Section I – General Rules

Medical Data Call is the bill detail that comes from medical services rendered. All medical transactions with a Jurisdiction State of Delaware are reportable. This includes all workers compensation claims, including medical-only claims. The Jurisdiction State corresponds to the state under whose Workers Compensation Act the claimant’s benefits are being paid.

All transactions must be submitted electronically to the Delaware Compensation Rating Bureau, Inc., 30 S. 17th Street, Suite 1500, Philadelphia, PA 19103.

The Call began with mandatory medical transactions occurring in 3rd Quarter 2010.

This manual contains copyrighted material of National Council on Compensation Insurance, Inc. (NCCI), used with permission.

Participation was initially required for carrier groups with at least 0.5% market share in the state of Delaware over the most recent three years (overall average equals 0.5% or more.)  As indicated in the DCRB Circular 1054, dated May 29, 2025, the Medical Data Call reporting requirement was expanded to include all carriers in Delaware, regardless of market share.  The expansion of the reporting requirements will be implemented in two phases.

Phase 1: Beginning with transactions effective July 1, 2026, carrier groups with a market share of 0.25% or greater in Delaware will be required to report transactions, with data due by December 31, 2026.

Phase 2: Beginning with transactions effective January 1, 2027, all remaining carriers with a market share below 0.25% will be required to report transactions, with data due by June 30, 2027.

For this purpose, market share will be determined by using Calendar Year Direct Net Written Premium from Statutory Page 14 for the years 2021, 2022 and 2023.

Questions regarding participation/eligibility of a carrier should be addressed to the DCRB.

1. Carrier Group Participation

When a carrier group is included in the Call, all companies that are aligned within that group are required to report under the Call.

2. Reporting Responsibility

Participants in the Call will have the flexibility of meeting their reporting obligation in several ways, including:

(a) Submitting all of their Call data directly to the DCRB
(b) Authorizing their vendor business partners (TPAs, Medical Bill Review Vendors, etc.) to report the data directly to DCRB

Regardless of who submits the Call to the DCRB, the data submitter must report the standard record layout in its entirety with all data elements populated.  Refer to the Record Layouts section of this manual.

Note: Although data may be provided by an authorized vendor on behalf of a carrier or carrier group, quality and timeliness of the data is the ultimate responsibility of the carrier.

3. Mergers and Acquisitions

If a carrier/group is required to report the Call prior to a merger or acquisition, the obligation to continue to report the Call remains.  If a carrier/group that was not previously required to report the Call merges with or becomes acquired by a reporting carrier/group, the acquired carrier/group is required to report the Call as part of that carrier/group.  DCRB will provide lead time for the acquired carrier/group to begin reporting the Call.

Example:

Mergers and Acquisition Scenarios

All medical transactions that occur within a specific quarter, based on the Transaction Date, must be reported by the end of the following quarter. DCRB accepts monthly or quarterly submissions.  Below are examples of monthly and quarterly submission schedules:

Monthly: Three monthly data submissions are submitted, with the entire quarter’s data due at the end of the following quarter (example: for 3rd quarter, the monthly reporting of July data can be reported in August, August data in September, September data in October—with the entire quarter’s data due by December 31).

Quarterly: One submission is reported by the end of the following quarter (example: 3rd quarter is due by December 31) but can be reported as early as October.

Note: The Key Field Change transaction can be submitted at any time regardless of quarter-end due dates.

1. Duration of Reporting:

Medical Data Call transactions are required to be reported until transactions no longer occur for the claim or 30 years from the claim Accident Date, whichever comes first.

Example: Reporting duration for claim with an accident date prior to 3rd quarter 2010
A medical transaction occurs in July 2010 for a claim whose accident date is August 1980. The medical transaction would have been reported with the 3rd quarter 2010 submission. No further reporting of medical transactions for this claim is expected. Medical transactions greater than 30 years may be reported but are not required.

Example: Reporting duration for claim with an accident date on or after 3rd quarter 2010.
A medical transaction occurs in August 2010 for a claim whose accident date is July 2010. The medical transaction is initially reported with the 3rd quarter 2010 submission. All subsequent transactions for this claim are reported through July 1, 2040. Transactions reported after July 1, 2040 will be accepted but are not required.

Medical Data Call transactions are to be submitted electronically to the DCRB through Compensation Data Exchange (CDX) or through Medical Data Manager (MDM). To submit files via MDM, refer to the Medical Data Manager User Guide.

CDX provides a common platform for insurance carriers and data collection organizations (CDX Members) to exchange data that conforms to the industry approved WCIO format. The use of CDX for the submission or retrieval of data and to provide access to other services or products is subject to availability and the terms and conditions of use established by CDX or individual DCOs. These guidelines may be accessed through the CDX web site at www.cdxworkcomp.org. CDX disclaims all liability, direct or implied, and all damages, whether direct, incidental, or punitive, arising from the use or misuse of the CDX site or services by any person or entity.

Before data submitters can send Medical Data Call production files using CDX, a completed Insurer User Management Group (UMG) Primary Administrator Application for each carrier/group must be on file, and each submitter’s electronic data submissions must pass Certification Testing. Refer to the Insurer User Management Group (UMG) Primary Administrator Application section of this manual for details and the Appendix of this manual for additional information.

If a carrier group has already established an UMG primary administrator and currently submits policy data or unit statistical data to the DCRB via CDX, a carrier does not need to submit an additional application to submit Medical Data Call transactions.

Each applicant is required to designate an Insurer User Management Group (UMG) Primary Administrator for the entire Group. The UMG primary administrator shall be solely responsible for the following activities: (a) establishing, controlling, and maintaining Applicant’s access to CDX and its products and services; (b) creating and maintaining accounts for the Applicant; (c) establishing and maintaining all Carrier User account levels; and (d) assessing and responding to all security issues and breaches.

For instructions on creating an Insurer User Management Group Primary Administrator, please visit www.cdxworkcomp.org to fill out and submit an application.

It is expected that 100% of medical transactions from workers compensation claims in the state of Delawrae will be reported in the Medical Data Call. The DCRB does recognize that in certain limited circumstances this can be very difficult, if not impossible, for participants (carrier groups) to comply with reporting 100% of the expected medical transactions.

Accordingly, a carrier group participating in the Call may exclude data for claims that represent up to 15% of gross premium (direct premium gross of deductibles) for the state of Delaware from its reporting requirement. This option may be utilized for small subsidiaries and/or business segments (e.g., coverage providers, branches, TPAs) where it may be more difficult for these entities to establish the required reporting infrastructure. The exclusion option must be based on a business segment, not claim type or characteristics. All requests for such exclusions must be presented to the DCRB for acceptance. Refer to Requests for Business Exclusion in this section.

The 15% exclusion does not apply to selection by:

• Medical services provided (pharmacy, hospital fees, negotiated fees, etc.)
• Claim characteristics such as claim status (e.g., open, closed)
• Claim types such as specific injury types (medical only, death, permanent total disability, catastrophic, etc.)

DCRB reviews previously filed exclusion requests annually to determine if a re-examination is warranted.

Once a claim has been reported under the Call, all related medical transactions must be reported according to the reporting requirements for the Call.

Example: Need to Exercise Business Exclusion Option:
A carrier group has a TPA that does not process medical bills electronically. The premium associated with this TPA represents less than 15% of the participant’s gross premium. The carrier group may exclude the TPA’s transactions from Call reporting.

Note: If a participant has unique circumstances that cannot be accounted for within the exclusion option, contact the DCRB’s Medical Data Reporting Department to submit documentation describing these circumstances. The DCRB will address these situations on a case-by-case basis.

1. Requests for Business Exclusion

Participants in the Call are required to submit their basis for exclusion to the DCRB for review.

All exclusion requests must include the following documentation:

(a) The nature of what data is to be excluded (e.g., any vendors or entities).
(b) An explanation as to why you are using the exclusion option.
(c) Output used to demonstrate that the excluded segment(s) will be less than 15% of premium. Refer to Methods of Determining Gross Premium for Business Exclusion in this section of the manual for premium determination methods (including examples).
(d) Contact information for the individual responsible for the review documentation.

Refer to Appendix of this manual for a Business Exclusion Request Form, worksheets, and submission instructions.

2. Methods of Determining Gross Premium for Business Exclusions

The measurement of the 15% business exclusion is based on direct workers compensation premiums, gross of deductibles. Below are four methods for estimating the proportion of business excluded; any of these four are acceptable to the DCRB.

Some methods use the NAIC Direct Premium, which is reported in the “Exhibit of Premiums and Losses (Statutory Page 14)” in the NAIC Annual Statement. This premium can be either written or earned premium, whichever is more convenient. This premium is net of deductibles.

There are four methods carriers may use to estimate the exclusion percentage:

Method 1—Carriers with Large Deductible Direct Premium less than 0.3% of their total premium (NAIC Direct Premiums) may determine their estimated exclusion using Direct Premium, without adjustment.

Example: Premium determination (Method 1)
A participant with Large Deductible Direct Premium less than 0.3% of its total needs to exclude business for two small subsidiaries. The participant determines the exclusion on July 1, 2013 utilizing Direct Written Premium to determine the percentage of excluded premium.

The following steps are performed to determine whether the proposed exclusions are less than 15% of the total gross written premium.

1. Based on premium data that it maintains; the carrier group determines the Calendar Year Direct Premiums Written in Delaware or Federal Act for each subsidiary to be excluded. It enters the information in Column B.
2. Add up the data in Column B to get the Delaware premium proposed to be excluded.
3. Determine the 2012 Calendar Year Direct Premiums Written in Delaware—the participant finds this information on Schedule T of its 2012 NAIC Annual Statement (due on April 1, 2013). This information is entered on the Total line in Column C.
4. Calculate percentages for Column D (equals Column B divided by Column C).
5. Compare the Total line percentage to the 15% requirement. In this case the proposed exclusion is less than 15%, so it is allowable.

Refer to Appendix of this manual for Premium Verification Worksheet and Instructions – Method 1 and submission instructions.

Method 2—Carrier groups with Large Deductible Direct Premium greater than 0.3% of their total premium (NAIC Direct Premiums) may use the table Large Deductible Net to Gross Ratio, included in this section, to determine their estimated exclusion using Direct Premium.

Determine the Large Deductible Net Ratio by calculating the ratio of excluded Large Deductible Direct Premium to total Direct Premium for Pennsylvania. Use this net ratio to look up the gross ratio using the Large Deductible Net to Gross Ratio table below. Calculate the ratio of excluded non-Large Deductible Direct Premium to total Direct Premium. Add the corresponding Gross Ratio found in the table to the ratio of excluded non-Large Deductible Direct Premium (if any) to determine the percentage of excluded Direct Premium.

Large Deductible Net to Gross Ratio

Example: Premium determination (Method 2)
A participant with Large Deductible Direct Premium greater than 0.3% of its total must exclude one of its medical data providers. The participant has the following premium values:

• Total Direct Premium in Delaware is $1,000,000
• Large Deductible Direct Premium to be excluded for Delaware is $20,000
• Non-Large Deductible Direct Premium to be excluded for Delaware is $40,000

The following steps are performed to determine whether the proposed exclusion is less than 15% of the total gross written premium:

1. Calculate the Large Deductible Net Ratio—$20,000 (Large Deductible Direct Premium to be excluded) divided by $1,000,000 (Total Direct Premium), multiplied by 100 equals a Large Deductible Net Ratio of 2.0% ($20,000 / $1,000,000 x 100 = 2.0%)
2. Use the Large Deductible Net Ratio of 2.0% and the table to determine the corresponding gross ratio of 9.3%
3. Calculate the excluded non-Large Deductible ratio—$40,000 (non-Large Deductible Direct Premium to be excluded) divided by $1,000,000 (Total Direct Premium), multiplied by 100 equals an excluded non-Large Deductible ratio of 4.0% ($40,000 / $1,000,000 x 100 = 4.0%)
4. Determine the percentage of excluded premium—4.0% (excluded non-Large Deductible ratio) added to 9.3% (Large Deductible gross ratio) equals excluded premium of 13.3% (4.0% + 9.3% = 13.3%)
5. Compare the excluded premium percentage to the 15% requirement; in this case, the proposed exclusion is less than 15%, so it is allowable

Refer to Appendix of this manual for Premium Verification Worksheet and Instructions – Method 2 and submission instructions.

Method 3—Another option for carrier groups with Large Deductible Direct Premium greater than 0.3% of their total premium (NAIC Direct Premiums) is to use the following Gross Premium Estimation Worksheet.

Fill in Items A, B, C, and D, and use the formulas to complete the worksheet. Only include premium from Delaware.

Premium Verification Worksheet – Method 3

If the ratio (I) is 15% or less, the exclusion is acceptable.

Example: Premium determination (Method 3)
A participant with Large Deductible Direct Premium greater than 0.3% of its total must exclude one of its medical data providers. The participant has the following premium values:

• Total Direct Premium including Large Deductible for Delaware is $1,000,000
• Large Deductible Direct Premium for Delaware is $300,000
• Large Deductible Direct Premium to be excluded for Delaware is $20,000
• Non-Large Deductible Direct Premium to be excluded for Delaware is $40,000

Premium Verification Worksheet – Method 3

The following steps are performed to determine whether the proposed exclusions are less than 15% of the total gross written premium:

1. From its records, the carrier group determines its Direct Written Premium for all Large Deductible policies, excluded Large Deductible policies, excluded non-Large Deductible policies, and the total for all policies including Large Deductibles
2. Input these values into the Amount column of the applicable row (Items A through D) of the Premium Verification Worksheet
3. Calculate Items E through I of the Premium Verification Worksheet
4. Compare the excluded premium percentage (Item I) to the 15% requirement; in this case, the proposed exclusion is less than 15%, so it is allowable

Refer to Appendix of this manual for Premium Verification Worksheet and Instructions – Method 3 and submission instructions.

Method 4—Use Unit Statistical premium data, gross of deductible, as reported in the Premium Amount field of the Exposure Record for the most recent 12 months of reported data. Calculate the ratio of total gross premium on business to be excluded to total gross premium on all business and compare the excluded premium percentage to the 15% requirement. Only include premium from the state of Delaware or Federal Act.

Example: Premium determination (Method 4)
A participant needs to exclude business for two subsidiaries that represent 1% of total gross premium. The participant determines the exclusion on July 1, 2018, utilizing gross premium to determine the percentage of excluded premium.

The following steps are performed to determine whether the proposed exclusions are less than 15% of the total gross written premium:

1. Based on premium data that it maintains; the affiliate carrier group determines the gross premiums for Delaware or Federal Act for each subsidiary to be excluded. It enters the information in Column B.
2. Add up the data in Column B to get the premium proposed to be excluded.
3. Determine the 2017 workers compensation gross premiums for the entire affiliate carrier group for Delaware or Federal Act. This information is entered on the Total line in Column C.
4. Calculate the percentage for Column D (equals Column B divided by Column C).
5. Compare the Total line percentage to the 15% requirement. In this case, the proposed exclusion is less than 15%, so it is allowable.

Refer to Appendix of this manual for Premium Verification Worksheet and Instructions – Method 4 and submission instructions.

3. Other Premium Determination Methods

Contact the DCRB for guidance if the methods described in this section are not appropriate for determining the exclusion percentage. The methods are not appropriate if they do not closely approximate prospective premium distribution in the current calendar year (e.g., a significant shift has occurred in a participant’s book(s) of business since the last NAIC reporting; or the participant writes a significant number of large deductible policies).

4. Business Exclusion Request Form

An example of the Business Exclusion Request Form is provided in the Appendix of this manual.