Data Management Forms

Claim Reporting Forms

FROI Instructions

First Report of Injury (FROI)
Used to report the occurrence of a workplace injury or occupational disease in a three stage process:

  1. An injured worker reports a workplace injury or occupational disease to their employer,
  2. The employer advances this information to their insurer or adjuster, 
  3.  The insurer or adjuster reports all claim data to the Montana Department of Labor and Industry

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

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.

Electronic Prior Claims (EPC) Forms

EPC System Access Agreement
Used by an insurer to obtain access to the EPC system.

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