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The Oregon Administrative Rules contain OARs filed through November 15, 2014
 
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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
WORKERS' COMPENSATION DIVISION

 

DIVISION 162

ELECTRONIC DATA INTERCHANGE; PROOF OF COVERAGE

436-162-0001

Authority, Applicability, Administration, and Purpose of these Rules

(1) These rules are promulgated under the director's authority contained in ORS 656.726(4).

(2)(a) These rules apply to workers’ compensation proof of coverage transactions filed with the director by electronic data interchange (EDI) on or after April 1, 2015.

(b) For coverage effective before July 1, 2009, the insurer must contact the director if the insurer is unable to file proof of coverage by EDI.

(3) The director’s purpose is to require workers’ compensation proof of coverage reporting by EDI.

(4) The director may waive procedural rules as justice requires, unless otherwise obligated by statute.

(5) Orders issued by the division in carrying out the director's authority to enforce ORS chapter 656 are considered orders of the director.

Stat. Auth: ORS 84, 656.264, 656.419, 656.423, 656.427 & 656.726(4)
Stat. Implemented: ORS 656.017, 656.407, 656.419, 656.423 & 656.427
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0004

Adoption of Standards

(1) The director adopts, by reference, IAIABC EDI Implementation Guide for Proof of Coverage, Release 2.1, dated July 1, 2010.

(2) The form, format, and delivery of data elements reported and definitions will conform to these standards, unless otherwise provided in these rules.

(3) A copy of the Release 2.1 guide is available for review during regular business hours at the Workers’ Compensation Division, Operations Section, 350 Winter Street NE, Salem OR 97301, 503-947-7742. IAIABC members may view a copy of the Release 2.1 guide, or non-members may purchase a copy, at the IAIABC website: http://www.iaiabc.org.

Stat. Auth: ORS 84, 656.264, 656.419, 656.423, 656.427 & 656.726(4)
Stat. Implemented: ORS 656.017, 656.407, 656.419, 656.423 & 656.427
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0005

General Definitions

For the purpose of these rules:

(1) "Director" means the director of the Department of Consumer and Business Services or the director's designee for the matter.

(2) "Division" means the Workers' Compensation Division of the Department of Consumer and Business Services.

(3) "Electronic data interchange" or "EDI" means a computer to computer exchange of information in a standardized electronic format.

(4) "Electronic record" means information created, generated, sent, communicated, received, or stored by electronic means.

(5) “Establishing document” means a transaction that reports coverage for one or more entities. Establishing document types are coverage notice/binders, new policies, rewrite/reissue transactions, renewals, reinstatements, add jurisdiction endorsements, or add employer/location endorsements.

(6) “Exclude (X)” means the data element must not be sent or cannot be sent.

(7) “Expected (E)” means the data element is expected on the transaction, but the transaction will be accepted with errors should it fail any edit.

(8) “Fatal Technical (F)” means the data element must be sent.

(9) “Fatal Technical/Conditional (FT)” means the data element must be sent when certain conditions are present.

(10) "FEIN" means the federal employer identification number or other federal reporting number used by the Internal Revenue Service (IRS) to identify a business entity and by the insurer, insured, or employer for federal tax reporting purposes.

(11) "Header record" means the record that precedes each transmission for the purpose of identifying a sender, the date and time of the transmission, and the transaction set within the transmission.

(12) "IAIABC" means the International Association of Industrial Accident Boards and Commissions, a professional trade association consisting of state workers' compensation regulators and insurance and corporate agency representatives (www.iaiabc.org).

(13) “If Applicable/Available with Item Accept if Invalid (IA)” means the data may or may not be populated. If present, may be edited for valid value or format. The division may or may not return an error on validity edits.

(14) "Industry code" means the code that indicates the nature of the employer's business as published in the North American Industrial Classification System (NAICS) manual, available in print and on CD-ROM from the National Technical Information Service (NTIS) http://www.ntis.gov/products/naics.aspx. NAICS codes may also be viewed at the U.S. Census Bureau webpage (http://www.census.gov/eos/www/naics/).

(15) "Information" means data, text, images, sounds, codes, computer programs, software, databases, or the like.

(16) "Insurer" means the State Accident Insurance Fund Corporation or an insurer authorized under ORS chapter 731 to transact workers' compensation insurance in Oregon.

(17) "Mandatory (M)" means the data element must be sent. If the data element is omitted or submitted in a format the division is unable to process, the transaction will be rejected.

(18) “Mandatory/Conditional (MC)” means the data element must be sent when certain conditions are present.

(19) “Not Applicable (NA)” means the data element is not required to be sent, but it may be sent. If it is sent, edits may be applied, but unsuccessful edits will not cause the transaction to be rejected.

(20) "Proof of coverage" means an electronic record or set of records identifying an insurer as providing workers' compensation coverage for a specific employer.

(21) "Record" means electronic record.

(22) “Restricted (R)” means the data element value will not be accepted if a stated condition exists.

(23) "Sender" means the vendor or insurer authorized to send EDI transactions to the division.

(24) "Trailer record" means the record that designates the end of a transmission and provides a count of transactions contained within the transmission, not including the header and trailer records.

(25) "Transaction" means a set of EDI records, defined according to standards in OAR 436-162-0004(1).

(26) “Transaction reason code” means the two-digit code identifying the type of transaction and why it was sent (e.g., 54, adding an employer location).

(27) “Transaction set purpose code” means the code identifying whether the transaction is an original, change, or replacement transaction (e.g., 00, original).

(28) “Transaction set type code” means the code identifying the purpose of individual records within the transaction (e.g., 42, canceled by insured).

(29) "Transmission" means a defined set of transactions, including both header and trailer records sent to the division or sender by EDI.

(30) “Triplicate code” means the series of three two-digit codes that define the specific purpose of individual records in a proof of coverage transmission in this order: transaction set purpose code, transaction set type code, and transaction reason code.

(31) "Vendor" means an agent identified by an insurer to submit transmissions to the division on behalf of the insurer.

Stat. Auth: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS 656.419, 656.423 & 656.427
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0030

Retention of Electronic Records

Insurers and self-insured employers must retain workers' compensation records under OAR 436-050-0120 and OAR 436-050-0220. Records may be retained in electronic format if the records can be reproduced.

Stat. Auth: ORS 656.726(4)
Stats. Implemented: ORS 656.455, 731.475
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11

436-162-0035

General Filing Information

(1) Senders must follow United States Postal Service guidelines for reporting all addresses.

(2) Transactions will be rejected if Mandatory or Mandatory/Conditional data elements are omitted or submitted in a form or format the division is unable to process.

(3) Not Applicable data element(s) in a transaction will be ignored if the data element is either omitted or submitted in a form or format the division is unable to process.

(4) Worker leasing company (also known in other jurisdictions as professional employer organization) policies will be accepted by EDI, subject to the same data and transaction editing standards as other policies. A policy filing for a worker leasing company does not eliminate the worker leasing company’s requirement to file worker leasing notices under OAR 436-050-0410.

(5) Wrap-up policies will be accepted by EDI, subject to the same data and transaction editing standards as other policies. Wrap-up projects and any change of insurer mid-project must be approved by the Oregon Insurance Division.

Stat. Authority: ORS 656.264, 656.419, 656.423, 656.427 & 656.726(4)
Stat. Implemented: ORS 656.419, 656.423 & 656.427
Hist.: WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0038

Acknowledgement

(1) The division will respond to submitted transmissions by providing either a Transaction Accepted (TA) or a Transaction Rejected (TR) acknowledgement.

(2) Transaction rejected acknowledgements will be generated for transactions with errors, including but not limited to:

(a) An omitted Mandatory data element;

(b) An improperly populated data element field, e.g., numeric data element field is populated with alpha or alphanumeric data, or is not a valid value;

(c) Transactions or electronic records within the transaction that require matching and cannot be matched to the division's database;

(d) Illogical data in a Mandatory or Mandatory/Conditional field, e.g., policy expiration date is before policy effective date;

(e) Duplicate transmission or duplicate transaction within the transmission;

(f) Invalid triplicate code; or

(g) Illogical event sequence relationship between transactions, e.g., endorsement transaction submitted before a policy transaction is submitted.

(3) The insurer must correct and resubmit any transactions rejected for which a law or rule requires reporting to the director.

(4) Transactions that are not rejected under section (2) of this rule will result in a Transaction Accepted acknowledgement.

(5) An insurer’s obligation to file proof of coverage for the purposes of this rule is not satisfied unless the director acknowledges acceptance of the transaction.

Stat. Auth: ORS 656.264, 656.419, 656.423, 656.427 & 656.726(4)
Stat. Implemented: ORS, 656.419, 656.423 & 656.427
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 12-2003, f. 12-4-03, cert. ef. 1-1-04; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; Renumbered from 436-160-0320, WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; Renumbered from 436-162-0320, WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0040

Recognized Filing Date

(1) An electronic record is considered filed on the date it is delivered to the director only if the division issues a Transaction Accepted acknowledgment.

(2) Rejected transactions are not considered filed and do not satisfy proof of coverage requirements until they are corrected, resubmitted, and accepted by the division.

Stat. Auth: ORS 656.264, 656.726(4)
Stats. Implemented: ORS 656.419, 656.423 & 656.427
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0060 [Renumbered to 436-162-0335]

436-162-0310

Electronic Filing Requirements

(1) Unless otherwise provided in these rules, insurers must transmit proof of coverage by EDI, and either use an approved vendor, or be approved as a sender.

(2) Unless otherwise provided in these rules, the data elements have the meaning provided in the data dictionary of the IAIABC EDI Implementation Guide for Proof of Coverage, Release 2.1, dated July 1, 2010, referenced in OAR 436-162-0004(1).

(3) Data elements are listed in Appendices A and B:

(a) Appendix A shows all proof of coverage data elements accepted by EDI in Oregon, and whether the data element is Exclude (X), Expected (E), Fatal Technical (F), Fatal Technical/Conditional (FT), Mandatory (M), Mandatory/Conditional (MC), Not Applicable (NA), or Restricted (R), for each transaction type.

(b) Appendix B lists Mandatory/Conditional data elements and the applicable conditions that make the data element mandatory.

(4) Filing due dates are listed in Appendix C, the Event Table.

(5) An insurer may file proof of coverage EDI by:

(a) Transmitting an electronic record of the proof of coverage data elements identified as Mandatory or Mandatory/Conditional, including a correct FEIN, as defined in OAR 436-162-0005(10), for each legally distinct employer included in the establishing document transaction; and

(b) Transmitting an establishing document transaction, coverage notice/binder, new/renew policy, rewrite/reissue policy, reinstatement, add location, add employer, or add jurisdiction.

(6) If an employer elects to include any nonsubject worker(s) for coverage, or subsequently to exclude such workers from coverage, the insurer must submit a transaction with a reason code for including or excluding a corporate officer, partner, member, sole proprietor, or any other nonsubject worker as described in ORS 656.027.

(7) Insurers may not:

(a) Submit placeholder or invalid FEINs; or

(b) Submit paper documents to the director without the director’s express permission.

[ED. NOTE: Appendix referenced is not included in rule text. Click here for PDF of appendix.]

Stat. Auth:ORS 656.264, 656.419, 656.423, 656.427 & 656.726(4)
Stat. Implemented: ORS 656.419, 656.423 & 656.427
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 12-2003, f. 12-4-03, cert. ef. 1-1-04; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10; Renumbered from 436-160-0310, WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0320 [Renumbered to 436-162-0038]

436-162-0335

Testing Procedures and Transaction Accuracy Standards

(1) An insurer that wants to self report proof of coverage must report through an approved vendor until the insurer completes all of the testing requirements in this rule and receives approval from the director to self report.

(2) To obtain approval, each sender must successfully complete the Secure File Transfer Protocol (SFTP) test, demonstrate ability to successfully transmit coverage data in the format specified in OAR 436-162-0004(1), achieve ninety percent reporting accuracy, and retrieve and process automated EDI acknowledgements.

(3) To begin the testing process for proof of coverage EDI, the sender must:

(a) Contact the division’s EDI coordinator. Contact information is on the division’s webpage: http://wcd.oregon.gov/operations/edi/ediindex.html#coverage; and

(b) Complete and submit the proof of coverage EDI transmission profile (Form 440-4979), available from: http://wcd.oregon.gov/operations/edi/ediindex.html#coverage.

(4) A successful EDI test is determined by the following:

(a) The resolution of any consistently recurring Fatal Technical errors identified by the division;

(b) Transmissions are sent to the division without errors in the header or trailer record;

(c) Transmissions are sent to the division without transaction level technical errors; and

(d) The sender is able to retrieve and process the automated EDI acknowledgement transactions.

(5) To move from testing to production:

(a) The sender must submit a minimum of three transmissions containing at least three records for each Oregon valid triplicate code included in Appendix A.

(b) Data transmitted during the proof of coverage EDI test must represent actual proof of coverage data, which will be discarded after the test.

(c) The division will provide the sender with an acknowledgement file to account for the processing outcome of each transaction, i.e., accepted or rejected. The sender should reconcile or correct identified data errors in their source data system as necessary.

(d) Ninety percent of transactions submitted during the testing phase must be accepted by the division. Additional proof of coverage EDI test transmission(s) may be required until a ninety percent accuracy rate is achieved.

(6) The director will notify senders once they have successfully completed testing.

(7) Once approved, the sender must maintain the accuracy as defined in sections (4) and (5)(d) of this rule. Failure to meet technical requirements may result in the revocation of EDI transmission approval.

(8) The division will inform the sender and insurer (if different) if accuracy standards for technical requirements fall below standards prescribed in sections (2) and (5)(d) of this rule.

Stat. Auth: ORS 656.264, 656.419, 656.423, 656.427 & 656.726(4)
Stat. Implemented: ORS 656.264, 656.419, 656.423 & 656.427
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; Renumbered from 436-162-0060, WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0340

Changes or Corrections

(1) Changes or corrections to proof of coverage information must be submitted under the standards referenced in OAR 436-162-0004(1).

(2) To report changes or corrections of an insured employer's name or address, or other data elements, the insurer must transmit the appropriate transaction to specify what data is being changed or corrected.

(3) The insurer's policy number is used to assist in matching each transaction to the appropriate employer. When an insurer changes a policy number, the insurer must report that change prior to the next transaction submitted for that policy. Failure to report a change in the policy number will prevent future filings from being processed by the division's information processing system and the insurer will receive a Transaction Rejected acknowledgement.

(4) To add or delete coverage for corporate officers, members of a limited liability company, partners, sole proprietors, or other nonsubject workers, the insurer must file the appropriate “include” or “exclude” endorsement transaction to the associated policy filing.

Stat. Auth: ORS 656.264, 656.419, 656.423, 656.427 & 656.726(4)
Stat. Implemented: ORS 656. 419, 656.423 & 656.427
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 12-2003, f. 12-4-03, cert. ef. 1-1-04; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10; Renumbered from 436-160-0340, WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0370

Proof of Coverage Terminations

When the insurer cancels coverage before the expiration of the policy term, the insurer must:

(1) Provide written notice to the employer under ORS 656.427(1) and (3);

(2) Retain a record of the written notice sent to the employer under ORS 656.427, and proof of mailing of that notice, for inspection by the division; and

(3) Provide notice to the director under ORS 656.427 by EDI.

Stat. Auth: : ORS 656.264, 656.427 & 656.726(4)
Stat. Implemented: ORS 656.427
Hist.: WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; Renumbered from 436-160-0370, WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0380

Cancellation of Coverage by the Employer

When the employer cancels coverage before the expiration of the policy term, the insurer must:

(1) Retain a record of the written or verbal notice provided by the employer to the insurer under ORS 656.423, including proof of date of receipt of that notice, for inspection by the division; and

(2) Provide notice to the director under ORS 656.423 by EDI.

Stat. Auth: ORS 656.264, 656.423 & 656.726(4)
Stat. Implemented: ORS 656.423
Hist.: WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0400

Monitoring and Auditing Insurers

(1) The director may monitor and conduct periodic audits of proof of coverage reporting data to ensure compliance with ORS chapter 656 and these rules. If the director finds violations of the reporting requirements of these rules the director may issue civil penalties under OAR 436-162-0440 and ORS 656.745.

(a) Proof of coverage must be reported timely. “Timely” means that an insurer reports data within the time allowed by these rules, including Appendix C, the Event Table.

(b) Proof of coverage must be reported accurately. “Accurately” means that the reported coverage data accepted by the division conforms to the reporting requirements of these rules, including Appendices A, B, and C.

(2) All records maintained or required to be maintained must be disclosed upon request by the director.

Stat. Auth: ORS 656.264, 656.726(4) & 656.745
Stat. Implemented: ORS 656.419, 656.423 & 656.427
Hist.: WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

436-162-0440

Assessment of Civil Penalties

(1) Under ORS 656.745, the director may assess a civil penalty against an insurer that fails to comply with ORS chapter 656 or the director’s rules and orders.

(2) The insurer is responsible for its own actions as well as the actions of others acting on the insurer’s behalf. If an insurer or someone acting on the insurer’s behalf violates any provisions of these rules, the director may impose a civil penalty against the insurer.

Stat. Auth: ORS 656.264, 656.726(4) & 656.745
Stat. Implemented: ORS 656.419, 656.423 & 656.427
Hist.: WCD 12-2014, f. 11-13-14, cert. ef. 4-1-15

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