Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 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

Current through Register Vol. 30, No. 28, July 12, 2024
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.