Number TE
15 Claim Administrator Claim Number TR TE TR TR TE TR
5 Agency Claim Number TR TE TR TR
73 Claim Status TR TE
74 Claim Type TR TR
75 Agreement to Compensate Code TR TE
76 Date Of Representation TR TR TR TR
77 Late Reason Code TE
78 Number of Perminant Impairments TR TRC
79 Number of Payment/Adjustments TR TRC
80 Number of Benefit Adjustments TR TRC
81 Number of Paid to Date/Reduced TR TRC
Earnings/Recoveries
82 Number of Death Dependant/Payee TR TRC

Error Messages







Code / ID Invalid
Date
DN
Relationships
Permanent Impairment Occurs Number of Permanent Impairment Times
83 Permanent Impairment Body Part Code TRC TE
84 Permanent Impairment Percent TRC TE
Payment/Adjustments Occurs Number of Payments/Adjustment Times
85 Payment/Adjustment Code TRC TR
86 Payment/Adjustment Paid To Date TRC TR TR
87 Payment/Adjustment Weekly Amount TRC TR
88 Payment/Adjustment Start Date TRC TR TE TE TE TE
89 Payment/Adjustment End Date TR C TR TE TE TE TE TE
90 Payment/Adjustment Weeks Paid TRC TR
91 Payment/Adjustment Days Paid TRC TR TR
Benefit Adjustments Occurs Number of Benefit Adjustment Times
92 Benefit Adjustment Code TRC TR
93 Benefit Adjustment Weekly Amount TRC TE
94 Benefit Adjustment Start Date TRC TR TE TE TE TE
Paid To Date/Reduced Earnings/Recoveries Occurs Paid To Date/Reduced Earnings/Recoveries Times
95 Paid To Date /Reduced Earnings TRC TR
/Recoveries Code
96 Paid To Date /Reduced Earnings TRC TR
/Recoveries Amount
Death Dependant/Payee Relationship Times

NJ CRIB EDI Implementation Guide
IAIABC
106
105
104
101
100
DN
99
98
97
Detail Record Count
Test / Production Indicator
Receiver ID
Dependant/Payee Relationship
Interchange Version ID
Time Transmission Sent

Date Transmission Sent
Sender ID
Header & Trailer Records (HD1 & TR1)
IAIABC Data Element Name
Error Messages
TRC
001
TR
TR
TR
TR
TR
TR
TR
Page 75
018 028 029

TR

TR

030
031 033 034 035
TR

037
Date
038 039 040 041 042 050 053 055 057

TR
TR
TR

March 15, 2002

TR

TR

Code / ID Invalid
058
TR
TR
TR

059 066 067 068 100
TR

Conditional Data Elements/Edits
IAIABC DN IAIABC Data Element Name Condition
First Report of Injury

5 Agency Claim Number Edited if present for MTC 00, 04 and AU
8 TPA FEIN If either DN 8 or 9 present, the other is required
9 TPA Name If either DN 8 or 9 present, the other is required
14 Claim Admin. Postal Zip If State is other than a USA state, error message 030 is applied;
058 refers to length of zip not to validity of the code
23 Employer Postal Code If State is other than a USA state, error message 030 is applied;
28 Policy Number If DN 24 = N, Policy Number is Mandatory
29 Policy Effective If DN 29 is present, then Policy Effective Date is Mandatory
30 Policy Expiration If DN 29 is present, then Policy Expiration Date is Mandatory
33 Postal Code of Injury Site If State is other than a USA state, error message 030 is applied;
50 Employee Postal Code If State is other than a USA state, error message 030 is applied;
51 Employee Phone Error Message 058 refers to the acceptable length --either 7 or 10
numerics
54 Marital Status Code If DN 57, Date of Death present, DN 54 is mandatory
55 Number of Dependents If DN 57, Date of Death present, DN 55 is mandatory
64 Number Of Days Worked If DN 65, Date Last Day worked completed then DN 64 Mandatory
65 Date Last Day Worked If DN 64, Number of Days Worked completed, then DN 65 Mandatory
Subsequent Report Transaction
8 TPA FEIN If TPA reported on FROI mandatory on SROI
55 Number Of Dependents If DN 57, Date of Death present, DN 55 is mandatory
56 Date Disability Began If DN 85 = 050 or 070, DN 56 is mandatory
65 Date Last Day Worked If DN 56, Date Disability Began, present then DN 65 Mandatory
71 Return to Work Qualifier If DN 72, Date of Return/Release to work present, DN 71 Mandatory
72 Date of Return/Release to Work If DN 71, Return to Work Qualifier present, DN 72 Mandatory
57 Employee Date of Death If DN 85 = 010, DN 57 Mandatory
78 Number of Perminant Impairments Error Message 058 refers to the number of valid occurrences

Conditional Data Elements/Edits
IAIABC DN IAIABC Data Element Name Condition
79 Number of Payment/Adjustments Error Message 058 refers to the number of valid occurrences
80 Number of Benefit Adjustments Error Message 058 refers to the number of valid occurrences
81 Number of Paid to Date/Reduced Error Message 058 refers to the number of valid occurrences
Earnings/Recoveries
82 Number of Death Dependant/Payee Error Message 058 refers to the number of valid occurrences
Relationships
83 Permanent Impairment Body Part Code If either DN 83 or 84 present the other other is required
84 Permanent Impairment Percent If either DN 83 or 84 present the other other is required
86 Payment/Adjustment Paid To Date If DN 85 present and other than 240 or 500, Mandatory
87 Payment/Adjustment Weekly Amount If DN 85 present and other than 240 or 500, Mandatory
88 Payment/Adjustment Start Date If DN 85 present and other than 240 or 500, Mandatory
89 Payment/Adjustment End Date If DN 85 present and other than 240 or 500, Mandatory
90 Payment/Adjustment Weeks Paid If DN 85 present and other than 240 or 500, Mandatory
91 Payment/Adjustment Days Paid If DN 85 present and other than 240 or 500, Mandatory
92 Benefit Adjustment Code If DN 93, Benefit Adjustment Weekly Amount present then Mandatory
93 Benefit Adjustment Weekly Amount If DN 92, Benefit Adjustment Code, present, then DN 93 is Mandatory
94 Benefit Adjustment Start Date If DN 92, Benefit Adjustment Code, present, then DN 94 is Mandatory
95 Paid To Date /Reduced Earnings /Recoveries If DN 96, PTD/RE/Recoveries Amt present then DN 96 is Mandatory
Code
96 Paid To Date /Reduced Earnings /Recoveries If DN 95 present, then DN 96 is Mandatory
Amount
97 Dependant/Payee Relationship At least one iteration of DN 97 is required if
DN 57, Date of Death present

Acknowledgement and Correction Process
The industry standard for State Reporting includes a process where the State edits and acknowledges
each report it receives. The Acknowledgement will show the status of each report as either:
• Transaction Accepted (TA),
• Transaction (accepted with) Errors (TE), or
• Transaction Rejected (TR).
A status of TA requires no response. A TE Acknowledgement will list the code of each data element that
failed editing, and the code of the edit that detected the error. Also, a status of TE requires that a
Correction transaction (FROI or SROI) record, as appropriate, be submitted with correct values for the
reported data errors. A status of TR requires that the report be resubmitted.

Transaction Sequence Requirements
First Reports
The first transaction that NJCRIB receives on a claim must be an Original (00), Acquired/Unallocated
(AU), or a Denial (04). Only one Original or Denial transaction is permitted per claim. Only one
Acquired/Unallocated transaction per claim administrator is permited per claim. A Cancel (01) or Change
(02) requires that an Original, Acquired/Unallocated, or Denial was previously submitted and accepted by
NJCRIB. A Correction (CO) is a response to an NJCRIB Acknowledgement with errors.
NJCRIB will edit all transactions it receives and notify the reporting administrator if a report was rejected,
accepted, or accepted with errors. Only transactions accepted with or without error by NJCRIB will be
considered as meeting NJCRIB reporting requirements. A transaction that is accepted without errors
satisfies that NJCRIB reporting requirement. A transaction that is rejected by NJCRIB must be resent. The
date of accepted transactions with or without errors is used to measure reporting compliance. However,
transactions accepted with errors require correction, even though the date originally received will be used
to measure reporting compliance.
Subsequent Reports
NJCRIB requires that a First Report, Original, Acquired/Unallocated, or Denial was previously submitted
and accepted by NJCRIB before a subsequent Semi-Annual (SA) or Denial (04) transaction will be
accepted.
A Subsequent Change (02) transaction requires that a Semi-Annual (SA) or Denial (04) transaction was
previously accepted.
A Subsequent Correction requires that an Acknowledgement had already been received on a Semi-
Annual (SA), Denial (04), or Change Transaction (02).
NOTE: Please refer to the IAIABC Release 1 Specifications for report transaction
(Maintenance Type Codes, e.g. SA, 04, 02, etc.) definitions and Transaction Sequence
Requirements.
IMPORTANT IMPLEMENTATION NOTE: The IAIABC EDI Reporting Process was

developed to meet diverse jurisdiction reporting requirements. Therefore the specifications
include numerous reports (MTCs) and the Transaction Sequence Requirements must
account for all possible transactions. Other jurisdictions that require the Semi-Annual
Transaction (SA) also require the Initial Payment (IP) or Full Salary (FS). Administrators
who report to these states probably apply the IAIABC Transaction Sequence rule before
submitting a SA. The absence of aN NJCRIB requirement of an IP or FS transaction may
be problematic for these administrators.

NJCRIB encourages claim administrators to recognize that other states will not require every transaction
and that similar perceived Transaction Sequence conflicts will arise. It is suggested that administrators
revisit their EDI process and augment it as follows. Program your system with IAIABC requirements.
When a claim event, such as issuance of an Initial Payment (IP) occurs, perform it as scheduled.
However, before submitting the corresponding Transaction (MTC), check the jurisdiction’s report
requirements. If the Report (MTC) is required, send it and continue processing as per the
acknowledgement it yields. If the Report (MTC) is not required, post your EDI management system so that
the requirement has been satisfied and allow any Transaction Sequence Rules dependent on previous
submission of that Report to function normally for all states.

Reporting Process Functions and Options
A comparison of the NJCRIB EDI Requirements with your manual and computer system processes may
identify both manual and technical deficiencies. The previous section provided the NJCRIB requirements.
This section depicts the State EDI Reporting Processes at a high level. It is followed by a section of EDI
Products that may be built in-house or acquired commercially. The objective of this section is to increase
your awareness of the process and potential solutions. It should be used in conjunction with your
organization’s formal project development plan.
The State EDI Reporting Process includes:
• Managing State Reporting Requirements.
• Capturing State Report Data.
• Editing for Data Content and Quality.
• Translating Data into or from IAIABC or ANSI Formats.
• Managing Communications (Report Transmissions).
• Managing Acknowledgements, Replacement Reports, and Corrections.
Manage State Reporting Requirements
State Reporting has typically been performed through the combined efforts of the Claim Adjuster and
Administration staff. EDI reporting provides the potential to replace Claim Adjuster report monitoring by
automated process based on claim system data or claim adjuster actions. The receipt of
Acknowledgements can initiate computer or claim adjuster responses. The level of sophistication can
range greatly between administrator processes.
Capture State Report Data
A common dilemma for Claim Administrators is the capture and electronic storage of data required by
State’s implementing EDI Reports. Although creating national standard data elements simplifies claims
administrator and state reporting, there is often a void between a State’s reporting data requirements and
data available through the claim administrator’s claim handling computer system.
How do you resolve the difference? If the missing data falls within the category of “Optional,” no
immediate fix may be required. If the missing data involves “Conditional” or “Mandatory” data an
immediate solution is in order.
Missing data solutions vary and are dependent on several factors, such as claim volume, age and
flexibility of your claim handling computer system, as well as priority of other business objectives and
projects. Solutions fall into three basic categories:
1. Modify your claim handling computer system and claim process to capture the missing data.
2. Supplement your claim handling computer system with an additional data entry and storage
application for the missing data.
3. Use a combination of computer system and manually captured data sources.

Data Entry Products
A Data Entry Product is a software product that augments an existing claim handling system. Such
systems usually contain the generic state reporting standard data and provide the capability to apply a
state’s report and data requirements. These products import data from the Claim Administrator’s
system and allow one or more staff to enter the missing Mandatory, Conditional, or Optional data.
Complexity of this application, cost, number of states to be implemented, and frequency of
requirement changes should be considered as part of a make/buy decision.
NJCRIB and NJDWC have provided an Internet data entry solution for statutory noninsured and for
other trading partners with less than 15 claim transactions per month at no cost. If more than 15
transactions are sent, a charge for the transactions will be billed to the trading partner. Or, the Trading
Partner may make arrangements to develop their own EDI solutions or make arrangements with other
experienced EDI vendors to send their transactions to NJCRIB.
An important aspect of the NJCRIB EDI State Reporting implementation is to improve the data quality
of the Reports NJCRIB and NJDWC receives. Attaining and sustaining “Production” status and
avoiding possible fines requires maintaining NJCRIB Data Quality minimum requirements. All NJCRIB
reports should be edited and corrected prior to submission to NJCRIB.
Data Content and Quality Editing Products
A data content and quality editing product is a software product that edits Claim Administrator state
report data against a state’s requirements. Such systems usually contain specific edits for state
reporting data content and business requirements. Data entry and data content and quality editing
features are often found in the same product.
Translate Data into or from IAIABC or ANSI formats
Claim Administrator Systems data is usually stored in a proprietary format that is not readily exchangeable
between organizations. Translation to specific technical data requirements and structuring the data in a
standard format such as IAIABC flat file or ANSI X12 148 transaction is required to make the report easily
received and processed by others.
Translator Products
A translator is a software product that converts data from one format to another. It may serve the
purpose of converting proprietary claim administrator computer system data into either IAIABC Flat
File or ANSI X12 transactions. Conversely, it is used to convert IAIABC Flat File and ANSI
Transactions into proprietary claim administrator computer system data.
Translators typically contain the capability to process one or more sets of related transactions. For
example, a translator will typically do all the Workers Compensation transactions. Some may also
include the ability to do health care, purchase orders, etc. They typically include the ability to recognize
versions of a transaction. For example, a translator may meet IAIABC Release 1 and Release II
requirements. To achieve these capabilities, the user is required to “map” their computer system data
names to the desired IAIABC or ANSI transactions.

Translators vary greatly in capability and the platforms on which they run. Some require a mainframe
environment while others only require personal computer (PC) capabilities. Claim Administrators with
large mainframe claim management applications have effectively used a PC translator to satisfy
multiple state EDI reporting. Translators often combine communication capabilities for processing
internal or external sources of data. In-house technical staff will be required to install and operate a
translator.
Manage Communications/Transmissions
Success of State EDI Reporting is dependent on the technical ability to pass data between organizations.
Data transfer may occur directly between organizations or through intermediaries. Data transfer
interruptions may occur and data could be lost.
This process includes:
• Managing trading Partner electronic addresses
• Scheduling transmission sends and receives (24 hours a day)
• Recording the success or failure of each attempted send and receive
• Backing up transmission data for a specific period follows a successful send or receive.
This process is a combination of automated software applications and technical operator review of
daily transmission results and intervention to identify technical difficulties or reinitiate transmission or
recovery operations.
Communications Management Products
These products consist of software and hardware components. The software component is used to
manage the movement of the data and to operate the associated communications hardware. These
products are likely to have certain limitations. Applications and sophistication of the software/hardware
may vary greatly.
VANs
A Value Added Network (VAN) is a facility used to exchange electronic files between organizations. A
VAN can be viewed as a huge community “hard drive” that contains separate storage (Mail Boxes) for
its subscribers. It provides a place for the Claim Administrator to send State Reports to and a place to
pick up acknowledgements from the states. Such facilities run 24 hours a day and provide “Federal
Quality” data security, reliable backup, and reliable data transfer with communication level
acknowledgement. It relieves each subscriber from considerable hardware, software, and personnel
investments and virtually extends your organization’s hours of operation. Unless EDI Volume is very
large, or an Organization has excess capacity, VANs probably provide a significant cost advantage.
Some protocol differences exist between the major VANS, but once established, VANs provide
expansive connectivity to States and Claim Administrators, Employers, and Medical Providers.

E-Mail Address
With the proliferation of Internet Access and E-mail accounts, E-mail could be used to pass attached
files (IAIABC or ANSI) much like a VAN stores EDI transmissions. This usage in a State Reporting
context is relatively new and feedback on its success is limited. Possible concerns with sending State
Reports via E-mail are file capacity limits, data security, and lack of communication
acknowledgements. When used between two trading partners, such as a Claim Administrator and
Vendor it may be a very viable solution. An experienced EDI Vendor providing connectivity to NJCRIB
may include this type of communication between your organization and the Vendor. At present,
NJCRIB will not accept EDI claims transactions via e-mail.
Manage Acknowledgements, Replacement Reports, and

Corrections
EDI is the reciprocal transfer of data between organizations. In State Reporting, the state responds to
each submitted report with an acknowledgement that the report was accepted, accepted with errors, or
rejected. It is the responsibility of the claim administrator to replace rejected reports with acceptable
reports and correct data on reports accepted with errors. A rejected report is not considered filed until it
has been corrected, retransmitted, and accepted with or without errors. Whereas some reports require the
prior acceptance of another report, failure to replace rejected reports can cause other reports to be
rejected and therefore to be late. This process involves review of state Acknowledgements one or more
times a day, to initiate correction. Failure to receive an acknowledgement of acceptance may be used to
stop additional reports on that claim until corrections are made.
Manage Acknowledgements, Replacement Reports, and Corrections

Products
This functionality may be built as an in-house product or acquired commercially. This function is
typically a feature within a multifeature product.
Submitting Options to Consider
A review of the NJCRIB Reporting Requirements and your current capabilities is a prerequisite to
evaluating the various solutions presented below. Products range from specific EDI functions to
integration with your existing system to meet all your state EDI reporting requirements. Make/buy cost
comparison, frequency of reporting criteria changes, maintenance, and available lead-times are a few of
the criteria that you should evaluate. The viability of any of these product types depends on your specific
needs. This IG and the options presented in it should be part of a formal process that includes
management, claim, and technical staff participation.

Workers Compensation EDI Reporting Products
State Reporting Products vary and may include several to all of the following features:
• Managing State Reporting Requirements.
• Capturing State Report Data.
• Editing for Data Content and Quality.
• Translating Data into or from IAIABC or ANSI formats.
• Managing Communications (report transmissions).
• Managing acknowledgements, replacement reports, and corrections.
Stand Alone and Server-Based Workers Compensation EDI Reporting

Products
Workers Compensation EDI reporting products are available in stand-alone and server-based
versions. A stand-alone version is a single workstation that can be used to process the entire
organization’s state reports. A server-based system allows multiple users so that EDI state reporting
data entry or management can be distributed to many workstations. Claim volume or number of
locations, and whether the claims system is centralized or distributed may affect the type and number
of EDI products needed. These solutions are probably best suited for moderate to high volume claim
systems. These services may include or specify a VAN or other communication method as part of the
process.
These systems can be used by employers to report to claim administrators or for claim administrators
to report to states.
Web-based Data Entry & EDI Reporting Services
Web-based worker’s compensation products allow an organization to meet its reporting requirements
through totally external processes. With this type of product, a designated claim person signs on to a
web site application, selects a state or claim administrator, and enters the data for the claim. The user
would log on later to receive the acknowledgement that the claim was accepted, accepted with errors,
or rejected and respond accordingly. Because this process requires manual data entry and does not
allow for loading data directly from a claim system process it is probably best suited to low volume
users. Expect the unit per claim charge to be higher than high volume solutions but requires little
commitment or investment.
to report to States.
Claim EDI Reporting Services
Several claim administrators have created or contracted with claim reporting services. These services
may accept claims reported by telephone, fax, or E-mail. When they serve as your EDI submitter, they
will perform the equivalent of the EDI reporting features 1 through 6 noted above. The details of each
service should be worked out with that particular vendor.
to report to States.

In-house Vs. Vendor Products and Services
Implementing EDI is a complex process. EDI knowledge and experience is of major value and
consideration to avoid the major pitfalls associated with developing and implementing EDI. Most EDI
implementations are a combination of in-house and EDI vendor products and services. Consider both
short term and long term EDI Objectives. Your success will depend on knowing which to use for what
purpose.
The involvement of vendors may simplify and reduce the analysis effort required by claim
administrators and ultimately lower implementation and operation costs. Many products include
specialized automated routines that require in-depth knowledge of EDI standards, protocols, and each
state’s requirements. Off-the-shelf products may avoid consuming talents from high priority projects,
cost less, and be available in the time allowed. Dedicated services and products may allow your
organization to focus on providing claim services instead of EDI reporting.
Each organization should analyze its capabilities, weaknesses, and Plan of Operation to decide upon
the best mix of in-house and vendor services. Questions to consider when choosing an EDI Vendor
Product or Service:
• Are they an experienced IAIABC standards vendor?
• How much IAIABC participation and knowledge of the EDI standards do they have?
• How much EDI experience and knowledge do they have?
• How much workers compensation experience and knowledge do they have?
• Are they in EDI production and in how many states?
• Do they have a strong client base?
• Do they provide dedicated customer & technical support?
• Do they provide EDI and software training?
• What experience do they have with the IAIABC flat files and ASC (ANSI) X12 record layouts?
• Are they committed to quality assurance in data submission and software testing?
• Are they financially secure?
• How do their clients evaluate their products and services?
What can an Experienced EDI Vendor or Service Provider do for you?
There are EDI Vendors experienced with the IAIABC standards that can provide EDI software
packages, Web based claim-reporting services, paper processing to EDI Services, value added
networks (VANs) service, Internet services and EDI consulting services. The IAIABC can provide a list
of vendors that are experienced in EDI technology and workers' compensation requirements.

Some of the Services and Products Vendors can Provide (but not limited to)
Include:
• Software to submit data electronically

• Data editing prior to transmission to the state
• Return acknowledgement processing
• Management tools and reports to ensure quality data is reported to the state
• Web-based claim form submission
• Liaison between the carrier/trading partner and the state
• Training and orientation in EDI, state requirements, software, etc
• Help with EDI testing and implementation
• Provide business and technical support
• Consulting services, analysis of your needs and system requirements
NOTE: NJCRIB does not recommend or advise against the products or services of any
vendor. NJCRIB suggests that NJCRIB EDI participants carefully review experienced
vendor products and claims as well as contacting customers and other participants to
benefit from their experience.

NJCRIB EDI Trading Partner Process
The usual steps taken to becoming a NJCRIB Trading Partner are given in this section. Some of these
steps involve tasks that have been explained in prior sections and are offered here as reminders.
You should note also that your business environment might dictate you take supplemental steps between
those being suggested below. Or, as an experienced EDI partner, trading with other jurisdictions, you may
find it unnecessary to repeat some of these steps to become a trading partner with the NJCRIB. We do,
however, emphasize that we require that you formally comply with Steps 1, 5, 6, and 8 listed below.
More information expanding on each step follows. When forms are referenced in these steps, how to find
instructions for completing the forms is also included. If, after reviewing the steps you would like to discuss
them further, please call the NJCRIB EDI Test Coordinator at 1-800-240-0088.
1. Contact the IAIABC/Purchase the IAIABC EDI Release I

Implementation Guide
A clear understanding of the IAIABC definitions and standards is required to be a successful EDI
Trading Partner in New Jersey. Visit their web site http:\\www.iaiabc.org, or call them at (608) 277-
1479 to obtain a copy of their Implementation Guide and other publications that may assist you in
implementing New Jersey requirements.
New Jersey Division of Workers Compensation and the New Jersey Compensation Rating &
Inspection Bureau’s EDI Implementation Guide (this Guide) provides supplemental, NJ-specific,
information to that provided in the IAIABC EDI Release I Implementation Guide.
2. Appoint an EDI Coordinator
Once NJCRIB has received the completed NJCRIB EDI Questionnaire, NJCRIB will pass the
information to the NJCRIB EDI Test Coordinator who will be expecting you to send in the Trading
Partner Agreement and Trading Partner Profile. Once the Trading Partner Agreement and Profile
have been received, the NJCRIB EDI Test Coordinator will contact you to develop and agree upon a
testing and implementation plan and schedule. During this initial contact, our EDI Test Coordinator will
ask for the name and contact information for your EDI Implementation Coordinator. Our expectations
is your EDI Implementation Coordinator will be a person knowledgeable about
• Your source data,
• How to retrieve it,
• Your business process and systems that support it,
• And be empowered to speak on behalf of your organization.
NJCRIB expects continuing implementation contacts will be handled through your EDI Implementation
Coordinator.
We recommend that your EDI Implementation Coordinator attend all NJCRIB informational meetings,
become involved in the IAIABC EDI committees, and other organizations that will assist your company
in becoming knowledgeable in the EDI standard processes. NJCRIB does not endorse nor will we

financially assist you in any of these endeavors. These are suggestions and recommendations that
you may find of assistance to you.
3. Review NJ EDI Data Requirements and Claim Events that

Require Reporting
Refer to Steps to Implement EDI and review the Report and Data Requirements and EDI Reports and
Related Events sections. From your review of this detail section your EDI Implementation Coordinator
will have a list of data elements (which use the IAIABC name and numbers defined in the IAIABC
Release 1 Implementation Guide) and the business events or situations that trigger specific EDI
transaction to be filed with NJCRIB.
4. Examine your NJ WC Business Processes and Determine how

NJ EDI Requirements Fit with Them
Review how the data elements NJCRIB requires on its EDI reports are:
• Captured in your claim data source system.
• How you will supplement your system’s data capture routines.
• How you will build the EDI transactions for transmission to NJCRIB.
5. Complete and Return the NJ EDI Trading Partner Agreement
NJCRIB requires that the Trading Partner Agreement form be completed by the business entity that is
the source for the claim data. The source is usually the Claim Administrator handling the claim but the
source may be the insurance carrier or a self insured or non-insured if a Third Party Administrator is
handling the claim on their behalf. Complete the Trading Partner Agreement immediately and send
the Agreement to the NJCRIB EDI Test Coordinator (either via fax or e-mail).
A sample Agreement form follows on the next page for illustrative purposes only. Note that it portrays
a partnership agreement between NJCRIB and a fictitious carrier. A blank NJCRIB EDI Trading
Partner Agreement for your use is included following the illustrative sample. You may remove it from
the Guide or you may photocopy it from the Guide and use the photocopy. Or, a blank form can be
downloaded from the NJCRIB web site, printed and used for the same purpose. If the NJCRIB EDI
Test Coordinator has not received a signed and dated Agreement two weeks prior to your mandatory
scheduled test date the Test Coordinator will contact you to determine the status of your Trading
Partner Agreement.
If you have applied for a variance, please inform the EDI Test Coordinator of that status and forward a
copy of the variance petition and grant so that we may schedule your test at an appropriate time.

NJCRIB EDI Project Agreement Sample
NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU ELECTRONIC DATA

INTERCHANGE (EDI) PROJECT AGREEMENT
This is an agreement between the parties named below to use Electronic Data Interchange (EDI)
technologies and techniques for the purpose(s) and objective(s) set out below or as amended from
time to time in writing by mutual agreement and such further purposes and objectives as the parties
may agree in writing from time to time with reference to this Agreement.
1. Parties. The parties to this agreement are: New Jersey Compensation Rating and Inspection
Bureau (hereafter NJCRIB); and The ABC Insurance Company of Newark, New Jersey_ (Partner
Company) and all other companies within the (Partner Company) authorized to write WC
insurance or provide insurance related services (hereafter Reporter).
2. Purpose. Reporter is either required to file or may be allowed by law or regulation to file for itself
or on behalf of customers or clients a First Report of Injury and Subsequent Report of Injury to the
NJCRIB. The Objective is to initiate, implement, and maintain First Reports of Injury and
Subsequent Reports of Injury through electronic filing.
3. Both agree that the Objective is lawful and performance hereunder shall be deemed complete
performance of the parties’ obligations under any law or regulation governing the Objective. This
document shall be deemed to fulfill any requirement on the part of the Reporter to apply to
NJCRIB or any related governmental entity for permission to file information electronically.
4. Exhibit A, annexed and incorporated in this Agreement, sets forth the following mutually agreed
elements of the arrangement between the parties.
a. The schedule form, including data element definitions, and format of the data transmissions
from the Reporter, including original submissions and corrections or resubmissions as needed
(data transmissions).
b. The test and implementation plan and schedule under which the parties will prepare to send
and receive data from each other.
c. The schedule, form, including data element definitions, and format of data transmissions from
the NJCRIB, including acknowledgments, notices of error or notices of acceptance as
applicable (data transmissions).
d. The Value Added Network (VAN) or other carrier that will be used to transmit and receive data
transmissions.
e. The allocation of data transmission costs between the parties.
5. Each party shall retain the content of data transmissions in confidence to the extent required by
law.
Agreed this 12th day of June 2000 for the parties by their duly authorized or lawfully empowered
representatives.
J. Paul Jones P.T. Administrator
(signature) (signature)
J. Paul Jones P.T. Administrator
(name) (name)
Branch Claim Manager Director
(title) (title)
ABC Insurance Company of Newark New Jersey Compensation Rating & Inspection Bureau

A.1. The Reporter and NJCRIB agree to use the national EDI standards for First and Subsequent Reports
of Injury, Release I, established by the International Association of Industrial Accident Boards and
Commissions, in any available format (i.e. flat file or ANSI X12).
B.1. The Project will commence with the transmission of the version of the First Report Injury defined per
paragraph C3 below on _July 1, 2002_________. During the testing phase, the Reporter will be
required to file paper forms in addition to the electronic transmission of records. Once the testing
requirements are met, the Reporter will no longer be required to file paper forms with the NJDWC. If
the Reporter’s customers are required to file a paper copy of the First Report, the NJCRIB agrees to
waive the requirement for all reports made to the NJCRIB by the Reporter on behalf of its customers.
B.2. The parties will perform a test of the reporting system. The test will determine whether the transmission
mechanism is acceptable. Acceptance will occur when the parties agree that 80% of all electronic first
reports (a) meet or pass all technical requirements for the test period, which shall be no longer than
four (4) consecutive weeks. The term of the test will not exceed 90 days unless an extension is agreed
to between the parties.
C.1. The format of data elements and definitions will conform to the International Association of Industrial
Accident Boards and Commissions (I.A.I.A.B.C.) data dictionary as it is today and as amended from
time to time and approved by the I.A.I.A.B.C. or as otherwise agreed between the parties in writing.
C.2. The transmission of data will occur on Tuesday of each week from the Reporter or as otherwise agreed
and will be received by the NJCRIB within the following business week.
C.3. The data elements for the First and Subsequent Reports and their priority are found on the attached
trading partner table. (Attachment 1) Additional tables for other reports and forms can become part of
this agreement by mutual agreement between the parties.
C.4. Any error in transmission will be timely identified by the NJCRIB, but not greater than five (5) business
days.
D.1. Transmission will be accomplished via the Value Added Network (VAN) or web as agreed between the
parties from time to time.
E.1. The Reporter shall pay transmission cost for all reports being sent to the NJCRIB. NJCRIB shall bear
the costs of any transmissions to the Reporter.

Trading Partner Agreement
NEW JERSEY COMPENSATION RATING & INSPECTION BUREAU ELECTRONIC DATA

INTERCHANGE (EDI) PROJECT AGREEMENT
This is an agreement between the parties named below to use Electronic Data Interchange (EDI)
technologies and techniques for the purpose(s) and objective(s) set out below or as amended from
time to time n writing by mutual agreement and such further purposes and objectives as the parties
may agree in writing from time to time with reference to this Agreement.
1. Parties. The parties to this agreement are: New Jersey Compensation Rating and Inspection
Bureau (hereafter NJCRIB); and _________________________________ _ (Partner Company)
and all other companies within the (Partner Company) authorized to write WC insurance or
provide insurance related services (hereafter Reporter).
2. Purpose. Reporter is either required to file or may be allowed by law or regulation to file for itself
or on behalf of customers or clients a First Report of Injury and Subsequent Report of Injury to the
NJCRIB. The Objective is to initiate, implement and maintain First Report of Injury and
Subsequent Report of Injury through electronic filing.
3. Both agree that the Objective is lawful and performance hereunder shall be deemed complete
performance of the parties’ obligations under any law or regulation governing the Objective. This
document shall be deemed to fulfill any requirement on the part of the Reporter to apply to
NJCRIB or any related governmental entity for permission to file information electronically.
4. Exhibit A, annexed and incorporated in this Agreement, sets forth the following mutually agreed
elements of the arrangement between the parties.
a. The schedule form, including data element definitions, and format of the data transmissions
from the Reporter, including original submissions and corrections or re submissions as
needed (data transmissions).
b. The test and implementation plan and schedule under which the parties will prepare to send
and receive data from each other.
c. The schedule, form, including data element definitions, and format of data transmissions from
the NJCRIB, including acknowledgments, notices of error or notices of acceptance as
applicable (data transmissions).
d. The Value Added Network (VAN) or other carrier that will be used to transmit and receive data
transmissions.
e. The allocation of data transmission costs between the parties.
5. Each party shall retain the content of data transmissions in confidence to the extent required by
law.
Agreed this ____ day of _________ 2002 for the parties by their duly authorized or lawfully
empowered representatives.
(signature) (signature)
(name) (name)
(title) (title)
New Jersey Compensation Rating & Inspection Bureau

A.1. The Reporter and NJCRIB agree to use the national EDI standards for First and Subsequent Reports
of Injury, Release I, established by the International Association of Industrial Accident Boards and
Commissions, in any available format (i.e. flat file or ANSI X12).
B.1. The Project will commence with the transmission of the version of the First Report Injury defined per
paragraph C3 below on ______________________. During the testing phase, the Reporter will be
required to file paper forms in addition to the electronic transmission of records. Once the testing
requirements are met, the Reporter will no longer be required to file paper forms with the NJDWC. If
the Reporter’s customers are required to file a paper copy of the First Report, the NJCRIB agrees to
waive the requirement for all reports made to the NJCRIB by the Reporter on behalf of its customers.
B.2. The parties will perform a test of the reporting system. The test will determine whether the transmission
mechanism is acceptable. Acceptance will occur when the parties agree that 80% of all electronic first
reports (a) meet or pass all technical requirements for the test period, which shall be no longer than
four (4) consecutive weeks. The term of the test will not exceed 90 days unless an extension is agreed
to between the parties.
C.1. The format of data elements and definitions will conform to the International Association of Industrial
Accident Boards and Commissions (I.A.I.A.B.C.) data dictionary as it is today and as amended from
time to time and approved by the I.A.I.A.B.C. or as otherwise agreed between the parties in writing.
C.2. The transmission of data will occur on Tuesday of each week from the Reporter or as otherwise agreed
and will be received by the NJCRIB within the following business week.
C.3. The data elements for the First and Subsequent Reports and their priority are found on the attached
trading partner table. (Attachment 1) Additional tables for other reports and forms can become part of
this agreement by mutual agreement between the parties.
C.4. Any error in transmission will be timely identified by the NJCRIB, but not greater than five (5) business
days.
D.1. Transmission will be accomplished via the Value Added Network (VAN) or web as agreed between the
parties from time to time.
E.1. The Reporter shall pay transmission cost for all reports being sent to the NJCRIB. NJCRIB shall bear
the costs of any transmissions to the Reporter.

6. Complete and Return the Sender’s Trading Partner Profile
The sender of the EDI transaction is required to complete the Trading Partner Profile. The sender may
or may not be the same business entity that is the source or owner of the data, otherwise referred to
as the data Reporter. The sender may be the Third Party Administrator or the sender may be the
insurance carrier or the self-insured, self-administered employer. However, the data Reporter must
advise the NJCRIB EDI Coordinator ofthe name and contact information for the sender of the data if
the sender is other than the Reporter who signed the Trading Partner Agreement forms (see #6
above).
The Sender ID is required on the Trading Partner Profile. A Sender ID is composed of the sender’s
Master FEIN and physical address postal code. A separate Trading Partner Agreement form for each
Sender ID (identification) is required.
For example: One Trading Partner Profile is required if a sender is forwarding the EDI information for
more than one company, from its same location (postal code). The sender may choose which FEIN it
designates as the master FEIN.
Multiple Trading Partner Profiles are required if a sender has more than one location (postal code)
from which it will be forwarding data. A separate Trading Partner Profile is required for each unique
FEIN/location (postal code) originating data transfers.
Further, if one company has a centralized computer location from which it is sending data for more
than one claim office then only one Sender Trading Partner Profile is required (all data transfers are
originating from the same FEIN and location). However, if one company is sending data from many
different offices each originating a data transfer from its decentralized computers, then separate
profiles are required for each sender location even though all are for the same company. In summary,
the administrator or organization acting on behalf of the administrator (to compile, transmit, and
correct reports required by NJCRIB) must complete this form as part of the preimplementation
requirements.
The Trading Partner Profile form follows on the next page. You may copy the form from the Guide or
you may download a copy of the form from the NJCRIB web site. Complete the copy of the form and
send it to the NJCRIB EDI Test Coordinator. Detail instructions for completing the form follow the
pages with the blank form.

New Jersey Trading Partner Profile Application and Confirmation Form
Form Data Entry Requirements: (M) Mandatory (C) Conditional (O) Optional
Purpose: [ ] Submit [ ] Change [ ] Delete Trading Partner
A. (M) Trading Partner Name:

B. (M) Trading Partner Type: [ ] Insurer [ ] Third Party Administrator
[ ] Self Insured Self Administrated
[ ] Statutory Noninsured
C. (M) In Production Status with other IAIABC State(s): [ ] No [ ] Yes
D. (M) Plan to use NJ Web Claim Data Entry Option: [ ] No [ ] Yes (Statuatory Noninsured Only)
(C) If yes, enter anticipated monthly volume:
E. Trading Partner (Sender) ID 1. (M) FEIN:
2. (O) TP 3 digit ID (If allowed by State):
3. (M) Postal Code:
F. Trading Partner Physical Address 1. (M) Street Address:
2. (M) City:
3. (M) State:
4. (M) Postal Code:
G. Trading Partner Mailing Address 1. (O) Street Address:
(If Different)
2. (O) City:
3. (O) State:
4. (O) Postal Code:
H. EDI Business Contact Info. 1. (M) Name:
2. (M) Title:
3. (M) Phone:
4. (M) E-mail Address
(preferred):
or Fax ) Fax:
Complete Section I if using a Vendor’s Data Entry Service or Web data entry EDI solution
I. Vendor Information 1. (M) Vendor Name:
2. (M) Vendor Contact Name:
3. (M) Vendor Contact Phone Number:
4. (O) Vendor Contact E-mail Address:
Complete Section J if your Information Technology Staff operates your EDI system, or Imports or Exports
Transactions to Client State
J. EDI Trading Partner’s Information 1. (M) Name:
Technology Contact Information
2. (M) Title:
3. (M) Phone:
4. (M) E-mail (preferred):
or Fax:
K. EDI Communication Information 1. (M) EDI File Type: IAIABC Flat File R1 [ ] R2 [ ] R3 [ ]
ANSI 148/824 Version (3041) [ ] TBD [ ]
2. (M) Network: [ ] AT&T
[ ] Transmitter User ID:
[ ] Advantis Mailbox ID:
Account ID
Message Class:

NJCRIB Trading Partner Information
A. Trading Partner: New Jersey Compensation Rating and Inspection Bureau
B. EDI Requirements:
1. Implementation Requirements
Release 1 Optional EDI Implementation Date: 04/15/2002
Release 1 Mandatory EDI Implementation Date: 07/05/2002
Release II Optional EDI Implementation Date: None at this time
Release II Mandatory EDI Implementation Date: None at this time
2. File Format Requirements
a. IAIABC R1 Flat Files
Record Delimiter: carriage return line feed
b. ANSI 148 & 824 Version (3041)
Segment Terminator: ~
ISA T/P Information: Test/Production
Data Element Separator: *
Sub Element Separator: >
ID: Use Master FEIN + extension if needed
Acknowledge 824 Transmissions? Yes
Acknowledge 997 Transmissions? Yes
C. Communication Information
1. NJCRIB (RECEIVER) ID:
FEIN: 226000325
Filler: Blank
Postal Code: 071025511
2. Network: (Use one of the following)
AT&T:
Mailbox ID: NJWCEDI
Transmitter:
User ID: NJ
Advantis
Mailbox ID: WCST032
Message Class: N/A
Account ID: WCST
D. Business Contact Information
1. Business Contact Name: EDI Coordinator
2. Business Contact Address: P.O. Box 381, Trenton, NJ 08625-0381
3. Business Contact Phone Number: (609) 292-2515
4. Business Contact E-mail Address: DWCEDI@DOL.STATE.NJ.US
5. General Information: MIS@NJCRIB.COM
E. EDI Coordinator & Technical Contact Information
1. IT Contact Name: Sharon Marion
2. IT Contact Phone Number: (800) 240-0088
3. IT Contact E-mail Address: NJEDI@HNC.COM
4. IT Contact Fax Number: 949-655-3375

Instructions for Completing the New Jersey Trading Partner Profile
Application and Confirmation Form
Each Sender completes New Jersey Trading Partner Profile Application and Confirmation Form parts
A through K. The NJCRIB Trading Partner Information section provides Receiver information which
your vendor or organization will require to submit claim reports to and receive acknowledgements
from NJCRIB. You may use a copy of this form from the NJCRIB IG or obtain a copy preprinted from
the NJCRIB Web Site. The completed form is to be faxed or e-mailed to the NJCRIB EDI Coordinator.
TRADING PARTNER PROFILE APPLICATION AND CONFIRMATION FORM (SENDER’S)
INFORMATION:
Purpose: Check one: Submit, Change, or Delete.
Check Submit to establish your NJCRIB account, which is required of all NJCRIB Trading Partners.
Check Change to revise any previously submitted contact information or vital processing information
such as Trading Partner ID, Vendor, Van, File Type, etc.
Check Delete to terminate a Trading Partner Account.
NOTE: The NJCRIB EDI Coordinator may contact you to verify information.
The NJCRIBEDI Coordinator will contact you if you have submitted vital processing
information changes to discuss the potential impact and make the associated EDI
Trading Partner migration/processing plans as necessary.
Sections A-G
Please enter all Mandatory Information. Definitions are provided to assist you. Failure to complete or
submit this form may affect your implementation schedule and place your organization in an out of
compliance status with New Jersey requirements. Please contact the NJCRIBEDI Coordinator if
questions arise or you need assistance.
Trading Partner Name: The name of the business entity that is reporting a New Jersey Workers’
Compensation Claim
Trading Partner Type: The type of Claim Administrator reporting a New Jersey Workers’
Compensation Claim
In Production Status with other IAIABC State(s): Indicates if the NJCRIB Trading Partner applicant
has attained production status using IAIABC standards in other states.
Plan to use NJ Web Claim Data Entry Option: Indicates if a NJCRIB Statutorily Noninsured Trading
Partner applicant will test using the NJ Web Claim Date Entry option.
If yes, enter anticipated monthly volume: The number of Claims/Transactions a NJCRIB Statutorily
Noninsured Trading Partner applicant using the NJ Web Claim Date Entry option expects to exchange
pert month.
Trading Partner (Sender) ID:
FEIN: The Federal Employer’s Identification Number of the Trading Partner.
TP 3-digit ID (If allowed by State): An optional 3-digit ID that may be used by the Trading
Partner to manage its EDI distribution process.
Postal Code: The 9-position ZIP code (ZIP+4) for the trading partner’s physical location address.

Trading Partner Physical Address:
Street Address: The street address of the trading partner’s physical location address. It will
represent where materials may be received when using delivery services other than the U.S.
Postal Service P.O. Box address regarding “this” trading partner.
City: The city of the trading partner’s physical location address.
State: The 2-character standard state abbreviation for the trading partner’s physical location
address.
Postal Code: The 9-position ZIP code of the street address. The ZIP code combined with the
trading partner’s FEIN is used to identify the sender.
Trading Partner Mailing Address (If Different): The mailing address used to receive deliveries via
the U. S. Postal Service. If this address is the same as the physical address, indicate “Same as
above.”
Sections H-J
Trading Partner Contact Information

In this section, include the information about those individuals we may contact regarding your EDI
filings. There are three types of contacts and each addresses a different areas of EDI processing
when issues are encountered and your organization’s assistance is needed to resolve the issue.
Though unusual, one person may serve as all three types. Please read the definitions below and
include the names and information as appropriate for your firm.
Business Contact: The individual most familiar with the overall data extract and transmission
process within your business entity. He/she may be the project manager, business systems analyst,
etc. This individual should be able to respond to any issues that may arise from other than the actual
process of transferring the data from your business to the NJCRIB’s receipt. Please provide the
following information:
Name: The name of the contact.
Title: A descriptive term for the duties that the contact person performs.
Phone: The telephone number where the contact can be reached during normal business hours.
E-mail Address (preferred): If the contact has an e-mail address, please include the exact
address where the NJCRIB EDI Coordinator may reach him/her.
FAX: If a FAX is available, please include the telephone number of the FAX maching.
Vendor Contact: The Vendor to be contacted if transmission or product/services issues arise. This
individual will be the point of contact for the appropriate product technical or business specialist.
Please note that compliance and data quality issues are referred to the Trading Partner and not to the
vendor. Please provide the following information:
Vendor Name: The name of the contact.
Ventor Contact Name: The name of the contact person at the vendor location.
Title: A descriptive term for the duties that the contact person performs.
Phone: The telephone number where the contact can be reached during normal business hours.
E-mail Address (preferred): If the contact has an e-mail address, please include the exact
address where the NJCRIB EDI Coordinator may reach him/her.
FAX: If a FAX is available, please include the telephone number of the FAX maching.

Technical Contact: The individual within your organization that is to be contacted if issues regarding
technical or transmission process arise . This individual may be a telecommunications specialist,
computer operator, etc. If your organization uses a vendor product where “all” report information is
keyed directly into that product, this type of contact does not apply to your organization.
Name: The name of the contact.
Title: Descriptive term for duties performed.
Phone: The telephone number where that contact can be reached during normal business hours
e-mail Address: If the contact has an email address please include the exact address at which
the NJCRIB EDI Coordinator may reach him/her.
FAX: If FAX facilities are available, please include the telephone number of the FAX machine.
Section K
EDI Communication Information
Please enter all Mandatory Information. Definitions are provided to assist you. Please contact the NJ
EDI Coordinator if questions arise or you need assistance. Failure to complete or submit this form
may affect your implementation schedule and put your organization out of compliance with New
Jersey Requirements.
A Value Added Network (VAN) will be used to exchange data; the trading partner will specify the
electronic mailbox to which data can be transmitted. Separate mailbox information may be provided
for transmitting production versus test data.
EDI FILE TYPE: Check the appropriate File Format(s)
NETWORK: Three VAN options are included on the profile. Complete the box for the VAN you will
be using. Leave the others blank.
USER ID: Identifies a trading partner’s VAN mailbox/services. (Transmitter Only)
ACCT ID: Identifies a trading partner’s VAN mailbox/services. (Advantis Only)
MESSAGE CLASS: Enter the message class if appropriate. (Advantis Only)

NJCRIB Trading Partner Profile
Trading Partner: The receiver is the New Jersey Compensation Rating & Inspection Bureau
(NJCRIB).
EDI Requirements
Implementation Requirements
Release 1 Optional EDI Implementation Date: The first date that a Trading Partner MAY submit
IAIABC R1 EDI Files under Production EDI transactions to NJCRIB
Release 1 Mandatory EDI Implementation Date: The date on which a Trading Partner MUST submit
IAIABC R1 EDI Files under Production EDI transactions to NJCRIB to be in compliance with New
Jersey Law.
File Format Requirements: The IAIABC Release that applies and the acceptable File Format types
and versions.
Receiver’s Flat File Record Delimiter: This character used by Trading Partners (claims
administrators) to indicate the end of each physical record when submitting flat file transactions
formatted according to the IAIABC proprietary standards.
Receiver’s ANSI X12 Transmission Specifications
Segment Terminator: A character that indicates the end of a segment.
ISA T/P Information: Used to identify a transaction as Test or Production to prevent the inappropriate
posting of data to test or production systems.
Data Element Separator: A character that separates data elements.
Sub Element Separator: A character that separates data elements within compound data elements.
ID: Identifies the trading Partner
Acknowledge 997: Indicates that a transmission will or will not be acknowledged in regard to
complete and structurally correct exchange of data.
Acknowledge 824: Indicates that a batch or transaction will or will not be acknowledged in regard to
business data content requirements and specific business deficiencies.
EDI Communication Information
This section specifies NJCRIB’s Value Added Network (VAN) mailboxes, to which claims
administrators can transmit EDI transactions to NJCRIB.
FEIN/Postal Code: The Federal Employer’s Identification Number and 9-position ZIP code (ZIP+4), of
NJCRIB that uniquely identifies NJCRIB as a trading partner.
Network: The name of the VAN service on which the NJCRIB’s mailbox can be accessed.
Network Mailbox Acct ID: The name of the NJCRIB mailbox on the specified VAN.
Network User ID: This is the identifier of the NJCRIB’s entity to the VAN.

Contact Information: This section identifies individuals assigned by NJCRIB to address EDI Claim
Reporting issues.
EDI Coordinator: This is the individual who is assigned to handle all Trading Partner Submissions,
Changes, or Deletions and route all TECHNICAL issues.
Business Contact: This is the individual assigned to address all business and New Jersey
Compliance questions.
All other inquires may be addressed to General Information.

7. Schedule Changes to your Internal Business Processes and
Systems
Complete any changes to your internal business processes and systems prior to creating test
transactions. The test criterion requires that you compile the test transactions from “actual” NJ
workers compensation claims that originate from your source system. This test data must be
transmitted to NJCRIB through whatever reporting and “sending” systems you will use once you are
approved to send “production” or live data to us.
8. Contact the NJCRIB EDI Test Coordinator to Review Schedule

Testing
Following receipt of the executed Trading Partner Agreement and the Trading Partner Profile (due at
least 2 weeks prior to your scheduled test date), we will prepare to accept test data from you. We will
review your Agreement and Profile to determine whether you may be exempted from part or all of the
mandatory testing and the test schedule if you have petitioned for and been granted a variance to
implement EDI at a date later than July 5, 2002.
Exemptions from Testing
If your organization or vendor has successfully passed previous New Jersey EDI connectivity testing
or demonstrated EDI competency in other IAIABC EDI jurisdictions, the EDI Coordinator will advise
you that your testing requirements have been waived or reduced accordingly.
If your vendor has not demonstrated EDI competency in other IAIABC EDI Jurisdictions, the first
scheduled test use of that service/product will apply to all users of that product. The New Jersey EDI
Coordinator will advise known users of the vendor of the scheduled test date. On successful
completion of vendor testing, subsequent Trading Partner Profile applications will advise the Trading
Partner that they may immediately move to production status. Trading Partner’s will be notified if the
vendor is unable to meet testing requirements within 2 weeks of the scheduled test date or two weeks
prior to the mandatory July 5, 2002 EDI Reporting date.
Test Status Advisory
The acknowledgement of your Trading Partner Profile and Agreements from the NJCRIB EDI Test
Coordinator will advise you of your test requirements by indicating how your Test/Production indicator
is to be set. You will be advised to set your Test/production status indicator to:
Production and begin sending production transactions to NJCRIB at any time (but no later than the
mandate date of July 5, 2002) if you are exempted from the test.
Test and to participate in the scheduled test during your assigned test period if you are not exempted
from testing.

Therefore, it is important to complete the Trading Partner Agreement and Trading Partner Profile
immediately to determine your test status in a timely fashion. If you do not complete testing and are
not approved to move into production status by the end of your assigned test period, you may not be
able to complete the required testing prior to the mandated implementation date and be exposed to
out-of-compliance sanctions from the New Jersey Division of Workers Compensation.
9. Schedule Training and Implementation for your Staff
Training of your staff in the NJCRIB requirements is your responsibility. Please feel free to use any of
the information contained in this Guide or to make and provide as many photocopies of this Guide as
may be needed to assist you in your training. The NJCRIB EDI Implementation Guide is not
copyrighted or protected by copyright. It is provided to assist you in the planning and implementation
of our reporting requirements. You may also find it helpful to contact others to identify training service
providers. NJCRIB does not endorse or require that you use any specific certified providers or follow
any specific training regimine. We offer these suggestions to assist you in planning your
implementation. NJCRIB will be holding a training session in April 2002 and you may find that session
helpful to your EDI Training coordinator.

NJCRIB Test and Production Process
Purpose
The purpose of the Test Period is to make certain that each Claim Administrator’s transmission meets
NJCRIB’s technical requirements and data quality standards. If granted a variance, testing will still be
required on the same basis as described herein but at a later time than the Scheduled Test Period. The
goals of the testing phase are to assure each trading partner demonstrates technical and business
competencies.
Technical Competence – extends to both the ability to communicate electronically and the ability to use
the file structure used is appropriate. Technical competence is demonstrated by the ability of each trading
partner to transmit and receive state reports in either the IAIABC flat file or ANSI 148 format. Specifically,
whether the Claim Administrator can successfully connect to and transmit the FROI and SROI andwhether
the NJCRIB can connect to and transmit the “Acknowledgement” to the Claim Administrator.
Business Competence – examines the data content to determine if it meets the quality standards of the
NJCRIB. Business competence is demonstrated by the ability of the FROI and SROI to pass the NJCRIB
EDI System’s edits for data content and values.
NJCRIB Test Schedule – Test Plan Development
All NJCRIB trading partners are randomly placed in the tiered NJCRIB Test Schedule and required to
complete the full test program with the following exceptions:
• Trading Partners who are using a vendor experienced in other jurisdictions with the IAIABC
standards are not required to participate in the NJCRIB Test Schedule.
• Trading Partners who volunteered to participate in the 2001 pre-law passage testing are not
required to participate in the 2002 NJCRIB Test Schedule.
• Trading Partners who are in Production status with another jurisdiction prior to implementing with
NJCRIB are required to participate only in a limited connectivity test. If the limited test is
successful then no further testing for the NJCRIB implementation is required.
If an exception applies to you and your firm’s name appears on the NJCRIB Test Schedule, you must
notify the NJCRIB EDI Test Coordinator immediately or testing will be assumed and required.
All other NJCRIB EDI Trading Partners are required to complete the Test Plan during their assigned Test
Plan Scheduled period unless the Trading Partner has been granted a variance. However, testing will be
required of all Trading Partners. Those with variances must complete a test prior to their variance
agreement’s implementation date.
Two weeks prior to the first day of the scheduled test period, the trading partner or vendor must complete
and submit the Trading Partner Agreement and the Sender Trading Partner Profile to the NJCRIB EDI
Test Coordinator. You may contact NJCRIB Test Coordinator in either of the following manners.
• Via e-mail at njedi@hnc.com or
• By telephone at (800) 240-0088.
• By fax at (949) 655-3385

You must contact the NJCRIB EDI Test Coordinator prior to sending any Test transaction(s):
• If you have any questions about the test,
• To confirm your testing readiness, or
• If you have not heard from the NJCRIB EDITest Coordinator the week before your scheduled test
period begins.
Test documentation required before the test begins is the completed and signed Trading Partner
Agreement and the Trading Partner Profile, and if applicable, a copy of any variance petitions granted by
the Workers’ Compensation Court System.
Though not required, every Trading Partner may benefit by a pretest review of the NJCRIB edits for each
data element.
Having a “test plan” does not mean or require that a formal, testing document be exchanged between the
participants. Rather, a discussion of a test plan is intended to take place and result in an understanding of
the procedures and the processes involved.
Test Plan Procedures
Different testing procedures apply depending upon the transmission mode you will be using to send data
to NJCRIB, see below description for Web Users and VAN Mailbox Users.
New Jersey Division of Workers Compensation will not accept reports on paper on or after July 5, 2002
unless the trading partner has applied for and was granted a variance to N.J.S.A. 34:15-96-99 by the New
Jersey Division of Workers’ Compensation. Therefore, all testing regardless of the transmission mode,
you choose must be completed prior to July 5, 2002 for you to be in compliance with the EDI legislation.
Test Overview for WEB Users
The NJCRIB Web Site is provided as an alternative for the low transaction volume reporter (15 or less
transactions per month) to enter each transaction’s data manually. Claim Administrators using the web
site data entry as the transmission mode need only test that they can access the NJCRIB web data entry
site with their user name and password. The user name and password are specified in the
Acknowledgement of the Trading Partner Profile.
Reporter/Sender need only successfully enter a single record of one “real New Jersey workers’
compensation claim. The “real” claim may be an open or closed claim – a claim with either status is
acceptable.
The entry of one claim is sufficient and needs to be done only once for First Reports and once for
Subsequent Reports. The web site will automatically perform data format and validation edits and will only
accept data in the correct format.

Test Overview for VAN Mailbox Users
During the testing process and until notified otherwise by NJCRIB’s EDI Test Coordinator, Claim
Administrators and their employer clients must continue to provide the NJ Workers’ Compensation
Division the appropriate First and Subsequent report paper report forms. No paper reporting process is to
be discontinued until the Claim Administrator has received written approval to specifically discontinue
paper-reporting processes. Any premature discontinuance by either the Employer or the Claim
Administrator could result in penalties and fines for improper reporting.
There are six steps in the NJCRIB testing process, as follows.
1. Pretesting Requirements
2. Technical Capability Test
3. Business Content Test File (First Reports of Injury)
4. NJ Test Completion (First Reports of Injury)
5. Business Content Test File (Subsequent Reports of Injury)
6. NJ Test Completion (Subsequent Report of Injury)
Testing will continue until the Claim Administrator meets NJ data quality requirements as detailed
following in Step 3. Continuing the testing may require additional test documents from those described in
the following steps may be required should the tester not pass a given level of testing.
Step 1: Pretest Requirements
Each Test submitter is required to consult the NJCRIB Test Schedule to determine the test time
period assigned to it. Once the test time frame is established, each Claim Administrator must prepare
for the test by completing and submitting a Trading Partner Profile and Trading Partner Agreement.
These forms and instructions for completing them can be found on preceding pages If a variance has
been granted, complete the two documents and forward them to the EDI Test Coordinator along with
a copy of your variance petition and grant.
Once NJCRIB EDI Test Coordinator has received and acknowledged the Trading Partner Profile and
Trading Partner Agreement, the NJCRIB EDI Test Coordinator will contact you to review testing
guidelines, address any questions you may have, and confirm the scheduled time frame for each
Claim Administrator to submit Test files. Test transactions are required to be submitted on actual or
“real” New Jersey open or closed workers compensation claims, chosen by the Claim Administrator.
Step 2: Technical Capability Test File
The first test is the technical capability test. Once received, NJCRIB will process and acknowledge the
test file (the claim administrator’s technical capability). During this phase of the test procedure, the
sender transmits a file of one Original First Reports of Injury to the NJCRIB. The test file must consist
of the following transactions:
• Header record (with the Test/Production indicator (DN 104) set to “T,”
• One “00,” Original First Report of Injury transaction,
• Trailer Record.

While five days are allowed for the test, on the first day of the scheduled test period, the Claim
Administrator forwards the Technical Capability Test File. Once the file is sent, the Claim
Administrator must notify NJCRIB the file has been sent. The advisory may be sent to NJCRIB EDI
Test Coordinator via e-mail at njedi@hnc.com or by telephone at (800) 240-0088. Include the
following information in the advisory:
• Date and time the test file was sent
• The identity of the VAN and mailbox address to which the test transaction was sent
In response to the Claim Administrator’s advisory, NJCRIB will process the test file through the
NJCRIB EDI System’s edit processes and will return an AK-1 Acknowledgement, to the Claim
Administrator. The acknowledgement to a Technical Capability Test File is a batch acknowledgement
and does not include a detail transaction edit response. Expect the Acknowledgement to contain
errors resulting from data edits. If the file is technically acceptable, the test for business edits begins. If
there are data content edits found in the technical capability test of the First Report of Injury, they will
not be corrected through a “CO” transaction. There is no need to do so since data content is not being
examined in this portion of the test.
Follow Up Procedures
Responses are electronically created. Therefore:

• If NJCRIB does not receive a recognizable test file within 48 hours of receipt of the e-mail or
phone call, the NJCRIB Test Coordinator will contact the Claim Administrator to investigate
the status of Claim Administrator’s test file.
• If the Claim Administrator does not receive an AK-1 batch acknowledgment within three days
of sending the test file, contact the NJCRIB EDI Test Coordinator at the E-mail or phone
number above.
When Step 2 has been completed, the NJCRIB Test Coordinator will advise the Claim Administrator
to proceed to Step 3 below.
Step 3: Business Content Test File
After NJ’s acknowledgement that the Technical Capability Test File has been received and the
NJCRIB EDI Test Coordinator has approved the capability portion of the test, the Claim Administrator
will forward the first of two business content test files of First Reports of Injury to NJCRIB. NJCRIB
requires that the two business content test files be sent in two separate batch transmissions sent on
two different dates during the claim administrator’s assigned test period.
Each Business Content Test File’s First Report of Injury transaction must meet the following
conditions:
• Must be sent from the Claim Administrator’s production EDI system.
• Must contain data from “actual claims” handled by the Claim Administrator, which may either
be open or closed claim files.
• Must reflect the full spectrum of required FROI reports (some of which are “00” Original First
Report of Injury and at least one “AU” Acquired/Unallocated First Report of Injury and one “04”
Denial First Report of Injury).

The business content test file must contain the following transactions, in the proper sequence:
• Header Record (with DN 104, Test/Production Indicator, set to “T”)
• Ten First Reports of Injury
• Trailer Record
The Claim Administrator may not send a second or follow up batch Business Content Test file until it
has received the acknowledgements from the previous batch of First Reports of Injury. Send the
second test file batch immediately after receiving the acknowledgement from the first test batch file.
The second test file batch must contain no more than 10 transactions and include the transactions
with the following MTCs.
• “CO” transactions for each previous transaction acknowledged with errors (assigned a TE
status code.
• “02” transactions for transactions previously sent with a change to one data element
previously sent.
• An “01” transaction canceling a transactions previously sent.
If the Claim Administrator has not received an acknowledgement to the Business Content Test File
within three days following the date it sent the file, contact the NJCRIB Test Coordinator by phone at
(800) 240-0088 or by e-mail at njcrib@hnc.com to determine the test file status.
Data Quality Requirements for Business Content Test Files
Upon receipt of a Business Content Test File, NJ will process the file through the NJCRIB EDI
system’s edit process and will return the AK-1 (or ANSI 824) detailed Acknowledgement. The Claim
Administrator must review the detailed acknowledgement and implement corrective claim handling
and technology solutions for each error on transactions assigned either a TE or TR status.
• TE status will be returned for each transaction accepted with error(s).
• TR status will be assigned to a transaction rejected for not passing requirements.
The testing and evaluation process continues until two consecutive batches of Business Content Test
Files are processed and acknowledged and on which the Claim Administrator has met the NJCRIB
data quality requirements. NJCRIB Business Content Test Files data quality requirements are:
• A minimum of 80% are accepted with a TA or TE status
• No more than 20 % are rejected with a TR status

Step 4: NJ Test Completion (First Report of Injury)
At the time the Claim Administrator successfully completes the FROI Business Content Testing, the
NJCRIB Test Coordinator will provide approval to move to the “Production” status for First Reports of
Injury. Congratulations – Partial Production Status Achieved!
When partial production status has been achieved, FROI testing will be discontinued. At this time, the
NJCRIB EDI Test Coordinator and the Claim Administrator (and Claim Administrator’s Reporter if
using a vendor) must agree and clearly establish a date, no later than July 5, 2002, when the Claim
Administrator will begin sending FROIs in the Production status. It is extremely important that the
Claim Administrator continues reporting using the New Jersey First Report of Injury paper report form
until the Claim Administrator begins sending the EDI reports. Once testing has been completed and
the claim administrator achieves “production” status designation, the claim administrator may
voluntarily begin sending EDI reports in the “production” status immediately or at any date prior to the
mandate date of July 5, 2002 as agreed upon by the EDI Test Coordinator. However, the Claim
Administrator must begin sending “production” EDI reports no later than July 5, 2002, unless the
trading partner has applied for and was granted a variance to N.J.S.A. 34:15-96-99 by the New Jersey
Division of Workers’ Compensation. At the time the Claim Administrator begins sending all First
Reports of Injury via EDI it may also cease sending the paper First Report of Injury to NJDWC on that
date as well.
Step 5: Business Content Test File (Subsequent Reports of Injury)
When the Claim Administrator has completed testing of First Reports of Injury and has been approved
to move into production status with the testing of Subsequent Reports of Injury begins. It is important
to complete both the First Report of Injury testing and the Subsequent Report of Injury testing during
the scheduled test period assigned to each claim administrator and prior to the mandate date of July
5, 2002.
Order of MTCs for Subsequent Report of Injury Testing
NJCRIB requires the Claim Administrator to have achieved the “production” status with FROI reports
before beginning the testing of SROIs.
The Claim Administrator is to send Subsequent Report test transactions that match the claims on
which the First Report of Injury test transactions were previously sent. (Otherwise, the Subsequent
Report test transaction(s) will fail the edit that requires a FROI to be present on the NJCRIB database
prior to the acceptance of a SROI.).
NJCRIB accepts the “SA,” “04,” “02,” and “CO” SROI “MTCs.” Any SROI MTCs other than SA, 04, 02,
or CO sent will be rejected as not jurisdictionaly valid. SROI MTC Data Element requirements, which
include the mandatory data element, and Agency Claim Number (assigned to the First Report of Injury
during the FROI test cycle), are outlined in the preceding section for each Subsequent Report type or
MTC.

Test File Submission
All SROI test file submissions require the following:

• Each SROI test file transaction must match to a previously transmitted FROI.
• SROI Business Content Test File transactions within a transmission are required to be in the
logical MTC sequence as follows (either an 04 or SA must precede the 02 or CO).
• Two SROI tests will be required. Do not send the second batch of SROI test files until the
acknowledgements from the first SROI test have been received.
SROI Test File Batch #1
Limit the combination of Subsequent Report MTCs (either on the same or a different FROI) in the first
batch of SROI Business Content Test Filess to SROI MTCs of Semi-Annual (SA) or Denial (04). Send
at least one SROI record with a code value error in one field so that it will result in a TE or Accepted
with Errors acknowledgment.
The first batch file must contain:
• Header (with the Test/Production indicator [DN 104] set to T)
• Minimum of ten SROI transactions with MTC of either 04 or SA
• Trailer
It is not necessary to either e-mail or telephone the NJ EDI Test Coordinator that you have sent the
SROI Business Content Test File. When received by NJCRIB, the SROI test file will be processed
through the NJCRIB EDI system, edits applied, and the Acknowledgement returned.
NOTE: If you have not received the AK1 Acknowledgement within three
working days, contact the NJCRIB EDI Test Coordinator at (800) 240-0088
or e-mail to njedi@hnc.com.
SROI Test File Batch #2
Once the first SROI Business Content Test File has been acknowledged and batch #1’s test
transactions have been assigned either a TE or TA status, send a second Business Content Test File
with the SROI “02” and “CO” MTC records. If any transactions were acknowledged with a “TR”
(Transaction Rejected) status, correct the error and resend the rejected transaction(s) in the second
SROI batch. At least one of each “02” and “CO” SROI MTC code must be included. However, there is
no other batch minimum or maximum number of transactions.
To send the “CO” a previously acknowledged SROI transaction must have been assigned a TE
(Accepted with Errors) status. If no SROI transaction from the first batch of test files was assigned a
“TE” status, send a test SROI SA transaction in the second batch with at least one data element with
a value that does not match the NJCRIB transaction requirements. Doing so should produce a “TE”
status on the acknowledgement.
Send the “CO” correction in a third SROI batch on the next business day to complete the testing. If
you are uncertain about which data element or entry to send to cause the “TE” status response,
contact the NJCRIB EDI Test Coordinator for assistance by phone at (800) 240-0088 or by e-mail at
njedi@hnc.com.
SROI Data Quality Requirements

As with the First Report of Injury testing, the SROI Business Content Testing will continue until the
Claim Administrator has met the NJCRIB Data Quality requirements. Refer to Data Quality
Requirements (page 108) for a review of NJCRIB Requirements.
When Step 5 testing is completed, the NJCRIB Test Coordinator will notify the Claim Administrator
that SROI Testing is complete. If you do not receive acknowledgements from the last batch of SROIs
sent within three days, contact the NJCRIB EDI Test Coordinator immediately.
Step 6: NJ Test Completion (Subsequent Report of Injury)
Reaching Step 6 means that the Claim Administrator has successfully completed both First Report of
Injury and Subsequent Report of Injury testing with the NJCRIB as advised by the NJCRIB test
coordinator. Congratulations – Full Production Status has been achieved.
Once the testing process for SROI reporting has been completed and acknowledged as such by the
NJCRIB EDI Test Coordinator, the Claim Administrator may then begin sending “production” SROI
reports on “actual” new EDI claims. Two reminders:
1. Remember to change the Test/Production indicator in the header record on Subsequent Reports
to “P” for Production before sending “actual” new claims.
2. All Subsequent reports require that a First Report on the same claim be sent previously and
acknowledged with a “TA” or “TE” status and an Agency Claim Number assigned to it. Do not
send an EDI SROI report on a claim where the First Report of Injury was sent on paper unless
you first send a FROI.
Continue with the “P” indicator unless informed by the NJCRIB that the data quality of Subsequent
Reports of Injury no longer meets NJ requirements, see Data Quality Requirements for Business
Content Test Files (page 108) for a review of these requirements.
Ongoing Monitoring of Production Status
NJCRIB will continue to monitor EDI data quality for every Claim Administrator through the test process
and will continue to do so throughout the Trading Partner relationship. If the Claim Administrator’s data
quality falls below the NJCRIB data quality requirements for five (5) consecutive transmissions, NJCRIB
requires the Claim Administrator to submit to the following:
• Paper reports will not be resumed and the Employer/Sender may be out of compliance with the
New Jersey EDI legislation’s mandate.
• Increasingly higher Data Quality requirements may be imposed to correct problems and to avoid
excessive submissions and the continuing review of the Administrator’s written responses.
• The Claim Administrator is required by NJCRIB to submit a written report to the NJCRIB EDI
Coordinator. The written report is to include the cause and corrective action taken by the
Employer/Sender for each error noted on the AK-1 Acknowledgement for the last five
transmissions.

Communication Requirements
Claim information must be transmitted to NJCRIB through IAIABC Release I FROI and Release IA
SROI EDI in either Flat File format with appropriate header and trailer records, or the ANSI 148 format.
This Guide must be used in conjunction with the IAIABC Release 1 EDI Implementation Guide. The
IAIABC Guide, which includes data element definitions, file formats, ANSI X12 requirements, etc., may be
purchased by contacting the IAIABC at (608) 277-1479.
Experienced vendor services will include at a minimum responsibility for report transmissions and
acknowledgements between the Sender and NJCRIB EDI System via NJCRIB recognized Value Added
Networks (VANs) of Advantis and AT&T. Vendor services and products often include the highly
recommended features of pretransmission data quality editing and management of EDI transmissions and
acknowledgements. Administrators who do not contract with a vendor for part or all of these functions will
be expected to perform those services. In this regard direct connects to NJCRIB will only be considered
for large claim volume Administrators and Vendors who provide compelling cost and efficiency reasons.
Vendors or Administrators seeking direct connection to the NJCRIB EDI System should refer to the
NJCRIB Connect policy which imposes stringent technical competency requirements, data security, and
application interoperability requirements.
New Jersey Policy for the Addition of External Connections
New Jersey supports an open Electronic Data Interchange (EDI) environment and opposes artificial
barriers to competition among EDI vendors.
To promote and facilitate EDI between State Workers Compensation Jurisdictions, Claim
Administrators, Employers, Providers, and Reporting Service Vendors, the New Jersey vendor will add
the ability for Vendors to Directly Connect to the NJCRIB EDI System. The request must be
authorized by NJCRIB. A one time fee based on programming and specific Connect related
requirements will apply per connection.
Technical capability requirements assure Jurisdiction EDI system users of reliable high quality data
transfer and processes. Organizations wishing to establish a “Connect” with the NJCRIB EDI System
must certify that they meet the following Network, Application, and Process requirements, and that
they will adhere to the Restrictions. A thirty-day period will be allowed to test and establish reliable
connectivity with each new Connect. Technical assistance is available from NJCRIB.
At the discretion of NJCRIB, a Connect may be disconnected for failure to meet requirements such as
transmission quality, customer complaints, etc. NJCRIB reserves the right to suspend a Connect
temporarily, when that Connect degrades the NJCRIB EDI System or associated processes
performance or connectivity.

Network Requirements
• Ability to communicate via modem (analog dial on POTS line) or Internet connection.
• Use verifiable file transmission protocols such as FTP or FMODEM/XMODEM, etc.
• Identify individual user accounts and provide at least password protection for account access.
• Route files to multiple receivers.
• Hold files for pickup by a receiver.
• Provide logging of file transmissions.
• Provide archive of file transmissions.
• Provide redelivery of files for at least two weeks after original transmission date.
• Ability to route X12 files based on ISA information.
• Provide reliable service (less than 3% down time during service hours).
Application Software Requirements
The VAN Vendor must provide software to connect to their service. NJCRIB will deliver transactions to
the Vendor software either through a programmatic interface or by placing files in common directories.
The Vendor software is completely responsible for delivery of the transactions to the Vendor’s
Network. The Vendor software must provide/perform the following:
• Provide a communications module callable from the NJCRIB EDI System that will perform
connection, file transfer, and delivery verification without intervention.
• Communications with the Vendor Network and transfer of files does not require manual
intervention.
• Provide adequate documentation for integration with the NJCRIB EDI System.
• If encryption is provided, include modules to perform encryption and decryption without
intervention.
• If encryption is provided, use industry standard encryption methods, with the Vendor bearing
the cost of licensing.
• Must be compatible with the NJCRIB EDI System operating environment (32 bit Windows).
• Must not interfere with NJCRIB EDI System or associated Jurisdiction system operations.
(e.g. must not crash or unnecessarily load the system.)

Processing Requirements
• Send and receive multiple files within a single connection session.

• Provide an outbound queue where the NJCRIB EDI System can place transactions before
sending.
• Provide an inbound queue where the NJCRIB EDI System can pick up transactions after
receiving.
• Provide logging information on communications status to the NJCRIB EDI System, including
success/failure notification.
• Identify sent files to prevent duplicate transmissions.
• Identify received files to prevent the NJCRIB EDI System from reprocessing them.
• Identify interrupted or failed transmissions and notify the NJCRIB EDI System.
• Recover from interrupted or failed transmissions and resend or rereceive files without creating
duplicate transmissions and without intervention.
Restrictions
• Vendor software will not perform any additional or unanticipated processing such as validation
of Acknowledgements, on the NJCRIB EDI System or other Jurisdiction systems.
• Vendor data will not be archived on the NJCRIB EDI Systems.

Appendices
Appendix 1 - Transaction Examples
First Report of Injury – Scenario
Employee John Jones was injured at 10:15 AM on 7/5/02 when he ran into a six foot stack of crates of
paper plates with the fork lift he was driving. The stack of cardboard crates fell onto Jones, who
complained of pain in his neck, back and right leg. Supervisor called to scene of accident. John Jones
was taken by ambulance to St. Vincent’s Hospital, where his broken leg was placed in a cast, a neck
brace applied and was put on bed rest for one week. He is not expected to return to work for 3 weeks.
The following information was taken from Mr. Jones’ personnel file and on 7/6/02 Jones’ employer,
Knox Paper Suppliers, sent a First Report of Injury to Manufacturers Insurance Company (MIC) of
Newark who assigned the claim to Smith Adjusting Service on 7/7/02. Smith Adjusting Service
forwarded the Original First Report of Injury to NJCRIB on 7/9/02.
IAIABC Flat Files
Header Record – Claim Administrator to NJCRIB
Data Data Element Data Entry Comment

Element Name For
Number Report
0001 Transaction Set ID HD1 Header
0098 Sender ID (25) (Composed of 25 characters in 3 subparts)
FEIN (9) 379876543 No hyphen
Filler (7) ------- (Blanks)
Postal Code (9) 071021102 No hyphen or spaces
0099 Receiver ID (25) (Composed of 25 characters in 3 subparts)
0100 Date Transmission 20020709
Sent
0101 Time Transmission 173000 (Sent at 5:30 PM – converted to Military
Sent Time)
0102 Original Date Blank
Transmission Sent
0103 Original Time Blank
Transmission Sent
0104 Test/Production P
Indicator
0105 Interchange 14801
Version ID

First Report of Injury – 00 Transaction – Claim Administrator to NJCRIB
Data Data Element New Jersey Data Entry for Report

Element Name Requirement
Number
1 Transaction Set ID Mandatory 148
2 Maintenance Type Mandatory 00 (Original First Report of Injury)
Code
3 Maintenance Type Mandatory 7/9/02 sent as 20020709
Code Date
4 Jurisdiction Mandatory NJ
5 Agency Claim Number Blank – Not Mandatory on all transactions except first
Applicable FROI.
6 Insurer FEIN Mandatory 15-0089764 (sent w/o hyphen)
7 Insurer Name Mandatory Manufacturers Ins Co of Newark
8 Third Party Conditional 37-9876543 (sent w/o hyphens)
Administrator FEIN
9 Third Party Conditional Smith Adjusting Service
Administrator Name
10 Claim Administrator Mandatory 22 Park Place, Suite 105
Address Line 1
11 Claim Administrator Optional
Address Line 2
12 Claim Administrator Mandatory Newark
City
13 Claim Administrator Mandatory NJ
State
14 Claim Administrator Mandatory 07102-1102 (sent w/o hyphen)
Postal Code
15 Claim Administrator Mandatory SAS78904
Claim Number
16 Employer FEIN Mandatory 26-23457800 (sent w/o hyphen)
17 Insured Name Optional New Jersey Paper and Cardboard
Suppliers
18 Employer Name Mandatory Knox Paper Suppliers
19 Employer Address Mandatory 3710 Tennessee Ave
Line 1
20 Employer Address Optional
Line 2
21 Employer City Mandatory Trenton
22 Employer State Mandatory NJ
23 Employer Postal Code Mandatory 07004-2710 (sent w/o hyphen)
24 Self Insured Indicator Mandatory N (for No)
25 SIC Code Mandatory 5113SC
26 Insured Report Optional
Number
27 Insured Location Optional
Number
28 Policy Number Optional SWC145632
29 Policy Effective Optional 1-1-02 (sent as 20020101)
30 Policy Expiration Optional 1-1-03 (sent as 20030101)
31 Date of Injury Mandatory 7-5-02 (sent as 20020705)
32 Time of Injury Mandatory 1015 AM (sent as 1015)
33 Postal Code of Injury Mandatory 07004
Site

Number
34 Employers Premises Mandatory Y (for Yes)
Indicator
35 Nature of Injury Code Mandatory 90
36 Part of Body Injured Mandatory 90
37 Cause of Injury Code Mandatory 46
38 Accident Description/ Mandatory EE drove forklift into stack of crates
Cause (paper plates). Resulted in broken right
leg, back and neck pain.
39 Initial Treatment Code Mandatory 3
40 Date Reported to Mandatory 7-5-02 (sent as 20020705)
Employer
41 Date Reported to Optional 7-7-02 (sent as 20020707)
Claims Administrator
42 Social Security Mandatory 261-46-8762 (sent w/o hyphens)
Number
43 Employee Last Name Mandatory Jones
44 Employee First Name Mandatory John
45 Employee Middle Initial Optional Q
46 Employee Address Mandatory 3701 First Street Apt 4B
Line 1
47 Employee Address Optional
Line 2
48 Employee City Mandatory Trenton
49 Employee State Mandatory NJ
50 Employee Postal Code Mandatory 07012-3215 (sent w/o hyphen)
51 Employee Phone Optional (213) 876-1211
52 Employee Date of Mandatory 3-15-72 (sent as 19720315)
Birth
53 Gender Code Mandatory M
54 Marital Status Code Conditional U
55 Number of Optional
Dependents
56 Date Disability Began Conditional 7-6-02 (sent as 20020706)
57 Employee Date of Conditional
Death
58 Employment Status Optional
Code
59 Class Code Mandatory 5210
60 Occupation Mandatory Warehouseman II
Description
61 Date if Hire Optional
62 Wage Mandatory $950.00 (sent as 000095000)
63 Wage Period Mandatory 1
64 Number of Days Mandatory 5
Worked
65 Date Last Day Worked Conditional 7-5-02 (sent as 20020705)
66 Full Wages Paid for Optional Y (yes)
Date of Injury Indicator
67 Salary Continued Mandatory N (no)
Indicator
68 Date of Return to Conditional
Work

Trailer Record – Claim Administrator ot NJCRIB

Element Name For
Number Report
0001 Transaction Set ID TR1 Trailer
0106 Detail Record Count 000000001 One transaction between header & trailer
Acknowledgement to First Report of Injury Scenario
Upon receiving the First Report of Injury, the NJCRIB edited the transaction and returned the following
Acknowledgement to Smith Adjusting Company noting the Agency Claim Number assigned to this
claim by NJCRIB. The First Report was acknowledged with no errors. The Agency Claim Number of
00001001 is now required on all reports/transactions following for this claim.
Header Record – NJCRIB to Claim Administrator

Element Name For
Number Report
Sent
0101 Time Transmission 083000 (Sent at 8:30 AM – converted to Military
Sent Time)
Transmission Sent
Transmission Sent
Indicator
0105 Interchange Version ID 1481A

Acknowledgement Transaction – NJCRIB to Claim Administrator
Data Data Element Name Data Returned by New Jersey CRIB

Element
Number
1 Transaction Set ID AK1
107 Record Sequence Number 000000001
108 Date Processed 7-10-02 (sent as 20020710)
109 Time Processed 2:15 AM (sent as 021500)
6 Insurer FEIN 15-0089764 (sent w/o hyphen)
14 Claim Administrator Postal Code 07102-1102 (sent w/o hyphen)
8 Third Party Administrator FEIN 37-9876543 (sent w/o hyphen)
110 Acknowledgement Transaction Set 148
ID
111 Application Acknowledgement Code TA
15 Claim Administrator Claim Number SAS78904
5 Agency Claim Number 00001001
2 Maintenance Type Code 00
(From original transaction)
3 Maintenance Type Code Date 7-9-02 (sent as 20020709)
(From original transaction)
112 Request Code (purpose)
113 Free Form Text
114 Number of Errors 00
Variable Segment (if Errors)
Error Code Error Code Occurs Number of Error 00
Times
115 Element Number 0000
116 Element Error Number 000
117 Variable Segment Number 0
Trailer Record – NJCRIB to Claim Administrator

Element Name For
Number Report
Subsequent Report of Injury (NJCRIB “Final” or SA Report) Scenario
Mr. Jones returned to work at full duty and full pay on 8/15/02 with no permanency. The Semi-Annual
report or final EDI report, due to NJCRIB on 2/15/03, was sent by Smith Adjusting Company on
2/14/03 as follows. Payments of Temporary Total Disability, doctor, hospital and other medical bills
was included along with Return to Work date, return to work qualifier and MMI date per NJCRIB
requirements.

Header Record – Claim Administrator to NJCRIB

Element Name For
Number Report
Sent
0101 Time Transmission 113001 (Sent at 11:30:01 AM – converted to Military
Sent Time)
Transmission Sent
Transmission Sent
Indicator
0105 Interchange A491A
Version ID
Subsequent Report of Injury Transaction – Claim Administrator to NJCRIB

Number
1 Transaction Set ID Mandatory A49
2 Maintenance Type Code Mandatory SA (Semi Annual) {NJ Final}
3 Maintenance Type Code Date Mandatory 2/14/03 (sent as 20030214)
4 Jurisdiction Mandatory NJ
6 Insurer FEIN Mandatory 15-0089764 (sent w/o
hyphen)
8 Third Party Administrator FEIN Conditional 37-9876543 (sent w/o
hyphen)
14 Claim Administrator Postal Mandatory 07102-1102
Code
42 Social Security Number Mandatory 261-46-8762 (sent w/o
hyphens)
55 Number of Dependents Conditional Blank (Mandatory if Death
Claim)
69 Pre-Existing Disability Conditional N (No)
56 Date Disability Began Conditional 7-6-02 (sent as 20020706)
70 Date of Maximum Medical Conditional 8-31-02 (sent as 20020831)
Improvement
71 Return to Work Qualifier Conditional 1
72 Date of Return/Release to Conditional 8-15-02 (sent as 20020815)
Work
57 Employee Date of Death Conditional

Number
62 Wage Mandatory $950.00 (sent as 000095000)
63 Wage Period Mandatory 1
64 Number of Day Worked Conditional 5 (Mandatory since this is a
disability claim of greater than
1 week)
67 Salary Continued Indicator Mandatory N (No)
31 Date of Injury Mandatory 7-5-02 (sent as 20020705)
26 Insured Report Number Optional
15 Claim Administrator Claim Mandatory SAS78904
Number
5 Agency Claim Number Mandatory 00001001
73 Claim Status Mandatory C
74 Claim Type Mandatory I
75 Agreement to Compensate Mandatory L
Code
76 Date of Representation Conditional
77 Late Reason Code Conditional
78 Number of Permanent Mandatory 00
Impairments
79 Number of Mandatory 01
Payment/Adjustments
80 Number of Adjustments Mandatory 00
81 Number of Paid to Mandatory 03
Date/Reduced Earnings/
recoveries
82 Number of Death Mandatory 00
Dependent/Payee
Relationships
83 Permanent Impairment Body Conditional Segment not sent
Part Code
84 Permanent Impairment Conditional Segment not sent
Percent
85 Payment/Adjustment Code Conditional 050
86 Payment/Adjustment Paid To Conditional $3673.37 (sent as
Date 000367337)
87 Payment/Adjustment Weekly Conditional $633.34 (sent as 000063334)
Amount
88 Payment/Adjustment Start Conditional 7-6-02 (sent as 200220706)
Date
89 Payment/Adjustment End Date Conditional 8-14-02 (sent as 20020814)
90 Payment/Adjustment Weeks Conditional 5
Paid
91 Payment/Adjustment Days Conditional 4
Paid
92 Benefit/Adjustment Code Optional Segment not sent
93 Benefit Adjustment Weekly Conditional Segment not sent
Amount
94 Benefit/Adjustment Start Date Conditional Segment not sent
95 Paid to Date/Reduced Conditional 350 (payments to doctors)
Earnings/Recoveries Code
96 Paid to Date/Reduced Conditional $757.39 (sent as 000075739)
Earnings/Recoveries Amount

Number
95 Paid to Date/Reduced Conditional 360 (payments to hospitals)
96 Paid to Date/Reduced Conditional $1015.89 (sent as
Earnings/Recoveries Amount 000101589)
95 Paid to Date/Reduced Conditional 370 (other medical payments)
96 Paid to Date/Reduced Conditional $112.32 (sent as 000011232)
Earnings/Recoveries Amount
97 Dependednt Payee Conditional Blank (Mandatory only if
Relationship death benefits payment
made)
Trailer Record – Claim Administrator to NJCRIB

Element Name For
Number Report

Department of Labor: Njcribimpguide4 4a

Cargado por

Información del documento

Título original

Derechos de autor

Formatos disponibles

Compartir este documento

Compartir o incrustar documentos

Opciones para compartir

¿Le pareció útil este documento?

¿Este contenido es inapropiado?

Copyright:

Formatos disponibles

Department of Labor: Njcribimpguide4 4a

Cargado por

Copyright:

Formatos disponibles

NEW JERSEY

EDI IMPLEMENTATION GUIDE

For the reporting of

First (FROI) and Subsequent (SROI) Reports of Injury

March 15, 2002

NJ CRIB EDI Implementation Guide Page 2 March 15, 2002

NJ CRIB EDI Implementation Guide Page 3 March 15, 2002

NJ CRIB EDI Implementation Guide Page 4 March 15, 2002

NJ CRIB EDI Implementation Guide Page 5 March 15, 2002

EDI Implementation Assistance

NJ CRIB EDI Implementation Guide Page 6 March 15, 2002

Required Implementation Date

Use of Data Received through EDI

NJ CRIB EDI Implementation Guide Page 7 March 15, 2002

NJ CRIB EDI Implementation Guide Page 8 March 15, 2002

NJ CRIB EDI Implementation Guide Page 9 March 15, 2002

Synonymous with Claim Administrator.

ANSI ASC X12

NJ CRIB EDI Implementation Guide Page 20 March 15, 2002

(EDI) is the computer-to-computer exchange of data or information in a standardized format. In

A term used to refer to IAIABC EDI Release 1 format and standards.

EXPERIENCED EDI VENDORS

NJ CRIB EDI Implementation Guide Page 21 March 15, 2002

International Association of Industrial Accident Boards and Commissions – an organization, whose

An abbreviation used to refer to an Implementation Guide.

NJ CRIB EDI Implementation Guide Page 22 March 15, 2002

NJ CRIB EDI Implementation Guide Page 23 March 15, 2002

NJ CRIB EDI Implementation Guide Page 24 March 15, 2002

NJ CRIB EDI Implementation Guide Page 25 March 15, 2002

NJ CRIB EDI Implementation Guide Page 26 March 15, 2002

NJ CRIB EDI Implementation Guide Page 27 March 15, 2002

NJ CRIB EDI Implementation Guide Page 28 March 15, 2002

NJ CRIB EDI Implementation Guide Page 29 March 15, 2002

NJ CRIB EDI Implementation Guide Page 30 March 15, 2002

NJ CRIB EDI Implementation Guide Page 31 March 15, 2002

NJCRIB/NJDWC Official Web Pages www.NJCRIB.com

NJCRIB Staff Phone & E-Mail Technical Contact:

NJCRIB Vendor Help Line and E-mail e-mail: njedi@hnc.com or

NJDWC Contact Information for Division of Workers’ Compensation

IAIABC Web Page & Phone Number Web Site address:

Frequently Asked Question www.njcrib.com

NJ CRIB EDI Implementation Guide Page 32 March 15, 2002

NJ CRIB EDI Implementation Guide Page 33 March 15, 2002

NJCRIB EDI Requirements

The objectives of this section are:

Specific Changes from the Current Process

Participant Specific Changes

NJ CRIB EDI Implementation Guide Page 34 March 15, 2002

NJ CRIB EDI Implementation Guide Page 35 March 15, 2002

First Report of Injury (FROI)

NJ CRIB EDI Implementation Guide Page 36 March 15, 2002

DN28 DN29 DN30

DN19, DN20, DN21, DN22, DN23

DN44, DN43, DN45 DN42 DN53

DN57 DN65 DN68

NJ CRIB EDI Implementation Guide Page 37 March 15, 2002

DN43, DN44, DN45

NJ CRIB EDI Implementation Guide Page 38 March 15, 2002

DN44, DN43, DN45

NJ CRIB EDI Implementation Guide Page 39 March 15, 2002

DN6 DN28 DN8

DN43, DN44, DN45

DN31 DN65 DN40 DN56

(insert printout of benefits paid by benefit type)

_ _ ___