Data Management Forms

Data Management Forms
Data Management Forms
First Report of Injury (FROI)
For reporting the occurrence of a workplace injury or occupational disease in a three stage process:
An injured worker reports a workplace injury or occupational disease to their employer,
The employer advances this information to their insurer or adjuster,
The insurer or adjuster reports all claim data to the Montana Department of Labor and Industry
FROI Online Form
FROI Printable Form
FROI Instructions
First Report of Injury (FROI) - Spanish Option
Para informar la ocurrencia de una lesión laboral o enfermedad ocupacional en un proceso de tres etapas:
Un trabajador lesionado informa una lesión en el lugar de trabajo o una enfermedad ocupacional a su empleador,
El empleador adelanta esta información a su asegurador o liquidador,
La aseguradora o tasador informa todos los datos de reclamaciones al Departamento de Trabajo e Industria de Montana.
Formulario FROI
Instrucciones FROI
Other Claim Reporting Forms
Subsequent Report of Injury
(SROI)
Used by insurer/adjuster to report on-going claim data to the Department.
Request for Jurisdiction Assigned Number
(JAN)
Used by a TPA when an injured worker's SSN is not available.
Notice Entry Forms
The purpose of this agreement is to provide access for a claim administrator or insurer and/or an insurer’s designated agent to the Notice Entry system for entering 14-day notices, Denials and Reservation of Rights.
Notice Entry Access Form
These are the instructions for those choosing to use the WebForm for Notice Entry
Notice WebForm entry instructions
These are the EDI requirements for those choosing to automate the Notice Entry
Notice Automation Requirements
Below is the link to access the Notice Entry System
Notice Entry System Access
EDI Proof of Coverage Reporting Notice Entry Forms
The forms below have Montana specific information for EDI POC data elements based on IAIABC standards of POC Release 3.0.
POC Event Table
-The Event Table will provide trigger criteria for each triplicate code. The table also provides the timelines for when each type of transaction should be sent based on the event that is being triggered.
POC Element Requirement Table
- The Element Requirement Table contains data elements that Montana accepts. This table includes the severity of each element for each triplicate code as well as conditional requirements.
POC Edit Matrix Table
-The Edit Matrix Table includes applied editing based on the IAIABC standards and Montana’s POC data requirements.
Insurers/Third Party Administrators Reporting Forms
Third Party Administrator/Adjuster Change Form
Used to report changes in adjuster, claim administrator, or third party administrators.
Third Party Administrator Profile
Used for adding new Third Party Administrators (TPA) and for changes to contact information for existing TPAs.
Electronic Data Interchange (EDI) Forms
Used by insurers and adjusters as a quick, efficient method of communicating data to the Department.
Trading Partner Agreement
Trading Partner Attachment - List of Insurers and/or Employers
Trading Partner Profile
DLI/ERD Trading Partner Profile
Electronic Prior Claims (EPC) Forms
Electronic Prior Claims (EPC) History Access Agreement
Used by an insurer to obtain access to the EPC system in order to obtain prior claim history on their claimants.
EPC Carrier Assignments
Used by an Insurer or Claim Administrator to list the carriers for which they are the "adjuster at risk."
EPC System Access Agreement
Used by an insurer to obtain access to the EPC system.
Employment Standards Division
Notice Entry Access
Electronic Prior Claim (EPC) History System
EPC System Login
Electronic Prior Claim (EPC) History System
Workers' Compensation Claim by Insurers
Workers' Compensation Claim by Insurers
First Report of Injury (FROI)
Past Notices
Subsequent Report of Injury (SROI Reporting)
Nature of Injury Codes
Cause of Injury Codes
Part of Body Codes
Montana First Report of Injury (FROI) Codes
Value of Employer Furnished Housing
Data Management
Data Management Forms
Department of Labor & Industry
Privacy & Security
Services
Agencies
Official Montana State Website
Contact Information
Phone
(406) 444-6543
Mailing Address
P.O. Box 8011
Helena, MT 59604
Physical Address
301 South Park Avenue
Floors 4 and 5
Helena, MT 59601
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