EDI General Interest
The New Mexico Workers' Compensation Administration (WCA) has completed changes to the IAIABC EDI Edit program and tables to accept the new Pandemic and COVID-19 codes for Cause and Nature. If you have technical or administrative questions, please contact the WCA Helpdesk email: WCA.Helpdesk@state.nm.us.
For telemedicine in workers' compensation medical cases with dates of service for the year 2020, the following directive applies. Starting January, 2021, the HCP Fee Schedule has included a telemedicine section.
Annual Expenditure Report Filing (AER)
Insurers are required to file an annual expenditure report with the WCA's Economic Research & Policy Bureau no later than February 15 of the year following the reporting period. The report must be submitted through the AER link and must identify the carrier(s), groups, pools or self-insured employer(s) by the name and the federal employers identification number (FEIN). All expenditures reported are for the calendar year (January 1 - December 31). Failure to timely file may be penalized (Rule 184.108.40.206 D).
Find the AER link for filing on our eServices page. Reporting closes February 15.
Health Care Providers' Fee Schedule/Billing Instructions
Access the HCP Fee Schedule and Billing Instructions issued by the WCA. The schedules and instructions are in order by year.
Find out more about the Hospital Ratios offered by the WCA.
For method of payment for Freestanding Ambulatory Surgery Centers, please see page 5 of the HCP Fee Schedule and Billing Instructions document.
Ratios Effective January 1, 2016 can be found on pages 4 and 5 of the HCP Fee Schedules and Billing Instructions.
For Hosptital Ratios effective January 1, 2016 or after, please see the appropriate HCP Fee Schedule and Billing Instructions document
EDI Filing (FROI/SROI)
The WCA maintains an electronic data interchange (EDI) system for entry of data related to workers' compensation claims. Data collection for an employer's first report of injury or illness (FROI) or second report of injury or illness (SROI) must be submitted electronically to the WCA's Economic Research & Policy Bureau within the required reporting times. Time frames are not waived for incorrect or incomplete report submissions. See Rule 220.127.116.11 for requirements.
Enter FROI/SROI data via the eServices page
The EDI Guide provides information on how to enter data into the system, and information on reporting requirements. Download the EDI Guide.
Inpatient Data Collection Filing (E9)
All workers' compensation payers are required to report inpatient hospital services data from information collected on the UB-04 form (Rule 18.104.22.168 A). Insurers must report inpatient hospital bills to the WCA within 10 to 90 days of payment of the bill. Reports must be submitted through the Inpatient Data Submission site from the insurer or its representative. The data can be entered daily, weekly or monthly. The insurer must report the inpatient bill not later than the 92nd day from the day of payment.
There are two ways of filing data: 1) electronically or 2) uploading a text file. Both methods require the insurer have an account with the WCA.
To submit an electronic format to the WCA, the sender must establish a profile. Contact the Economic Research & Policy Bureau at (505) 841-6044 and see the Inpatient Data Collection Instructions for further information. The instructions document is also found on our Publications page. The Inpatient Medical Data Provider Partner Profile form (E9) can be found on our Forms page. Once an account is established, data is input via the portal on the eServices page.
Proof of Coverage
New Mexico requires insurers to provide proof of workers' compensation coverage through third-party vendors. The following companies can be contracted for these services.
The proof of coverage system ensures the WCA's Employer Compliance Bureau is informed about employers who have recently cancelled a policy or whose policy has expired.
Insurance Services Offices Inc.
545 Washington Blvd.
Jersey City, NJ 07310
National Council on Compensation Insurance (NCCI)
Customer Service Department
901 Peninsula Corporate Circle
Boca Raton, FL 33487
Technical Support: 1-800-NCCI-123
Fax (561) 998-6971
For questions on whether or not an employer has workers' compensation insurance coverage, contact the NMWCA Employer Compliance Bureau at (505) 841-6851.
Proof of Coverage Manual
The WCA requires proof of coverage (POC) reporting in the IAIABC flat file format, which must be submitted through approved vendors (see proof of coverage vendors, above). Approved vendors submit POC data through a web interface. Vendors provide carriers several options for data submission.
Download the Proof of Coverage Manual
Approved Providers for Independent Medical Examinations
The WCA approves providers for independent medical examinations (IMEs) through a process. Interested providers apply to the WCA between March 1 and April 30 every year. Comments on existing IME providers or those under consideration are accepted at the WCA between May 1 and May 31 each year.
Download the list of current IME providers.
For a list of applicants under consideration as IMEs, contact the WCA Medical Cost Containment Bureau at (505) 841-6844.
Some large businesses and governmental entities are permitted to provide their own insurance coverage. The rules for qualifying as a self-insured employer are set forth by the director of the WCA, and can be found in Part 8: Rules and Regulations of the WCA's procedural Rules. Every company that wants to self-insure must apply to the WCA and receive written approval from the director before choosing this option.
A group of employers in the same or similar industry may join together for group self-insurance coverage. This is typically done through an industry association. WCA approval is required, based on standards set by law.Group self-insurance differs from commercial insurance in that group members take on a major responsibility called joint and several liability. All members of the group may be legally responsible for losses within the group, should the group become insolvent.
To find out who qualifies for self-insurance or group self-insurance, and what forms are needed, visit our self-insurance page.