Statutes, codes, and regulations
Arizona Administrative Code
Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCEChapter 05 - INDUSTRIAL COMMISSION OF ARIZONA
Article 14 - MUNICIPAL FIREFIGHTER CANCER REIMBURSEMENT FUND AND FIREFIGHTER AND FIRE INVESTIGATOR CANCER CLAIM REPORTING
Section R20-5-1407 - Cancer Reporting; Required Claim-Specific Data Elements

Ariz. Admin. Code § 20-5-1407

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Current through Register Vol. 30, No. 50, December 13, 2024
Section R20-5-1407 - Cancer Reporting; Required Claim-Specific Data Elements
A. Unique Claim Identifier: The unique, alphanumeric claim identifier (up to 20 characters, but no less than seven characters) assigned by the carrier, self-insured employer, or self-insurance pool to a specific claim. The claim identifier shall remain the same throughout the life of the claim. Usage of the commission's claim number is prohibited. Usage of claimant name, personally-identifiable information, or carrier/self-insured employer/self-insurance pool name in identifier is prohibited.
B. Transaction Type Code: The code that identifies a report as an initial report (01) or subsequent report (02).
C. Occupational Descriptor Code: (01) = Firefighter (02) = Fire Investigator.
D. Sex Code: The sex of the injured worker. (M = Male, F = Female, N = Not Reported.)
E. Birth Year: The 4-digit birth year of the injured worker.
F. Year Claim Reported: The 4-digit year the claim was reported to the carrier/self-insured employer/self-insurance pool.
G. Year of Loss: The 4-digit year when the injury (cancer) became manifest.
H. Year of Hire: The 4-digit year when the injured worker was hired by the employer as a firefighter or fire investigator (either full-time or part-time). If unknown, enter (U).
I. Name of Carrier, Self-Insured Employer, or Self-Insurance Pool: Complete business name of insurance carrier or self-insured employer/pool responsible for the claim.
J. Employer Name: The complete business name of the employer (including a DBA, if applicable) related to the claim.
K. County Code: The code corresponding to Arizona county primarily served by the employer (01) = Apache; (2) = Cochise; (3) = Coconino; (4) = Gila; (5) = Graham; (6) = Greenlee; (7) = La Paz; (8) = Maricopa; (9) = Mohave; (10) = Navajo; (11) = Pima; (12)= Pinal; (13) = Santa Cruz; (14) = Yavapai; (15) = Yuma.
L. Claim Acceptance Date: The date the claim was first accepted as compensable. If the claim was denied, enter (D).
M. Claim Denial Code: The code corresponding to the reason a claim was denied. (01) = Claim not compensable; (02) No coverage; (03) Other reason. If the claim was accepted, enter (A).
N. Claims Status Code: The code corresponding to the claim's status as of the loss valuation date. (01) = claim is open (not reopened) on the loss valuation date; (02) = claim is closed on the loss valuation date; (03) = claim is reopened on the loss valuation date. If the claim was denied, enter (D).
O. Benefit Code: The code that identifies under which provision of the law benefits are being paid on the loss valuation date. (01) = Death; (02) = Permanent Total Disability; (03) Permanent Partial Disability - Unscheduled; (04) Permanent Partial Disability "" No Loss; (05) Temporary Total Disability; (06) Temporary Partial Disability; (07) Claim Denied.
P. Settlement Code: (00) = Claim not subject to settlement during the reporting period; (01) = Full and final settlement during the reporting period; (03) Stipulated award during the reporting period; (05) Noncompensable settlement during the reporting period; (06) = Compromise settlement during the reporting period; (09) Other settlement during the reporting period; (10) Multiple settlements during the reporting period.
Q. Lump Sum Indicator: Indicates whether the claim has been settled by a lump sum amount. N = No; Y =Yes.
R. Closed Date: If the claim closed during the reporting period, report the date of claim closure. (Required if the claim closed during the reporting period.)
S. Reopened Date: If the claim re-opened during reporting period, report the date of claim reopening. (Required if the claim reopened during the reporting period.)
T. Primary Type of Cancer Code: The primary type of cancer involved in the claim on the loss valuation date. Options are brain (01), bladder (02), rectal (03), colon (04), lymphoma (05), leukemia (06), adenocarcinoma (07), mesothelioma of the respiratory tract (08), buccal cavity (09), pharynx (10), esophagus (11), large intestine (12), lung (13), kidney (14), prostate (15), skin (16), stomach (17), ovarian (18), breast (19), testicular (20), non-Hodgkin's lymphoma (21), multiple myeloma (22), and malignant melanoma (23). Nonlisted cancers may be designated as "other" (30).
U. Secondary Type of Cancer Code: If applicable, the secondary type of cancer involved in the claim on the loss valuation date. Options are brain (01), bladder (02), rectal (03), colon (04), lymphoma (05), leukemia (06), adenocarcinoma (07), mesothelioma of the respiratory tract (08), buccal cavity (09), pharynx (10), esophagus (11), large intestine (12), lung (13), kidney (14), prostate (15), skin (16), stomach (17), ovarian (18), breast (19), testicular (20), non-Hodgkin's lymphoma (21), multiple myeloma (22), and malignant melanoma (23). Non-listed cancers may be designated as "other" (30). (Required if applicable.)
V. Amounts Paid (as of loss valuation date):
1. Indemnity Paid: The total amount of paid indemnity for the claim as of the loss valuation date. These losses consist of all paid benefits due to an employee's lost wages or inability to work, including compensation paid to a deceased claimant prior to death, burial expense, claimant's attorney fees, vocational rehabilitation benefits, indemnity settlement payments, and employer's liability losses and expenses. Allocated loss adjustment expense ("ALAE") for other than employer's liability coverage shall be excluded from indemnity losses.
2. Medical Paid: The total amount of medical losses paid for the claim as of the loss valuation date, including medical settlement payments.
3. ALAE Paid: The total amount of ALAE paid for the claim as of the loss valuation date.
4. Death Benefits Paid: The total amount of death benefits paid for the claim as of the loss valuation date.
W. Incurred Amounts (as of loss valuation date):
1. Incurred Indemnity Amount: The total of "Indemnity Paid" plus the current outstanding reserve indemnity benefits, excluding loss adjustment expenses (e.g., ALAE and unallocated loss adjustment expense ("ULAE")).
2. Incurred Medical Amount: The total of "Medical Paid" plus the current outstanding reserve medical benefits, excluding loss adjustment expenses (e.g., ALAE and ULAE).
3. Incurred ALAE Amount: The total of "ALAE Paid" plus the current outstanding reserve ALAE.
4. Incurred Death Benefits Amount: The total of "Death Benefits Paid" plus the current outstanding reserve death benefits, excluding loss adjustment expenses (e.g., ALAE and ULAE).

Ariz. Admin. Code § R20-5-1407

New section made by final rulemaking at 28 A.A.R. 1481, effective 6/10/2022.