Legal Insights

Caution Urged with the PA WC Bureau's New EDI Recommendations for COVID-19 Claims

March 30, 2020
By: Stephen S. Bloomburg

On March 24, 2020, the Bureau of Workers’ Compensation published suggested guidance to workers’ compensation stakeholders, and more specifically to workers’ compensation insurance carriers and third-party administrators, as to how COVID-19 claims should be documented with the Bureau through the Electronic Data Interchange (EDI) platform. The Bureau suggests such claims be documented as follows:

   COVID-19 EDI Reporting

The Workers' Compensation Insurance Organizations (WCIO) has approved the addition of a new Cause Code of 83 for Pandemic and a new Nature Code of 83 for COVID-19. Pennsylvania's system has been updated to accept these codes for reporting COVID-19 claims. The codes are anticipated to be used for the reporting for any COVID-19 claim effective December 2019 or later. The International Association of Industrial Accidents, Boards, and Commissions (IAIABC) recommends that EDI reporting and collection systems be modified to recognize these new codes by April 1, 2020. However, until you are able to update your system to use these codes, we ask that you use Type of Loss field, DN0290 as Occupational Disease and listing COVID-19 in the Accident/Injury Description Narrative, DN0038 so we can both easily identify these claims.

Workers’ compensation insurance carriers and third-party administrators should exercise caution following this suggested guidance.

First, an Employer’s obligation to document an injury with the Bureau through a First Report of Injury (FROI) is not triggered where the disability is less than the day, shift or turn in which the injury was received. Section 438, 77 P.S. § 994. If an employee makes a request for COVID-19 testing, but is not otherwise missing a day, shift or turn from work, the obligation to file an FROI will not be triggered. Likewise, if the Employer, through its workers’ compensation insurance carrier/third-party administrator simply agrees to cover the cost of the COVID-19 testing, the obligation to file an FROI will not be triggered.

Second, if an employee reports COVID-19-related symptoms, which the employee believes developed as a result of exposure to the virus at work, without concomitantly providing the Employer with proof of a positive diagnosis of COVID-19, and without confirming that exposure to the virus occurred at work, the obligation to issue an FROI will not be triggered.

Third, if an employee receives a positive COVID-19 test result and reports that positive COVID-19 test result as being work-related, the workers’ compensation insurance carrier/third-party administrator has the option of either: 1) issuing a Notice of Workers’ Compensation Denial if the facts warrant; or 2) accepting the claim by issuing a Notice of Temporary Compensation Payable/Notice of Compensation Payable. However, it must be remembered that if the coding sequence suggested by the Bureau is used to accept liability for a claim, the Employer could be found to have permanently accepted the COVID-19 diagnosis and would be limited in its ability to raise any defenses against the claimed COVID-19 diagnosis in future proceedings.

Fourth, the Bureau’s suggested guidance that a COVID-19 claim be coded as an occupational disease claim is not recommended. At present, COVID-19 is not an enumerated disease listed in §§ 108(a)-(m.1), (o)-(r), 77 P.S. §§ 27.1(a)-(m.1), (o)-(r) of the Pennsylvania Workers’ Compensation Act, nor is it a given that an employee could establish liability under § 108(n) of the Act. Under § 108(n), the employee must prove

1. Exposure to the disease by reason of employment;
2. That the disease is causally related to the industry or occupation, and;
3. That there is a substantially greater incidence of the disease in that industry or occupation than in the general population.

In those claims where the Employer, through its workers’ compensation insurance carrier/third-party administrator, is certain they wish to accept liability for a COVID-19-related claim, an alternative EDI coding sequence from that suggested by the Bureau is as follows:

1. Nature of Accident (or Cause of Injury):  99 - Other-Miscellaneous, NOC;
2. Body Part:  60 – Lungs; and
3. Nature of Injury:  73 – Contagious Disease.

Given the present dearth of medical and epidemiological evidence on COVID-19, it is submitted that this alternative EDI coding sequence satisfies the obligations of workers’ compensation insurance carriers/third-party administrators to timely and accurately document COVID-19-related claims with the Bureau, while at the same time preventing unnecessary exposure in uncharted legal waters.