Florida Division of Workers’ Compensation Claims EDI Release 3 Update August 2009.

Florida Division of Workers’ Florida Division of Workers’ Compensation Compensation

Claims EDI Claims EDI Release 3 Release 3

UpdateUpdateAugust 2009August 2009

Presenter: Presenter: Linda Yon Linda Yon

Sr. Management Analyst Supv.Sr. Management Analyst Supv.

Bureau of Data Quality and Bureau of Data Quality and CollectionCollection

FL Division of Workers’ FL Division of Workers’ Compensation Compensation

This is a mini EDI This is a mini EDI Training that will give Training that will give you an update on EDI you an update on EDI Rule 69L-56 F.A.C. and Rule 69L-56 F.A.C. and will clarify certain R3 will clarify certain R3 requirements/errors for requirements/errors for which the EDI Team which the EDI Team receives numerous receives numerous questions.questions.

This overview assumes you This overview assumes you have received Claims EDI have received Claims EDI R3 training and have a R3 training and have a basic understanding of R3 basic understanding of R3 and various EDI and various EDI terminology, e.g., FROI, terminology, e.g., FROI, SROI, MTC, etc. SROI, MTC, etc.

We recognize that your We recognize that your system or your vendor’s system or your vendor’s system may use different system may use different terms and code values terms and code values than those presented here.than those presented here.

We encourage you We encourage you to raise your hand to raise your hand and ask lots of and ask lots of questions. questions.

If you prefer, you may If you prefer, you may write down your question write down your question and give it to Linda after and give it to Linda after the presentation is over. the presentation is over. Include your email address Include your email address so the EDI Team can so the EDI Team can respond to you following respond to you following the conference. the conference.

A FL R3 Production A FL R3 Production Status Update can Status Update can be found in the EDI be found in the EDI

Update article in Update article in the FCEC Daily the FCEC Daily News magazine News magazine distributed this distributed this

morning.morning.

Helpful Helpful Resource Resource DocumenDocuments are ts are available available on the on the Claims Claims EDI EDI WebpageWebpage..

Bookmark the FL Bookmark the FL Claims EDI Claims EDI Webpage and Webpage and Check It For New Check It For New or Updated or Updated Information Information http://www.myfloridacfo.com/wc/edi_clhttp://www.myfloridacfo.com/wc/edi_clms.htmlms.html

Due to the national Due to the national standard format and standard format and sequencing sequencing requirements, FL requirements, FL requires the reporting requires the reporting of more business of more business events (MTC’s) than events (MTC’s) than were required via were required via paper forms.paper forms.

Therefore, not all MTC Therefore, not all MTC filing requirements set out filing requirements set out in Rule 69L-56, F.A.C., can in Rule 69L-56, F.A.C., can be equated to a DWC be equated to a DWC Form.Form.A complete accounting of A complete accounting of MTC’s required by FL is set MTC’s required by FL is set out in Rule 69L-56, F.A.C., out in Rule 69L-56, F.A.C., and in the and in the “FL Claims EDI “FL Claims EDI Event Table”Event Table” (and “ (and “MTC MTC Filing InstructionsFiling Instructions”)”)

UPDATE UPDATE to to

RULE 69L-56, RULE 69L-56, F.A.C.F.A.C.

Rule 69L-56 was Rule 69L-56 was recently revised recently revised effectiveeffective May 17, May 17, 20092009, primarily with , primarily with regards to new POC regards to new POC filing requirements filing requirements for PEO’s…for PEO’s…

Also, repealed section 69L-Also, repealed section 69L-56.330 (electronic formats 56.330 (electronic formats for reporting 8th day info for reporting 8th day info for R1 submitters), and for R1 submitters), and deleted the provision in deleted the provision in 69L-56.30169L-56.301 that formerly that formerly allowed substitution of the allowed substitution of the Employer’s address for the Employer’s address for the Employee’s address Employee’s address protected under 119.071, protected under 119.071, F.S.F.S.

Per current statute, Per current statute, 440.185, F.S440.185, F.S., the Division ., the Division must collect certain must collect certain identifying Employee data, identifying Employee data, including the employee’s including the employee’s SSN and mailing address.SSN and mailing address.FLFL Statute 119.071(4)(d)8 Statute 119.071(4)(d)8 requires the Division to requires the Division to protect the release of the protect the release of the address and other confidential address and other confidential information for certain classes information for certain classes of employees, if they (or their of employees, if they (or their employer) write the Division employer) write the Division and request that their and request that their information remain information remain confidential.confidential.

Accordingly, new editing Accordingly, new editing (implemented 8/12/09) will (implemented 8/12/09) will preclude EDI filings that preclude EDI filings that report the employer’s report the employer’s address for the employee’s address for the employee’s address.address.

The Most The Most Important Important Component Component of Claims EDI of Claims EDI is…is…

Data Data QualityQuality

Incoming data will Incoming data will undergo rigorous edits as undergo rigorous edits as documented in our Edit documented in our Edit Matrix! Matrix!

Pay close attention to the Pay close attention to the accuracy of your data. accuracy of your data.

Research and resolve Research and resolve errors timely. errors timely.

The Division will be The Division will be conducting on-going data conducting on-going data quality reviews to identify quality reviews to identify ‘suspect’ data elements ‘suspect’ data elements that are not currently that are not currently being inspected by being inspected by routine R3 Claims EDI routine R3 Claims EDI program edits, but which program edits, but which data appear to be data appear to be inaccurate,inaccurate, e.g., Number e.g., Number of Days Worked Per Week of Days Worked Per Week reported as “7”. reported as “7”.

Claims ManagersClaims Managers - Ensure - Ensure there is sufficient staff there is sufficient staff dedicated to reviewing the dedicated to reviewing the results of each day’s results of each day’s transmissions and transmissions and immediately resolve issues immediately resolve issues with any transactions that with any transactions that rejected (TR). rejected (TR).

Investigate rejections and Investigate rejections and email any email any concerns/questions to concerns/questions to [email protected]

Also, DWC Auditors will Also, DWC Auditors will be conducting data be conducting data validation reviews on validation reviews on audit to confirm that audit to confirm that the data submitted via the data submitted via EDI is accurate and EDI is accurate and consistent based on consistent based on information in the information in the Claim Administrator’s Claim Administrator’s file.file.

Examples of some of the Examples of some of the EDI data elements EDI data elements reviewed on audit for reviewed on audit for accuracy include:accuracy include:

Date Reported to Employer/CADate Reported to Employer/CA

Initial Date Disability BeganInitial Date Disability Began

Initial Date of Lost Time (8Initial Date of Lost Time (8thth day) day) & Knowledge of& Knowledge of Lost Time (88thth day) day)

Claim TypeClaim Type

Empr Paid Salary Ind./Salary Empr Paid Salary Ind./Salary Through DateThrough Date

The Division has instituted The Division has instituted regular verification of the regular verification of the reported SSN/DOB via reported SSN/DOB via information obtained from the information obtained from the Social Security Administration Social Security Administration (SSA). If the SSN reported does (SSA). If the SSN reported does not match the Name reported, not match the Name reported, according to SSA’s records, a according to SSA’s records, a Division Assigned Number Division Assigned Number (DAN) will be issued. If only one (DAN) will be issued. If only one number in the SSN is number in the SSN is transposed, SSA will provide transposed, SSA will provide the corrected number.the corrected number.

If the SSN and name match, If the SSN and name match, but the DOB does not match but the DOB does not match SSA’s records, SSA will SSA’s records, SSA will provide the valid DOB.provide the valid DOB.

The Claims EDI Team will The Claims EDI Team will make the change in our make the change in our system and notify the Claim system and notify the Claim Admin of a new DAN or Admin of a new DAN or corrected SSN or DOB to use corrected SSN or DOB to use with future EDI filings. No with future EDI filings. No MTC 02 filing is necessary.MTC 02 filing is necessary.

The Claim Admin will need to The Claim Admin will need to update its database with the update its database with the DAN and DOB to match DAN and DOB to match DWC’s database. DWC’s database.

If Claim Admin. later obtains If Claim Admin. later obtains what it determines to be the what it determines to be the correct SSN, contact EDI correct SSN, contact EDI Team for manual process Team for manual process (MTC 02 won’t work).(MTC 02 won’t work).

Do Do notnot alter any alter any factual data factual data or or Benefit/Payment Benefit/Payment information to attempt information to attempt to to pass an edit.pass an edit.

Thoroughly research Thoroughly research the the problem and problem and either correct either correct the the inaccurate data or email inaccurate data or email

the EDI team if you the EDI team if you suspect suspect our our program/edit is at fault.program/edit is at fault.

If you have If you have investigatedinvestigated the error and you still do the error and you still do not understand it, please not understand it, please send an email to the send an email to the Claims EDI Team at Claims EDI Team at [email protected]..

The EDI Team will The EDI Team will answer all questions answer all questions via an email so that via an email so that both parties have a both parties have a copy of the response copy of the response for future reference. for future reference.

By emailing your By emailing your question, the EDI Team question, the EDI Team has the opportunity to has the opportunity to research the specific research the specific details of the problem details of the problem thoroughly. Phone calls thoroughly. Phone calls do not allow for do not allow for adequate time for this adequate time for this research. We appreciate research. We appreciate your understanding.your understanding.

Monitor filing outcomes Monitor filing outcomes via the online Claims via the online Claims EDI Data Warehouse by EDI Data Warehouse by ~ 8:00 a.m. the ~ 8:00 a.m. the following morning to following morning to correct and quickly re-correct and quickly re-file any rejected file any rejected transactions.transactions.

Also monitor errors to Also monitor errors to determine if there are determine if there are consistent filing issues consistent filing issues that could be prevented that could be prevented through training or through training or enhanced system enhanced system editing. editing.

See Your Report Card See Your Report Card posted in the Data posted in the Data Warehouse for your Top Warehouse for your Top 5 Fatal Errors.5 Fatal Errors.

FL processes FL processes transmissions transmissions 7 days a 7 days a week, week, including including holidays.holidays.

Processing Processing outcomes (TA, TR) outcomes (TA, TR) for the previous for the previous day’s day’s transmission(s) will transmission(s) will be posted by 9:00 be posted by 9:00 a.m. the following a.m. the following morning in the EDI morning in the EDI Data Warehouse.Data Warehouse.

Transmissions received Transmissions received on or on or beforebefore 9:00 p.m., 9:00 p.m., E.S.T., will be processed E.S.T., will be processed by DWC the same day by DWC the same day the transmission was the transmission was sent.sent.

Transmissions will be Transmissions will be acknowledged the next acknowledged the next calendar day (usually by calendar day (usually by 9:00 a.m. E.S.T.) 9:00 a.m. E.S.T.)

Transmissions received Transmissions received afterafter 9:00 p.m. EST will 9:00 p.m. EST will be processed by DWC the be processed by DWC the following calendar day,following calendar day,

and will be acknowledged and will be acknowledged the day after the the day after the transmission is transmission is processed.processed.

If you need to confirm if If you need to confirm if or when a particular filing or when a particular filing or group of filings were or group of filings were received by the Division, received by the Division, you can “Search for you can “Search for Batches” in the Data Batches” in the Data Warehouse to determine Warehouse to determine when the FROI and/or when the FROI and/or SROI batch was received SROI batch was received (Click on the “Batch ID” (Click on the “Batch ID” for batch details. for batch details.

The on-line Claims EDI The on-line Claims EDI Data Warehouse will Data Warehouse will assist claim assist claim administrators in administrators in resolving EDI errors resolving EDI errors faster, faster, and and may also assist may also assist in in resolving issues resolving issues

with the Centralized with the Centralized Performance System Performance System (CPS).(CPS).

Claims Claims EDI EDI

WarehouWarehousese

If you are If you are unfamiliaunfamiliar with r with how to how to use the use the FL EDI FL EDI Data Data WarehouWarehouse, se, please please review review this this PowerPoiPowerPoint.nt.

If a transaction is If a transaction is improperly rejected by improperly rejected by the Division, the entire the Division, the entire batch will be re-processed batch will be re-processed and re-acknowledged using and re-acknowledged using the the ‘AKC’‘AKC’ Acknowledgement format. Acknowledgement format. (see the (see the technical training technical training PowerPoint on DWC PowerPoint on DWC website for more details on website for more details on the the Acknowledgement Process)Acknowledgement Process)

If a transaction is If a transaction is improperly rejected by improperly rejected by FL, the Claim FL, the Claim Administrator will Administrator will receive credit for the receive credit for the date the transaction date the transaction was originally received was originally received by the Division after it by the Division after it has been re-processed has been re-processed (re-loaded). (re-loaded).

FL does FL does notnot use the use the TE – TE – “Transaction Accepted “Transaction Accepted with Errors” with Errors” Acknowledgement Acknowledgement Code; however, certain Code; however, certain errors will display in errors will display in the warehouse as the warehouse as “TA-“TA-FLFL” and must be ” and must be addressed by the claim addressed by the claim administrator.administrator.

Communicate filing Communicate filing issues with your IT staff issues with your IT staff or vendor so they can or vendor so they can address potential address potential programming issues programming issues and implement and implement solutions quickly. solutions quickly.

Florida has made Florida has made many corrections and many corrections and adjustments to its EDI adjustments to its EDI program to program to accommodate filing accommodate filing situations we did not situations we did not initially anticipate. initially anticipate.

FL may enhance its FL may enhance its EDI program weekly or EDI program weekly or bi-weekly as needed. bi-weekly as needed. But if a new filing But if a new filing requirement will result requirement will result in a rejection, we in a rejection, we typically allow a 3 typically allow a 3 month implementation month implementation period before enforcing period before enforcing the new edit.the new edit.

Upper or Lower Case?Upper or Lower Case?

Data can be sent in Data can be sent in mixed case format; mixed case format; however, DWC’s Match however, DWC’s Match criteria requires that the criteria requires that the case must be the same case must be the same between FROI and SROI between FROI and SROI combos combos (e.g. 00/IP…either (e.g. 00/IP…either all upper or all lower or the all upper or all lower or the same mixed text).same mixed text).

FL has aFL has a “relational database” “relational database” and storesand stores one name, SSN and one name, SSN and DOB for the EE. DOB for the EE. If your system If your system stores multiple names for stores multiple names for different DOI’s, such could different DOI’s, such could result in a rejection of the result in a rejection of the record if the name does not record if the name does not match that on file with the match that on file with the Division.Division.

Note: Note: FL Recently relaxed FL Recently relaxed match data requirements on match data requirements on Middle Initial/Name Middle Initial/Name (i.e., no (i.e., no longer required if on file or longer required if on file or previously sent.)previously sent.)

If FL receives a FROI/SROI payment If FL receives a FROI/SROI payment transaction from one claim transaction from one claim

administrator, and a FROI 04 denial administrator, and a FROI 04 denial from a different claim from a different claim

administrator, a new JCN is NOT administrator, a new JCN is NOT established for that denied claim. established for that denied claim.

If FL’s If FL’s “relational database” “relational database” reflects a different name for the reflects a different name for the EE, the EDI team will contact the EE, the EDI team will contact the claim admin to amend the EE’s claim admin to amend the EE’s

name on their denial. name on their denial.

Note: Note: If two claim admins pay on If two claim admins pay on the same claim, two different JCN’s the same claim, two different JCN’s are established.are established.

Consistent Consistent Errors, Lessons Errors, Lessons Learned and Learned and

Helpful Helpful HintsHints

During July 2009, the During July 2009, the Top 5Top 5 Fatal (TR) % errors industry-Fatal (TR) % errors industry-wide were wide were (not including error (not including error # 0001-042: # 0001-042: Both FROI & SROI Must Both FROI & SROI Must Pass Edits to Accept FilingPass Edits to Accept Filing):):

1. 0288-044: 1. 0288-044: Nbr of Benefits should Nbr of Benefits should not be > what is on filenot be > what is on file

2. 0002-063: 2. 0002-063: No SROI S1-8, 04, CD, No SROI S1-8, 04, CD, VE, PY or PD on file VE, PY or PD on file (when FN (when FN attempted)attempted)

3. 0078-045: 3. 0078-045: Nbr of Perm Nbr of Perm Impairments Must be > 0Impairments Must be > 0 (when PI (when PI info required)info required)

44. 0087-045: . 0087-045: Net < FL Calc Net < FL Calc Gross Amt Minus Adj/Credit Gross Amt Minus Adj/Credit Amts Amts (From AWW reported, Net is (From AWW reported, Net is more than $.05 less than what is more than $.05 less than what is calculated)calculated)

5. 0288-059:5. 0288-059: Ben Type Code Ben Type Code Previously Reported Not Previously Reported Not Sent on SROISent on SROI (lesser amount of (lesser amount of indemnity benefits reported indemnity benefits reported compared to what is on file, e.g., compared to what is on file, e.g., employer paid benefits left off employer paid benefits left off transaction)transaction)

Also, we are seeing errors Also, we are seeing errors in relation to the Comp in relation to the Comp Rate. If benefits are not Rate. If benefits are not being paid at the statutory being paid at the statutory comp rate, the weekly comp comp rate, the weekly comp amount must still be amount must still be reported as the statutory reported as the statutory 66 2/3’s % of AWW. 66 2/3’s % of AWW. Continues to be in the top Continues to be in the top 20 fatal errors, along with 20 fatal errors, along with “Jurisdiction Claim Number “Jurisdiction Claim Number (JCN) missing”.(JCN) missing”.

To avoid late filing To avoid late filing penalties for an Electronic penalties for an Electronic First Report of Injury or First Report of Injury or Illness, the EDI FROI/SROI Illness, the EDI FROI/SROI should be triggered should be triggered immediately upon the Claim immediately upon the Claim Admin’s disposition of the Admin’s disposition of the claim (payment or denial).claim (payment or denial).

This will allow time for This will allow time for correction of potential correction of potential errors and resubmission errors and resubmission and subsequent and subsequent receipt/acceptance by the receipt/acceptance by the Division within the filing Division within the filing due dates specified in Rule due dates specified in Rule 69L-56, F.A.C.69L-56, F.A.C.

When you see the error… When you see the error… “BOTH FROI & SROI MUST “BOTH FROI & SROI MUST PASS EDITS TO ACCEPT PASS EDITS TO ACCEPT FILING”…FILING”…this means that when this means that when submitting an original First submitting an original First Report (MTC 00), you are Report (MTC 00), you are required to submit a required to submit a corresponding SROI initial corresponding SROI initial payment or equivalent. If one payment or equivalent. If one of the two required of the two required transactions fails edits, the transactions fails edits, the other transaction will other transaction will automatically fail for this automatically fail for this reason.reason.

““Current” date values Current” date values (i.e., Current Date Last (i.e., Current Date Last Day Worked, Current Day Worked, Current Date Disability Began & Date Disability Began & Current Return To Work Current Return To Work Date) must represent a Date) must represent a secondsecond period of period of disability.disability. Do NOT populate Do NOT populate “Current” date values “Current” date values with “Initial” date values. with “Initial” date values.

“ “Current” date values Current” date values should be updated each should be updated each time a new date is time a new date is applicable to that field… applicable to that field… Current Date Last Day Current Date Last Day Worked, Current Date Worked, Current Date Disability Began or Disability Began or Current Return To Work Current Return To Work Date.Date.

If you initially reported a If you initially reported a Return to Work Type Code “R” Return to Work Type Code “R” (Released) and/or Physical (Released) and/or Physical Restrictions “Y” in conjunction Restrictions “Y” in conjunction with the Initial RTW Date, and with the Initial RTW Date, and you subsequently learn the you subsequently learn the “Actual” return to work date“Actual” return to work date (not required)(not required),, or Phys Rest or Phys Rest has changed to N, you should has changed to N, you should report a report a revised Initial RTW revised Initial RTW DateDate and RTW Type Code and RTW Type Code (Actual) via MTC 02(Actual) via MTC 02. .

Do not report this as a Do not report this as a Current RTW.Current RTW.

RTW data is required if RTW data is required if reporting payment of BTC reporting payment of BTC 070 (TP) benefits. 070 (TP) benefits.

The “Initial RTW Date” The “Initial RTW Date” should be representative of should be representative of the first day the EE RTW or the first day the EE RTW or was released to RTW after was released to RTW after the accident, not the first the accident, not the first date the EE RTW following date the EE RTW following the initial disability period. the initial disability period.

For example, if the EE For example, if the EE was injured and continued was injured and continued to work restricted duty to work restricted duty following the accident and following the accident and TP was commenced the TP was commenced the next day (never stopped next day (never stopped working), the Initial RTW working), the Initial RTW would be reported as the would be reported as the DOI or DOI +1 (TP start DOI or DOI +1 (TP start date). date). (depends if empr paid for DOI) (depends if empr paid for DOI)

New edit effective New edit effective 10/1/200910/1/2009: : “Initial RTW “Initial RTW Date”Date” will be required if will be required if reporting BTC 030 reporting BTC 030 onlyonly to to ensure the application of the ensure the application of the correct formula (75% vs. correct formula (75% vs. 37.5% of Comp Rate).37.5% of Comp Rate).

In this case, the “Non-In this case, the “Non-consecutive Period Code” of consecutive Period Code” of “W” will not be required“W” will not be required (it is (it is assumed EE RTW’d within waiting assumed EE RTW’d within waiting week if only IB’s were paid.)week if only IB’s were paid.)

If paying BTC 030 (IB) If paying BTC 030 (IB) onlyonly, , “Current Date Disability “Current Date Disability should not be sent if there is should not be sent if there is no actual disability post-RTW no actual disability post-RTW date reported. Although date reported. Although InitialInitial Date Disability Began Date Disability Began is not required and is not is not required and is not stored by DWC for IB only, stored by DWC for IB only, Current Date Dis Began is Current Date Dis Began is loaded if sent – This affects loaded if sent – This affects the expected payment the expected payment amount for IB’s if it appears amount for IB’s if it appears the EE is back off work.the EE is back off work.

If your system requires an If your system requires an InitialInitial Date Disability Began Date Disability Began even ifeven if paying BTC 030 (IB) paying BTC 030 (IB) onlyonly, the appropriate , the appropriate InitialInitial Date Disability Began is the Date Disability Began is the day after MMI, which should day after MMI, which should be the Benefit Start Date for be the Benefit Start Date for 030. No CDDB should be sent.030. No CDDB should be sent.

Any and all Benefits Any and all Benefits segments previously segments previously reported must be reported reported must be reported on on everyevery subsequent subsequent transaction sent on that transaction sent on that claim. claim.

We are seeing Benefits We are seeing Benefits segments previously segments previously reported being left off of reported being left off of MTC 02 transactions MTC 02 transactions because that segment was because that segment was not being changed. This not being changed. This will reject.will reject.

Any Any MTCsMTCs previously previously reported reported at the Benefit at the Benefit levellevel, should not be left in , should not be left in the Benefit segment, if not the Benefit segment, if not applicable to the current applicable to the current MTC being reported. MTC being reported.

For example, do not leave For example, do not leave MTC IP in the 050 Benefits MTC IP in the 050 Benefits segment if you are now segment if you are now sending MTC PY to report a sending MTC PY to report a full settlement (which will full settlement (which will include a 500 Benefits include a 500 Benefits segment). This will reject.segment). This will reject.

Benefit Types and Benefit Types and Other Benefit Types Other Benefit Types previously reported, previously reported, must be reported on must be reported on each subsequent each subsequent transaction, unless transaction, unless explained via certain explained via certain codes (e.g., Reduced codes (e.g., Reduced Benefit Amount Codes Benefit Amount Codes & Recovery Codes).& Recovery Codes).

Benefit Type/Other Benefit Type/Other Benefit Type Amounts Benefit Type Amounts reported must not be reported must not be less than previously less than previously reported on prior reported on prior transaction, without transaction, without justification (eg: justification (eg: Reduced Benefit Amount Reduced Benefit Amount Code – R for Code – R for reclassification). This reclassification). This will reject.will reject.

In FL, if MTC is In FL, if MTC is reported reported in any Benefits in any Benefits segmentssegments, the segment , the segment will be considered an will be considered an “Event” Benefits “Event” Benefits segment, which means segment, which means allall “Event” Benefits “Event” Benefits segment data elements segment data elements will be required to be will be required to be present.present.

For example: If TT For example: If TT previously paid and now previously paid and now changing from TP to IB, changing from TP to IB, MTC CB is now required in MTC CB is now required in the 070 TP and the 030 IB the 070 TP and the 030 IB segments. These are segments. These are Events. If the MTC is also Events. If the MTC is also put in the 050 TT segment, put in the 050 TT segment, it too will be edited as an it too will be edited as an Event, and all data will be Event, and all data will be required and edited.required and edited.

Exception:Exception: If the ‘Date Claim If the ‘Date Claim Administrator Had Knowledge Administrator Had Knowledge of the Injury’ preceded its R3 of the Injury’ preceded its R3 “go live” date, Gross and Net “go live” date, Gross and Net Amounts and Effective Dates, Amounts and Effective Dates, and Benefit Period Start and and Benefit Period Start and Through Dates will Through Dates will notnot be be required (nor edited), even required (nor edited), even for Event Benefit Segmentsfor Event Benefit Segments (Because not previously required (Because not previously required for legacy paper or R1 filings.)for legacy paper or R1 filings.)

The The BenefitsBenefits segment segment should reflect should reflect current current valuesvalues at the time of at the time of transmission, based upon transmission, based upon the Benefit Type Codes the Benefit Type Codes paid on the claim paid on the claim (snapshot).(snapshot).

A Benefits Segment will A Benefits Segment will be excused if be excused if Reduced Reduced Benefit Amount Code Benefit Amount Code “S”“S” (Settlement on (Settlement on Another DOI) is Another DOI) is reported.reported.

A Benefits Segment will A Benefits Segment will be also excused if OBT be also excused if OBT 430 (Unallocated 430 (Unallocated Indemnity) is reported Indemnity) is reported where the acquiring where the acquiring Claim Admin. has not Claim Admin. has not yet issued their initial yet issued their initial payment at the time of payment at the time of filing.filing.

FLFL Calculation Table Calculation Table (Proprietary) (Proprietary)

Edit MatrixEdit Matrix

FL bases all financial FL bases all financial calculations on the Average calculations on the Average Wage sent. This includes Wage sent. This includes calculations of Calculated calculations of Calculated Weekly Comp Amount, Gross Weekly Comp Amount, Gross Weekly Amount, Net Weekly Weekly Amount, Net Weekly Amount and Benefit Type Amount and Benefit Type Amount Paid. Amount Paid.

FLFL Calculation Table Calculation Table (Proprietary) (Proprietary)

Edit MatrixEdit Matrix

Although you may have paid Although you may have paid benefits at a Gross/Net Weekly benefits at a Gross/Net Weekly rate that is rate that is more or less thanmore or less than 66 66 2/3’s of the AWW, the Weekly 2/3’s of the AWW, the Weekly Compensation Amount, a/k/a Compensation Amount, a/k/a Comp Rate must equal 66 2/3’s Comp Rate must equal 66 2/3’s of the Wage (within 5 cents). of the Wage (within 5 cents). This ensures the validation of This ensures the validation of Average Wage since this DN is Average Wage since this DN is used to check indemnity used to check indemnity payments.payments.

Do not continue to Do not continue to resend a resend a rejected rejected transaction if you have transaction if you have not changed any data…it not changed any data…it will will only reject again, only reject again, and will cost and will cost your your company money if you company money if you pay by the transaction. pay by the transaction.

A A Non-consecutive Non-consecutive Period CodePeriod Code will be will be expected when the expected when the DWC’s program DWC’s program detects that there detects that there were non-consecutive were non-consecutive periods of disability periods of disability per individual BTC per individual BTC (not across benefits). (not across benefits).

When initiating or When initiating or reinstating a BTC (i.e., IP, reinstating a BTC (i.e., IP, EP, RB, ER, CB, AB), the Start EP, RB, ER, CB, AB), the Start Date of the Benefit Type Date of the Benefit Type being affected is the date being affected is the date benefits are changed, benefits are changed, reinstated, etc. (vs. the reinstated, etc. (vs. the original start date.) original start date.)

Non-consecutive Period CodeNon-consecutive Period Code may be required if amount of may be required if amount of time represented by the time represented by the Start Date and is more than Start Date and is more than total number of weeks total number of weeks reported for the affected reported for the affected BTC.BTC.

Initial Date of Lost Time Initial Date of Lost Time (8(8thth Day) must be sent on Day) must be sent on all cases with Claim Type L all cases with Claim Type L (Became Lost Time).(Became Lost Time).

Initial Date of Lost Time Initial Date of Lost Time (8(8thth Day) must not = Initial Day) must not = Initial Date Disability Began (1Date Disability Began (1stst day of waiting week)day of waiting week)

Date Claim Administrator Date Claim Administrator Had Knowledge of Lost Had Knowledge of Lost Time (8Time (8thth Day) must also be Day) must also be sent on all cases with sent on all cases with Claim Type L (Became Lost Claim Type L (Became Lost Time).Time).

Date Claim Administrator Date Claim Administrator Had Knowledge of Lost Had Knowledge of Lost Time (8Time (8thth Day) must not be Day) must not be sent earlier than the Initial sent earlier than the Initial Date of Lost Time (8Date of Lost Time (8thth day) day) itself.itself.

If Initial Date of Lost Time If Initial Date of Lost Time and Date Claim and Date Claim Administrator Had Administrator Had Knowledge of Lost Time is Knowledge of Lost Time is sent with Claim Type “I” sent with Claim Type “I” instead of “L”, these fields instead of “L”, these fields are not required for Claim are not required for Claim Type “I” and will not be Type “I” and will not be loaded or used for loaded or used for determining timely determining timely payment/filing…. payment/filing….

……therefore, MTC 02 must therefore, MTC 02 must be sent to correct the be sent to correct the Claim Type, or Initial Claim Type, or Initial Date of Lost Time Date of Lost Time information (if sent information (if sent incorrectly). When the incorrectly). When the 02 has received a TA, 02 has received a TA, notify your CPS notify your CPS specialist if a penalty specialist if a penalty must be re-evaluated.must be re-evaluated.

Note:Note: Effective Effective 10/1/0910/1/09, , we will also be editing the we will also be editing the appropriateness of Claim appropriateness of Claim Type sent as “L” that Type sent as “L” that should have been reported should have been reported as “I”, where it appears as “I”, where it appears disability was immediate disability was immediate and continuous because and continuous because the Initial Date Disability the Initial Date Disability Began was sent as the day Began was sent as the day of/day after the accident of/day after the accident and no RTW data.and no RTW data.

The R3 The R3 Benefit Payment Benefit Payment Issue Date/Payment Issue Issue Date/Payment Issue DateDate (“Date First Payment (“Date First Payment Mailed” - paper term) Mailed” - paper term) must be the date the must be the date the initial payment was initial payment was actually mailed. If you are actually mailed. If you are reporting the day the reporting the day the check is issued by your check is issued by your system, you must ensure system, you must ensure the check is actually the check is actually mailed that same day. The mailed that same day. The audit team WILL validate.audit team WILL validate.

Do not pay the Do not pay the waiting week only waiting week only and therefore and therefore prematurely report prematurely report the 00/IP to avoid the 00/IP to avoid potential late potential late payment and/or filing payment and/or filing penalties.penalties. This will This will reject. reject.

Payment of the Payment of the waiting week early is waiting week early is gratuitous, and the gratuitous, and the claim is considered a claim is considered a “medical only” claim “medical only” claim until the employee until the employee has been disabled at has been disabled at least 8 days…least 8 days…

… … Also, do not send Also, do not send MTC EP to report MTC EP to report the payment of BTC the payment of BTC 240 or any BTC 2xx 240 or any BTC 2xx only (salary in lieu only (salary in lieu of comp) for the of comp) for the waiting week (Days waiting week (Days 1-7) only.1-7) only.

Do not send MTC Do not send MTC S1 just to report S1 just to report RTWRTW information. information. Suspension codes Suspension codes should only be sent should only be sent to report the to report the cessation of cessation of ALLALL indemnity indemnity benefits…benefits…

……For example, if TT For example, if TT benefits were paid and benefits were paid and the employee has the employee has either actually RTW or either actually RTW or has been RTRTW with has been RTRTW with restrictions, MTC 02 restrictions, MTC 02 should be sent to should be sent to communicate RTW if communicate RTW if there is a possibility there is a possibility TP benefits may be TP benefits may be paid. paid.

If the Claim Admin. filed If the Claim Admin. filed an incorrect Suspension an incorrect Suspension CodeCode via R3 (e.g., S6 vs. via R3 (e.g., S6 vs. S7),they can correct the S7),they can correct the MTC error by re-sending MTC error by re-sending another Suspension MTC, another Suspension MTC, as long as the as long as the Suspension Suspension Effective DateEffective Date is the same is the same as the previous one.as the previous one.

If a Suspension If a Suspension transaction was transaction was filed filed in errorin error, but accepted, , but accepted, and you subsequently and you subsequently receive a rejection receive a rejection when trying to report a when trying to report a change in amount, change in amount, benefit type, etc., do benefit type, etc., do not file an RB to get not file an RB to get around the edit that is around the edit that is expecting an RB after expecting an RB after Sx... Sx...

… … Instead, contact the Instead, contact the EDI team for special EDI team for special processing assistance. processing assistance. We may be able to We may be able to manually remove the manually remove the suspension status suspension status from our file and re-from our file and re-process the CA, CA, process the CA, CA, etc.etc.

Conversely, if the Conversely, if the claim was suspended, claim was suspended, but an RB was but an RB was subsequently filed and subsequently filed and accepted in error accepted in error (benefits not really (benefits not really reinstated, but RB sent reinstated, but RB sent to fix edit error) and to fix edit error) and now your FN is now your FN is rejecting because rejecting because there is no Suspension there is no Suspension ‘on file’, ‘on file’, do notdo not file a file a “fake” Sx.“fake” Sx.

Instead, contact the Instead, contact the EDI team for special EDI team for special processing assistance. processing assistance. We may be able to We may be able to manually put the claim manually put the claim back in suspension back in suspension status and re-load the status and re-load the FN. FN.

Do not report Do not report MTC S1MTC S1 (RTW) prematurely before (RTW) prematurely before the last indemnity the last indemnity payment is reported on payment is reported on the transaction. the transaction.

If the “Benefit Period If the “Benefit Period Through Date” on the Through Date” on the current transaction sent current transaction sent post-S1 is greater than the post-S1 is greater than the through date reported on through date reported on the S1, the current the S1, the current transaction will reject.transaction will reject.

Reduced Benefit Reduced Benefit Amount Code Amount Code “R”“R” should only be sent should only be sent when benefits when benefits previously reported previously reported have actually been have actually been reclassified, reclassified, or theor the wrong BTC wrong BTC was was previously reportedpreviously reported and needs to be and needs to be corrected to a different corrected to a different BTC. BTC.

Reduced Benefit Reduced Benefit Amount Code Amount Code “R”“R” will will explain why there are explain why there are fewer/different fewer/different benefits on the benefits on the current transaction current transaction than were previously than were previously reported.reported.

Once reported, Once reported, the the Reduced Reduced Benefit Amount Benefit Amount CodeCode must be sent must be sent on all subsequent on all subsequent transactions. transactions.

CAUTION: If CAUTION: If Reduced Reduced Benefit Amount CodeBenefit Amount Code “R”“R” is sent and one or is sent and one or more BTC’s were more BTC’s were incorrectly left off of incorrectly left off of the current transaction, the current transaction, the BTC’s on the the BTC’s on the current transaction will current transaction will be the benefits against be the benefits against which DWC’s program which DWC’s program will compare future will compare future transactions.transactions.

This means that because This means that because of the presence of the of the presence of the “R” code, the DWC’s “R” code, the DWC’s program therefore did program therefore did not question the not question the ‘disappearance’ of a ‘disappearance’ of a BTC(s), and if the BTC(s), and if the ‘missing” BTCs show up ‘missing” BTCs show up on a subsequent on a subsequent transaction…transaction…

… … that transaction will that transaction will reject reject (and the former (and the former benefits will have to be benefits will have to be re-introduced via one or re-introduced via one or more MTC CB filings.)more MTC CB filings.)

If If Reduced Benefit Reduced Benefit Amount Code Amount Code “R”“R” was reported in error, was reported in error, the Division can the Division can remove the code remove the code from its system upon from its system upon request.request.

To minimize these To minimize these requests, new editing requests, new editing was instituted to was instituted to preclude the preclude the acceptance of acceptance of Reduced Reduced Benefit Amount Code Benefit Amount Code “R”,“R”, e.g., on an 00/IP, e.g., on an 00/IP, and where benefits are and where benefits are unchanged from unchanged from previously reported.previously reported.

You may receive an You may receive an error message error message indicating indicating “Reduced “Reduced Benefit Amount Code Benefit Amount Code Missing”;Missing”; however, however, this does not always this does not always mean that the code is mean that the code is applicable and should applicable and should be sent…be sent…

In some cases, this In some cases, this error is generated error is generated because one or more because one or more BTC’s previously BTC’s previously reported were reported were accidentally left off the accidentally left off the current transaction. current transaction.

If you receive this error If you receive this error message, Reduced message, Reduced Benefit Amount CodeBenefit Amount Code “R”“R” maymay need to be to need to be to be reported to allow be reported to allow the lesser amount of the lesser amount of BTC’s to pass edits, BTC’s to pass edits, or…or…

… … you may actually you may actually need to send the need to send the correct Number of correct Number of BTCs and add back BTCs and add back the missing BTC(s). In the missing BTC(s). In this case, you would this case, you would notnot report report Reduced Reduced Benefit Amount Code Benefit Amount Code “R” “R” ((even though the error even though the error message indicates it is message indicates it is missing.)missing.)

For example, MTC SA For example, MTC SA reported BTC 050 and reported BTC 050 and 070; Subsequent MTC CA 070; Subsequent MTC CA reported only BTC 050 reported only BTC 050 reflecting a change in the reflecting a change in the Net Amount for 050 Net Amount for 050 (070 (070 was left off the was left off the transaction.)transaction.)

MTC CA rejected for the MTC CA rejected for the errors, “Nbr of Benefits < errors, “Nbr of Benefits < Previous”, and missing Previous”, and missing “R” code…“R” code…

If all of the prior 070 had If all of the prior 070 had been reclassified to 050, been reclassified to 050, then the ‘R’ code would be then the ‘R’ code would be applicable to ‘fix’ the CA; applicable to ‘fix’ the CA; However, if 070 was However, if 070 was accidentally left off the CA, accidentally left off the CA, the CA would need to be the CA would need to be re-sent to include both re-sent to include both 070 and 050 and “R” code 070 and 050 and “R” code should should notnot be sent in this be sent in this case.case.

We continue to see this We continue to see this code sent when it is code sent when it is absolutely inappropriate absolutely inappropriate (i.e., where there has (i.e., where there has been no change in been no change in benefit types, dates, benefit types, dates, amounts). amounts).

We will be adding more We will be adding more edits to preclude edits to preclude acceptance of the filing acceptance of the filing when the “R” code is when the “R” code is N/A.N/A.

..

Sending this code when Sending this code when not appropriate will not appropriate will cause edit errors cause edit errors downstream, since the downstream, since the presence of this code presence of this code allows benefits to drop allows benefits to drop off and resets the off and resets the benefit picture on the benefit picture on the Division’s file. Division’s file.

For example, when the For example, when the next SA is sent and next SA is sent and includes all of the BTC’s includes all of the BTC’s paid to date, the SA will paid to date, the SA will reject for the error, reject for the error, Nbr of Nbr of Benefits should not be > Benefits should not be > what it on file.what it on file.

This may require multiple This may require multiple subsequent transactions subsequent transactions to be sent to fix the to be sent to fix the benefit picture.benefit picture.

MMI and PI % are MMI and PI % are now both required now both required if if one or the other is one or the other is sentsent, even if the PI , even if the PI % = 0.% = 0.

We DO want 0% PI We DO want 0% PI ratings reported, ratings reported, although they were although they were not required on not required on paper.paper.

A/C/R SegmentA/C/R Segment (adjustment, (adjustment, credit, redistribution codes, credit, redistribution codes, dates, amounts) are not dates, amounts) are not required to be included on all required to be included on all SROI’s if the beginning and SROI’s if the beginning and ending of the offset or ending of the offset or redistribution was previously redistribution was previously sent (paper or R3).sent (paper or R3).

However, all Benefit Type However, all Benefit Type Amount Paid values must be Amount Paid values must be cumulative (just like paper cumulative (just like paper DWC-13). DWC-13).

However, if A/C/R SegmentHowever, if A/C/R Segment data is continuing to be data is continuing to be applied after moving to R3, applied after moving to R3, then A/C/R information must then A/C/R information must continue to be reported on continue to be reported on SROI’s until the A/C/R is SROI’s until the A/C/R is ended or claim is ended or claim is denied/settled.denied/settled.

MTC 01 Cancel does MTC 01 Cancel does notnot cancel/negate a particular cancel/negate a particular transaction – transaction – it cancels the it cancels the entire claim.entire claim. If you filed an If you filed an MTC 01 in error and SROI’s MTC 01 in error and SROI’s are now rejecting, contact are now rejecting, contact the EDI Team. Depending the EDI Team. Depending on the circumstances, we on the circumstances, we may be able to un-cancel may be able to un-cancel the status of our claim so the status of our claim so SROI’s can be re-loaded.SROI’s can be re-loaded.

FL requires an MTC SA (Sub-FL requires an MTC SA (Sub-Annual) be filed every 6 Annual) be filed every 6 months from the DOI until the months from the DOI until the claim is closed and an FN is claim is closed and an FN is sent.sent.The first MTC SAThe first MTC SA must not be must not be sent prior to sent prior to the end of six (6) the end of six (6) months from the DOI, or the months from the DOI, or the transaction will reject. transaction will reject.

““Sequencing Rule” Sequencing Rule” (in Edit Matrix) for(in Edit Matrix) for

MTC “SA” (Sub-Annual)MTC “SA” (Sub-Annual)

If a subsequent MTC SA is If a subsequent MTC SA is sent more than 7 days prior sent more than 7 days prior to the date it is due, it will to the date it is due, it will be considered an be considered an amendment amendment to the to the previously accepted MTC SA, previously accepted MTC SA, rather rather than a duplicate or the than a duplicate or the next next required MTC SA filing.required MTC SA filing.

““Duplicate Processing” Duplicate Processing” NoteNote

(in Edit Matrix) for (in Edit Matrix) for ““SA after SA”SA after SA”

Example: Example: DOI = 9-1-06DOI = 9-1-06

11stst SA: SA:File no earlier than File no earlier than 3-3-1-071-07 and no later and no later than than 3-31-073-31-07 (Not always exactly 180 days-use (Not always exactly 180 days-use calendar mo’s) calendar mo’s)

22ndnd SA: SA: File no earlier than 7 File no earlier than 7 days prior days prior to 9-1-07 and to 9-1-07 and no later than 30 no later than 30 days days after 9-1-07 (10-1-07) to after 9-1-07 (10-1-07) to

fulfill the 2fulfill the 2ndnd SA filing SA filing reqm’t.reqm’t.

““Duplicate Processing” Duplicate Processing” Note Note

(SA after SA)(SA after SA)

Another Example: Another Example: DOI = 8-31-DOI = 8-31-0606

11stst SA: SA: File no earlier than File no earlier than 3-3-1-071-07 and no later and no later than than 3-31-073-31-07.. (If 6 mo. interval yields invalid date, use 1st (If 6 mo. interval yields invalid date, use 1st day of next mo.)day of next mo.)

22ndnd SA: SA: File no earlier than 7 File no earlier than 7 days prior days prior to 8-31-07 to 8-31-07 and no later than 30 and no later than 30 days days after 8-31-07 (9-30-07) to after 8-31-07 (9-30-07) to

fulfill the 2fulfill the 2ndnd SA filing SA filing reqm’t.reqm’t.

““Duplicate Processing” Duplicate Processing” Note Note

(SA after SA)(SA after SA)

FL is seeing a decline in the FL is seeing a decline in the proper filing of Claim Cost proper filing of Claim Cost reports electronically (MTC reports electronically (MTC SA). A “missing SA-Sub SA). A “missing SA-Sub Annual listing” will soon be Annual listing” will soon be available in the EDI Data available in the EDI Data Warehouse, and will identify Warehouse, and will identify for a trading partner a listing for a trading partner a listing of claims due an SA of claims due an SA transaction, and those for transaction, and those for which no SA or FN has been which no SA or FN has been filed in accordance with our filed in accordance with our rule. rule.

MTC SA missingMTC SA missing

We advise Claim Admins to We advise Claim Admins to ensure they have sent an SA ensure they have sent an SA (and received a TA)(and received a TA) every 6 every 6 months from DOI until the months from DOI until the claim is closed and an FN is claim is closed and an FN is sent and accepted. Missing sent and accepted. Missing SA’s or FN’s should be SA’s or FN’s should be triggered and filed. triggered and filed. The Bureau of Monitoring The Bureau of Monitoring and Audit will also have and Audit will also have access to query this listing. access to query this listing.

MTC SA missingMTC SA missing

MTC “02” MTC “02” ChangeChange

MTC “02” ChangesMTC “02” ChangesIf the Claim Admin. needs If the Claim Admin. needs to change certain data to change certain data related to the initial related to the initial payment, and subsequent payment, and subsequent MTC’s have been accepted MTC’s have been accepted since the FROI/SROI, the 02 since the FROI/SROI, the 02 will not update certain will not update certain fields. Contact an EDI Team fields. Contact an EDI Team member to make the member to make the change manually.change manually.

If a data element is If a data element is changed and changed and not requirednot required per FL’s Element per FL’s Element Requirement Table for the Requirement Table for the particular MTC being particular MTC being reported, but is sent reported, but is sent on that MTC…. on that MTC…. that data element that data element will will notnot be processed/loaded to the be processed/loaded to the Division’s database Division’s database because it is not required.because it is not required.

MTC “02” ChangesMTC “02” Changes

This particular MTC may This particular MTC may have been accepted have been accepted (received a TA), even (received a TA), even though the “non-required” though the “non-required” data element may be data element may be invalid or in error. invalid or in error.


If a subsequent MTC 02 is If a subsequent MTC 02 is sent which contains the sent which contains the same invalid data from the same invalid data from the previous MTC which previous MTC which received the TA…received the TA…this 02 may now reject or this 02 may now reject or receive an error because a receive an error because a jurisdiction can not tell jurisdiction can not tell what is changing on an 02, what is changing on an 02, and can not identify what is and can not identify what is required on an 02, and required on an 02, and must must edit EVERY fieldedit EVERY field. .


Alternatively, you may send in Alternatively, you may send in an MTC 02 which received a an MTC 02 which received a TA…TA…Then send a subsequent Then send a subsequent transaction that receives the transaction that receives the Mandatory Field Not Present Mandatory Field Not Present error (001), and you wonder error (001), and you wonder why the previous 02 did not why the previous 02 did not reject for this error. This is reject for this error. This is because we do not do all because we do not do all presence edits on an MTC 02, presence edits on an MTC 02, because you can’t identify because you can’t identify “required fields” on an 02.“required fields” on an 02.


If MTC 02 is a If MTC 02 is a subsequent filing, the subsequent filing, the MTC 02 must be includedMTC 02 must be included in the Benefits segmentin the Benefits segment (“Event”) in order for (“Event”) in order for DWC’s program to DWC’s program to process any changes to process any changes to the Benefit, Payment, the Benefit, Payment, OBT or A/C/R segment OBT or A/C/R segment data sent on the 02.data sent on the 02.


Data previously required Data previously required or reported on another or reported on another transaction will be transaction will be expected to be included expected to be included on the MTC 02 on the MTC 02 transaction.transaction.


Change Previously Sent Change Previously Sent Data to SpacesData to SpacesFlorida will Florida will notnot be setting be setting data to spaces (removing) data to spaces (removing) based on MTC 02.based on MTC 02.

If a data element was If a data element was reported in error and needs reported in error and needs to be to be removedremoved (vs. (vs. changed), the Claim changed), the Claim Administrator should Administrator should contact the EDI Team for contact the EDI Team for special handling. special handling.

Again, if inaccurate data Again, if inaccurate data results in a CPS penalty, the results in a CPS penalty, the claim admin. must send claim admin. must send MTC 02 (or other MTC 02 (or other appropriate MTC) to correct appropriate MTC) to correct the data. the data.

After the MTC is accepted, After the MTC is accepted, the claim admin. should the claim admin. should request re-evaluation of the request re-evaluation of the penalty by the CPS penalty by the CPS Specialist. Specialist.

If initial payment-related If initial payment-related information sent on the 00/IP information sent on the 00/IP needs to be corrected, and a needs to be corrected, and a subsequent MTC has received a subsequent MTC has received a TA on this file before the 02 is TA on this file before the 02 is sent, an EDI team member will sent, an EDI team member will have to manually input/correct have to manually input/correct data in DWC’s system. data in DWC’s system.

The data will be manually The data will be manually updated, provided the updated, provided the information was indeed changed information was indeed changed on the on the MTC 02 MTC 02 and received a TA. and received a TA. After the system is updated, the After the system is updated, the EDI analyst will notify the party EDI analyst will notify the party who requested the correction.who requested the correction.

In general, the Benefit In general, the Benefit Segment is not edited Segment is not edited when MTC 02 is not when MTC 02 is not included in the Benefit included in the Benefit Segment. However, Segment. However, if if SROI 02 is the FIRST EDI SROI 02 is the FIRST EDI filing for the claimfiling for the claim, the , the benefits information IS benefits information IS LOADED to the DWC’s LOADED to the DWC’s database and ‘sets the database and ‘sets the benefit picture’... benefit picture’...

As a result, benefit As a result, benefit segments on segments on subsequent SROI’s will subsequent SROI’s will be compared to the be compared to the benefit segments sent benefit segments sent on this SROI 02 (1on this SROI 02 (1stst R3 R3 filing on claim).filing on claim).

Unless this is the 1Unless this is the 1stst R3 R3 filing for the claim, filing for the claim, ‘new’ benefits cannot be ‘new’ benefits cannot be initially reported via initially reported via MTC 02. To report a BTC MTC 02. To report a BTC that was inadvertently that was inadvertently ‘left off’ the last filing, ‘left off’ the last filing, even if it is a BTC paid even if it is a BTC paid in the past, you will in the past, you will need to file a CB (vs. need to file a CB (vs. 02).02).

Questions?Questions?

DenialsDenials

Full (Total) Full (Total) Denial Denial FROI MTC FROI MTC

“04”“04”See Rule 69L-56.301(2), F.A.C.See Rule 69L-56.301(2), F.A.C.

Full (Total) Denial Full (Total) Denial If Compensability / all If Compensability / all Indemnity Indemnity andand Medical Medical benefits are being benefits are being denied, the denied, the Electronic Electronic First Report of Injury or First Report of Injury or Illness Illness and and Notice of Notice of DenialDenial is represented by is represented by sending:sending:

FROI 04FROI 04

If compensability of the If compensability of the claim is being denied, even claim is being denied, even if the claim is a “medical if the claim is a “medical only” at this time, it is only” at this time, it is required to be reported to required to be reported to DWC. DWC.

Full (Total) Denial Full (Total) Denial

The FROI 04 must contain The FROI 04 must contain the the

““Full Denial Reason Full Denial Reason Code”, Code”,

““Denial Reason Denial Reason Narrative”, and Narrative”, and

““Full Denial Effective Full Denial Effective Date” Date”

Full (Total) Denial Full (Total) Denial

The The “Full Denial Effective “Full Denial Effective Date”Date” is the date from is the date from which the Claim which the Claim Administrator is denying all Administrator is denying all benefits for the claim. benefits for the claim.

Typically, for a FROI 04 Full Typically, for a FROI 04 Full Denial, it is the Date of Denial, it is the Date of Injury.Injury.

FROI MTC “04” FROI MTC “04” SCENARIOSCENARIO

Claim Type “M” must be Claim Type “M” must be sent to represent a case sent to represent a case which began as a which began as a compensable Medical Only compensable Medical Only claim, but for which claim, but for which compensability is now compensability is now being denied.being denied.

If a Full Denial Claim (FROI If a Full Denial Claim (FROI 04) Began as a compensable 04) Began as a compensable “Medical Only”: “Medical Only”:

Claim Type “M” is necessary Claim Type “M” is necessary to identify Denied First to identify Denied First Reports that initially began Reports that initially began as compensable Medical Only as compensable Medical Only claims (whether or not Lost claims (whether or not Lost Time is later claimed).Time is later claimed).

If “denials” are included in CPS If “denials” are included in CPS in the future, the “M” Claim in the future, the “M” Claim Type will differentiate this type Type will differentiate this type of denial from straight lost of denial from straight lost time and MO to LT Denials. time and MO to LT Denials.

Claim Type “L” cannot be Claim Type “L” cannot be used for this situation used for this situation because there is often no because there is often no actual or ‘claimed’ actual or ‘claimed’ disability dates to report disability dates to report since compensability is since compensability is being denied in general, being denied in general, and there might not be and there might not be 8th day of disability 8th day of disability information, which is information, which is required to be reported in required to be reported in conjunction with Claim conjunction with Claim Type “L”. Type “L”.

SROISROI MTC MTC “04”“04”(Full Denial (Full Denial after IP)after IP)

See Rule 69L-56.3012(1), See Rule 69L-56.3012(1), F.A.CF.A.C..

Full Denial Full Denial afterafter Payment Payment

If the entire compensability If the entire compensability of the claim is denied of the claim is denied following the Initial following the Initial Payment (or equivalent),Payment (or equivalent), an an Electronic Notice of Electronic Notice of DenialDenial is due and is due and represented by sending:represented by sending:

SROI 04SROI 04

The The SROI 04 SROI 04 will include:will include:

Full Denial Reason Code, Full Denial Reason Code,

Full Denial Effective Date, Full Denial Effective Date, andand

Denial Reason Narrative.Denial Reason Narrative.

Full Denial Full Denial afterafter Payment Payment

A A SROISROI “04” must be sent “04” must be sent to deny the claim in its to deny the claim in its entirety entirety afterafter the claim has the claim has been established (FROI).been established (FROI).

The “04” SROI may act like The “04” SROI may act like a suspension when a suspension when benefit(s) are being benefit(s) are being terminated at the time of terminated at the time of the denial.the denial.

SROI “04” DENIAL SROI “04” DENIAL RULESRULES

Partial Partial (Indemnity (Indemnity

Only)Only) Denial Denial

FROI 00 + SROI FROI 00 + SROI PDPD

If the claim is determined to If the claim is determined to be compensable; however, be compensable; however, Indemnity benefits are denied Indemnity benefits are denied in whole but medical benefits in whole but medical benefits will be paid, the will be paid, the Electronic Electronic First Report of InjuryFirst Report of Injury and and Electronic Notice of DenialElectronic Notice of Denial,, is is represented by sending:represented by sending: FROI 00, andFROI 00, and SROI PDSROI PD

Partial (Indemnity Only) Partial (Indemnity Only) DenialDenial

It must contain the It must contain the

Partial Denial Code (A or Partial Denial Code (A or E), andE), and Denial Reason Narrative Denial Reason Narrative to provide the details to provide the details about why indemnity about why indemnity benefits will not be paid.benefits will not be paid.


AA Denying Indemnity in Denying Indemnity in whole, but not Medical whole, but not Medical (Indemnity Only Denied Case)(Indemnity Only Denied Case)

BB Denying Indemnity in part, Denying Indemnity in part, but not Medical but not Medical

EE Denying Indemnity in whole Denying Indemnity in whole and Medical in part and Medical in part (Indemnity Only Denial)(Indemnity Only Denial)

GG Denying both Indemnity Denying both Indemnity and Medical in partand Medical in part

Partial Denial Codes Partial Denial Codes for FLfor FL

The Partial Denial Code The Partial Denial Code should represent the should represent the current current status of the claim status of the claim (vs. an overall status) in (vs. an overall status) in relation to indemnity and relation to indemnity and medical benefits being medical benefits being denied. denied.

For example, ….For example, ….

… If indemnity benefits If indemnity benefits were previously paid and were previously paid and the Claim Admin decided the Claim Admin decided to deny all future to deny all future indemnity (not all indemnity (not all medical), they would send medical), they would send a a Partial Denial Code “A” Partial Denial Code “A” or “E”or “E” to indicate that ALL to indicate that ALL indemnity is indemnity is currentlycurrently being denied (vs. “B” or being denied (vs. “B” or “G” since some indemnity “G” since some indemnity benefits had been paid in benefits had been paid in the past.) the past.)

Denial Reason NarrativeDenial Reason Narrative mustmust be used to convey be used to convey the specific benefits and the specific benefits and reasons for the denial.reasons for the denial. The narrative should The narrative should NOTNOT be defaulted to the text be defaulted to the text description of the code. description of the code. This will result in This will result in additional additional correspondence from correspondence from EAO.EAO.


MTC MTC “PD”“PD” (Partial (Partial Denial) is Denial) is not not used in used in conjunction with the conjunction with the Full Denial data Full Denial data elements: elements:

Full Denial Reason CodeFull Denial Reason CodeFull Denial Effective DateFull Denial Effective Date

DENIEDENIEDD


If the Claim Admin. If the Claim Admin. originally filed 00/PD with originally filed 00/PD with PD Code A or E and PD Code A or E and subsequently decided to subsequently decided to pay some or all indemnity, pay some or all indemnity, it must file an IP with a it must file an IP with a Denial Rescission Date. Denial Rescission Date.

If indemnity benefits are If indemnity benefits are still being partially denied, still being partially denied, a subsequent PD will have a subsequent PD will have to be filed to put the claim to be filed to put the claim back in denial status.back in denial status.

If the Partial Denial Code If the Partial Denial Code needs to be changed needs to be changed because the claim because the claim administrator has changed administrator has changed its position, but the claim its position, but the claim is still in denial status and is still in denial status and new benefits are not being new benefits are not being initiated, this would be initiated, this would be accomplished via another accomplished via another PD, PD, e.g., changing from e.g., changing from Partial Denial Code B or G Partial Denial Code B or G to an A or E, or vice versa.to an A or E, or vice versa.

But if changing from But if changing from A to B, E or G, an A to B, E or G, an IP/PY would still have IP/PY would still have to be filed to report to be filed to report the initiation of the initiation of indemnity benefits.indemnity benefits.

If Partial Denial Code needs If Partial Denial Code needs to be changed because the to be changed because the original was sent in error, original was sent in error, this can be done with MTC 02; this can be done with MTC 02; however, if Benefits are however, if Benefits are commencing for the first commencing for the first time, this can not be time, this can not be completely done via an 02. completely done via an 02. Another transaction will need Another transaction will need to be sent to communicate to be sent to communicate the initiation of benefits the initiation of benefits (e.g.: IP, PY) because neither (e.g.: IP, PY) because neither an 02 or PD can initiate an 02 or PD can initiate benefits. benefits.

If the claim is still in a If the claim is still in a partial denial status, a partial denial status, a subsequent PD would have subsequent PD would have to be sent.to be sent.

A Partial Denial Code can A Partial Denial Code can be changed on an 02 or be changed on an 02 or PD, but neither PD, but neither transaction will represent transaction will represent the initiation of indemnity the initiation of indemnity benefits.benefits.

There is no specific DN for There is no specific DN for ‘partial denial date”, so FL ‘partial denial date”, so FL uses the MTC Date uses the MTC Date associated with the SROI associated with the SROI PD filing for comparison to PD filing for comparison to other data. other data.

e.g., DEN RESC DTE MUST BE e.g., DEN RESC DTE MUST BE >= DEN EFF DTE OR >= DEN EFF DTE OR PD MTC PD MTC DTEDTE

SROI MTC “PD” SROI MTC “PD”

Partial Denial after Partial Denial after PaymentPayment (not filed with (not filed with

FROI “00”)FROI “00”)See Rule 69L-56.3012(2), See Rule 69L-56.3012(2),

F.A.CF.A.C..

Partial Denial after Partial Denial after PaymentPayment

If indemnity benefits are If indemnity benefits are denied (in whole or denied (in whole or part) following the report part) following the report of Initial Payment (or of Initial Payment (or equivalent), anequivalent), an Electronic Electronic Notice of DenialNotice of Denial is is represented by sending:represented by sending:

SROI PDSROI PD

The The SROI PD SROI PD must include:must include:

Partial Denial Code A, B, E, or Partial Denial Code A, B, E, or G, and G, and

Denial Reason Narrative. Denial Reason Narrative.

Partial Denial after Partial Denial after PaymentPayment

Payment After Payment After DDenial enial

(Denial (Denial Rescission)Rescission)

See Rule 69L-56.3012(6), See Rule 69L-56.3012(6), F.A.CF.A.C..

If a If a Full Denial is rescindedFull Denial is rescinded (i.e., entire compensability of (i.e., entire compensability of claim accepted after the claim claim accepted after the claim was initially denied in its was initially denied in its entirety), and the First Report entirety), and the First Report of Injury or Illness is already on of Injury or Illness is already on file, an file, an Electronic Notice of Electronic Notice of Rescinded DenialRescinded Denial is is represented by sending:represented by sending:

SROI IP, AP, PY, RB, CD, VE, or SROI IP, AP, PY, RB, CD, VE, or ERER

Payment After Denial Payment After Denial (Denial Rescission) (Denial Rescission)


SROI IP, AP, PY, RB, CD, VE, or SROI IP, AP, PY, RB, CD, VE, or ERER

OR,OR,

If a If a Partial Denial is rescindedPartial Denial is rescinded (some or all indemnity (some or all indemnity benefits previously denied benefits previously denied will now be paid), and a First will now be paid), and a First Report of Injury or Illness is Report of Injury or Illness is already on file, an already on file, an Electronic Electronic Notice of Rescinded DenialNotice of Rescinded Denial is is represented by sending:represented by sending:

The Denial Rescission Date The Denial Rescission Date must be reported. must be reported.

Note: The Note: The Denial Rescission Denial Rescission DateDate equates to the date you equates to the date you took the action to rescind the took the action to rescind the denial, NOT the effective date denial, NOT the effective date from which benefits will be from which benefits will be paid. paid.


For For MTC AP, IP or PY filings:MTC AP, IP or PY filings: Report the Report the Benefit Payment Benefit Payment Issue DateIssue Date. .

For For MTC IP & PYMTC IP & PY filings: filings: A Payment segment must A Payment segment must also be included, with also be included, with Payment Payment Issue DateIssue Date. .


Edits will also allow a SROI Edits will also allow a SROI MTC 02 to report a rescission MTC 02 to report a rescission of a denial, where the Claim of a denial, where the Claim Admin. has changed its Admin. has changed its disposition of the disposition of the compensability of the claim, compensability of the claim, but is not making a payment but is not making a payment of indemnity at the time of of indemnity at the time of rescission. rescission.

The Denial Rescission Date The Denial Rescission Date must be reported on the SROI must be reported on the SROI MTC 02. MTC 02.


At present, Total Denial (04) At present, Total Denial (04) after Payment, different after Payment, different Claim Administrator, will be Claim Administrator, will be recorded on the same claim recorded on the same claim record in DWC’s database.record in DWC’s database.

Conversely, payment after Conversely, payment after Total Denial, different claim Total Denial, different claim administrator, will also be administrator, will also be recorded on the same claim.recorded on the same claim.

However, if two (or more) However, if two (or more) different Claim Admin’s have different Claim Admin’s have reported payment of indemnity, reported payment of indemnity, two separate claim records will two separate claim records will be established in DWC’s be established in DWC’s database (same SSN/DOI, but database (same SSN/DOI, but different JCN). different JCN).

If the 2If the 2ndnd payer/Claim Admin payer/Claim Admin filed with JCN assigned to claim filed with JCN assigned to claim by 1by 1stst paying Claim Admin, DWC paying Claim Admin, DWC will have to manually establish will have to manually establish a new claim record to obtain a a new claim record to obtain a different JCN for 2different JCN for 2ndnd payer/Claim payer/Claim Admin.Admin.

Lump Sum Lump Sum Payments/SettlePayments/Settle

mentsments

Lump sum payments Lump sum payments /settlements are reported /settlements are reported via via MTC “PY”MTC “PY”. .

00/PY:00/PY: EDI DWC-1 EDI DWC-1 equivalentequivalentPY only:PY only: EDI DWC-4 EDI DWC-4 equivalentequivalent

Lump Sum Lump Sum Payments/Settlement RulesPayments/Settlement Rules

If a washout settlement If a washout settlement includes future indemnity, includes future indemnity, even if the claim is a even if the claim is a “medical only” at this time, “medical only” at this time, it is required to be reported it is required to be reported to DWC. Any and all to DWC. Any and all settlements must be settlements must be reported.reported.00/PY:00/PY: EDI DWC-1 EDI DWC-1 equivalentequivalentPY only:PY only: EDI DWC-4 EDI DWC-4 equivalentequivalent

Lump Sum Lump Sum Payments/Settlement RulesPayments/Settlement Rules

MTC PY requires MTC PY requires both a both a BenefitsBenefits segment segment andand a a Payments segmentPayments segment, , unless Reduced unless Reduced Benefit Amt Code = Benefit Amt Code = “S”.“S”.

Reduced Benefit Amt Reduced Benefit Amt Code “S”Code “S” is sent when is sent when reporting a settlement reporting a settlement that covers more than that covers more than one DOI, where the one DOI, where the settlement $ are paid on settlement $ are paid on another DOI. This code another DOI. This code will ‘excuse’ the non-will ‘excuse’ the non-presence of Benefit Type presence of Benefit Type Amount Paid for 500 on Amount Paid for 500 on the DOI being reported.the DOI being reported.

A settlement agreed upon by all A settlement agreed upon by all parties to end past, present, and parties to end past, present, and future liability of all benefits. future liability of all benefits.

SFSFLump Sum Payment/Settlement CodesLump Sum Payment/Settlement Codes

No future indemnity or medical No future indemnity or medical benefits are due.benefits are due.

Settlement Full (washout)Settlement Full (washout)

BTC 500BTC 500 or or 524524 is required is required (Unless Reduced Benefit Amount (Unless Reduced Benefit Amount Code = S.)Code = S.)

Settlement PartialSettlement Partial

All medical on a case in which All medical on a case in which indemnity benefits were indemnity benefits were previously settled. previously settled. BTC 500, 524 BTC 500, 524 or 501or 501 is required (Unless Red. is required (Unless Red. Ben Amount Code = S.)Ben Amount Code = S.)

SPSP

Lump Sum Payment/Settlement CodesLump Sum Payment/Settlement Codes

A settlement agreed upon by all A settlement agreed upon by all parties to end past, present, and parties to end past, present, and future liability of:future liability of:All indemnity benefits, but not All indemnity benefits, but not medical.medical.

The Payment segment The Payment segment must include a must include a “Payment “Payment Issue Date”Issue Date”

Per 69L-56.002(43), Per 69L-56.002(43), “Payment Issue Date”“Payment Issue Date” for for MTC “IP” (Initial Payment), MTC “IP” (Initial Payment), and and “PY”“PY” (Payment) means (Payment) means the date payment of a the date payment of a specific indemnity benefit specific indemnity benefit corresponding to the MTC corresponding to the MTC being reported being reported left the left the control of the claim control of the claim administrator ...”administrator ...”

Therefore, if the check is in Therefore, if the check is in the possession of the claim the possession of the claim admin.’s admin.’s defensedefense attorney, attorney, it is still in the control of it is still in the control of the claim administrator the claim administrator and is not considered and is not considered “paid”. “paid”.

The day the defense The day the defense attorney surrenders the attorney surrenders the check to the EE or to the check to the EE or to the EE’s representative is the EE’s representative is the day it is considered day it is considered “paid/mailed”. “paid/mailed”.

A A 00/PY00/PY is considered to is considered to be timely filed if it be timely filed if it receives a TA on or beforereceives a TA on or before 14 days after the Date the 14 days after the Date the Initial Payment was Initial Payment was MailedMailed (a/k/a (a/k/a “Payment “Payment Issue Date”Issue Date”).).

MTC PYMTC PY also requires an also requires an ““Award Order DateAward Order Date” ” (except (except when reporting lump sum when reporting lump sum payment of IB’s or advances payment of IB’s or advances << $2000).$2000).

““Award/Order Date”Award/Order Date” means means the date an award, stipulated the date an award, stipulated agreement, advance, lump agreement, advance, lump sum settlement order, or sum settlement order, or order approving attorney fees order approving attorney fees for a lump sum settlement for a lump sum settlement was signed by a (JCC), …was signed by a (JCC), …

… … or the date a stipulated or the date a stipulated agreement or settlement agreement or settlement was signed by a mediator was signed by a mediator or approved by both the or approved by both the claim administrator and claim administrator and employee. employee.

(proposed rule verbiage (proposed rule verbiage for next revision of the for next revision of the rule).rule).

If a settlement check is If a settlement check is issued/delivered to the issued/delivered to the EE’s attorney EE’s attorney earlyearly, e.g., , e.g., a month before the order a month before the order was actually signed, the was actually signed, the Claim Admin. may Claim Admin. may receive a penalty for receive a penalty for untimely reporting of the untimely reporting of the 00/PY00/PY (EDI DWC-1 (EDI DWC-1 equivalent) because … equivalent) because …

… … the the 00/PY00/PY is due 14 days is due 14 days after the date payment after the date payment was mailed, but the 00/PY was mailed, but the 00/PY cannot be successfully cannot be successfully filed without the filed without the Award/Order Date.Award/Order Date.Therefore, the Claim Therefore, the Claim Admin. has to wait until Admin. has to wait until the order is signed the order is signed before it can file the before it can file the 00/PY,00/PY, even though even though payment was issued payment was issued weeks prior. weeks prior.

The Penalty section The Penalty section will address protests will address protests stemming from this stemming from this particular filing particular filing situation on an as situation on an as needed basis.needed basis.

MTC PY OnlyMTC PY Only (EDI DWC-4 (EDI DWC-4 equivalent) for lump sum equivalent) for lump sum payment/settlement payment/settlement (not the (not the initial payment)initial payment) is considered is considered timely filed if it receives a TAtimely filed if it receives a TA on or before 14 days after the on or before 14 days after the award/order is signedaward/order is signed (vs. 14 (vs. 14 days from date payment days from date payment mailed for 00/PY.)mailed for 00/PY.)

Note:Note: Both EDI filing timeframes Both EDI filing timeframes were modeled after existing paper were modeled after existing paper DWC-1 and DWC-4 filing DWC-1 and DWC-4 filing requirements.requirements.

However, a However, a ‘PY only’‘PY only’ that that reports a lump sum reports a lump sum payment for IB’s or an payment for IB’s or an Advance Advance << $2000 where $2000 where there is no JCC involvement there is no JCC involvement and therefore no award or and therefore no award or order signed by a JCC, is order signed by a JCC, is considered timely filed if it considered timely filed if it receives a TA on or before receives a TA on or before 14 days after the date the 14 days after the date the payment was mailedpayment was mailed by the by the Claim Administrator.Claim Administrator.

Lump Sum Lump Sum Payments/SettlementPayments/Settlement

s As Washout-Out s As Washout-Out with Annuity with Annuity

PurchasePurchase

Lump Sum Lump Sum Payment/SettlementPayment/Settlement

If a Final settlement involves If a Final settlement involves the purchase of an annuity the purchase of an annuity for an agreed upon for an agreed upon settlement amount, the $ settlement amount, the $ annuity amount should be annuity amount should be sent as the Benefit Type sent as the Benefit Type Amount Paid for BTC 500 Amount Paid for BTC 500 (and BTC 501 if medical (and BTC 501 if medical settlement amount settlement amount specified.) specified.)

Lump Sum Lump Sum Payment/SettlementPayment/SettlementHowever, the claim does not However, the claim does not

have to remain open until have to remain open until the annuity is paid out, even the annuity is paid out, even those settled per “Platt” those settled per “Platt” decision that contain decision that contain language holding the insurer language holding the insurer liable for payments of an liable for payments of an insolvent annuity company. insolvent annuity company.

MTC FNMTC FN can be filed to can be filed to closed the claim.closed the claim.

Lump Sum Lump Sum Payment/SettlementPayment/Settlement Settlement Settlement

agreements where no agreements where no money is paid by the money is paid by the WC Claim Admin are WC Claim Admin are also required to be also required to be reported to the reported to the Division (usually for Division (usually for waiver of a third waiver of a third party lien)party lien)..

Proposed Reduced Proposed Reduced Benefit Amt Code “N”Benefit Amt Code “N” is is being currently going being currently going through the IRR process. through the IRR process.

This code would be used This code would be used (once approved) when (once approved) when reporting a settlement reporting a settlement that occurs, but no that occurs, but no payment is made by the payment is made by the WC Claim Admin, usually WC Claim Admin, usually due to waiver of a lien. due to waiver of a lien.

Mini-Mini-Training Training

ScenariosScenarios

ScenarioScenario MTCMTCClaim Admin paid disability Claim Admin paid disability days 1-7 only in first days 1-7 only in first check.check.

EP filed; IP filed; Sx filed; EP filed; IP filed; Sx filed; and now the Employer is and now the Employer is paying IB’s.paying IB’s.

IP filed; Sx filed; and now IP filed; Sx filed; and now the Employer is paying IB’s.the Employer is paying IB’s.

EP filed; IP filed; and now EP filed; IP filed; and now the Employer is paying IB’s.the Employer is paying IB’s.

NONENONE

ERER

EPEP

CBCB

ScenarioScenario MTCMTCDWC1 filed (paper); First R3 DWC1 filed (paper); First R3 filing was CA with filing was CA with incomplete benefit picture; incomplete benefit picture; SA filed & rejected because SA filed & rejected because “# Benefits > than what is “# Benefits > than what is on file”.on file”.

CB rejects because “No CB rejects because “No SROI ER or RB on file” SROI ER or RB on file” (previously filed Sx )(previously filed Sx )

IP filed with TT; TT ended IP filed with TT; TT ended due to rls to RTW; TP to be due to rls to RTW; TP to be determineddetermined

Incorrect MTC filed (Do NOT Incorrect MTC filed (Do NOT file Cancel)file Cancel)

CB to CB to add add Benefits Benefits then re-then re-file SAfile SAER or ER or RBRB02 to 02 to rpt rpt RTWRTWCONTACCONTACT EDI T EDI TeamTeam

ScenarioScenario MTCMTCFROI 04 filed with Denial FROI 04 filed with Denial Narrative Narrative incomplete/inaccurate (per incomplete/inaccurate (per EAO)EAO)

IP filed with TT; TT ended & IP filed with TT; TT ended & TP started and new TP started and new AWW/Comp Rate rep’t AWW/Comp Rate rep’t which affected TT & TPwhich affected TT & TP

IP filed with TT; CB filed to IP filed with TT; CB filed to change from TT to TP; Sx change from TT to TP; Sx filed; MMI reached & IB filed; MMI reached & IB benefits to be commenced benefits to be commenced weekly.weekly.

… … (after above situation) IB (after above situation) IB paid in full.paid in full.

0202

CBCB

RBRB

S7S7

ScenarioScenario MTCMTCPaying TP; reached MMI Paying TP; reached MMI and given PI%; actually and given PI%; actually RTW w/Restrictions; need to RTW w/Restrictions; need to pay IB pay IB

Filed FROI 04; and now Filed FROI 04; and now realized should’ve been realized should’ve been “indemnity only” denial. “indemnity only” denial.

SA filed; and now realized SA filed; and now realized Weeks and Benefit Amount Weeks and Benefit Amount reported incorrectly.reported incorrectly.

FN filed; now need to FN filed; now need to reopen to pay ongoing reopen to pay ongoing indemnity benefits.indemnity benefits.

CB if CB if paying paying wkly, or wkly, or PY if lump PY if lump sumsumPD PD

Another Another SASA

RBRB

SCENARIO: SCENARIO: Initial RTW DateInitial RTW Date was previously reported with was previously reported with

RTW Type Qualifier “R” RTW Type Qualifier “R” (Released to RTW). The EE (Released to RTW). The EE

subsequently returned to work subsequently returned to work on a different date.on a different date.

If there has not been another If there has not been another period of disability, you wouldperiod of disability, you would NOT NOT report the actual RTW report the actual RTW date as the “Current Return To date as the “Current Return To Work” date. Work” date.

Rather, the revised RTW Rather, the revised RTW date would be reported as adate would be reported as a new new INITIAL RETURN TO INITIAL RETURN TO WORK DATEWORK DATE and theand the RTW RTW Type Code Type Code would be would be changedchanged toto “A” (Actual). “A” (Actual). Physical Restrictions Indicator Physical Restrictions Indicator may also be changed this way.may also be changed this way.

Update:Update: 2009 R3 guide allows for the 2009 R3 guide allows for the Restrictions/Type Code to change Restrictions/Type Code to change without the IRTW Date changing, and without the IRTW Date changing, and the jurisdiction is to use the MTC Date the jurisdiction is to use the MTC Date on the 02. FL is discussing this approach on the 02. FL is discussing this approach for the future.for the future.

SCENARIO:SCENARIO: If MTC S8 If MTC S8 (Jurisdiction Transfer) was (Jurisdiction Transfer) was sent by mistake instead of sent by mistake instead of S1-S7, do NOT send MTC 01 S1-S7, do NOT send MTC 01 to retract the S8 (MTC 01 to retract the S8 (MTC 01 cancels the ENTIRE CLAIM.) cancels the ENTIRE CLAIM.)

Instead file the appropriate Instead file the appropriate MTC Sx, ensuring the MTC Sx, ensuring the Suspension Effective Date is Suspension Effective Date is the same as previously the same as previously reported. reported.

SCENARIO:SCENARIO: Full Settlement Full Settlement of Death Benefits (BTC 010)of Death Benefits (BTC 010)

Report under BTC 500 Report under BTC 500 rather than 510 if washing rather than 510 if washing out all indemnity (not just out all indemnity (not just death benefits.)death benefits.)

SCENARIO:SCENARIO: Claim Admin. Claim Admin. learns EE had concurrent learns EE had concurrent employment; concurrent employment; concurrent Empr continues salary, but Empr continues salary, but not at rate = 66 2/3’s of not at rate = 66 2/3’s of Average Wage for both jobs. Average Wage for both jobs. Claim Admin for accident Claim Admin for accident employer must compensate employer must compensate ee for the difference.ee for the difference.

File MTC AB to report the File MTC AB to report the payment of both 2xx and 0xx payment of both 2xx and 0xx benefits for the same time benefits for the same time period. period.

SCENARIO:SCENARIO: PT Supp rate is PT Supp rate is increased January 1 of each increased January 1 of each year.year.

Report MTC CA – Change in Report MTC CA – Change in AmountAmount

Employer Paid Employer Paid Salary in Lieu of Salary in Lieu of

CompComp

Per 69L-56.002(22), F.A.C Per 69L-56.002(22), F.A.C (Definitions), the term, (Definitions), the term, “Employer Paid Salary in Lieu of “Employer Paid Salary in Lieu of Compensation”Compensation” means the means the employer paid the employee employer paid the employee salary, wages, or other salary, wages, or other remuneration for a period of remuneration for a period of disability for which the insurer disability for which the insurer would have otherwise been would have otherwise been obligated to pay indemnity obligated to pay indemnity benefits. benefits. This does not include This does not include the waiting week if the the waiting week if the employee was not disabled for employee was not disabled for 22 or22 or more days”.more days”.

EMPLOYER PAID EMPLOYER PAID BENEFITSBENEFITS

00/EP00/EP: EDI DWC-1 : EDI DWC-1 equivalentequivalent

This transaction This transaction represents that at the represents that at the time of filing, the ee time of filing, the ee has received has received only only salary in lieu of salary in lieu of compensation compensation from the from the employer.employer.


00/EP00/EP = The first report = The first report of payment of an of payment of an indemnity benefit other indemnity benefit other than a lump sum than a lump sum payment/settlement payment/settlement that has been paid by that has been paid by the employer the employer in lieu in lieu of compensationof compensation..


The Claim Administrator The Claim Administrator has not yet initiated its has not yet initiated its payment of indemnity payment of indemnity benefits. benefits.

Therefore, if by the 14th Therefore, if by the 14th day after the claim day after the claim administrator’s administrator’s knowledge of the injury, knowledge of the injury, the employee has the employee has received payment of received payment of “Days 1 thru 7” from his “Days 1 thru 7” from his employer and payment for employer and payment for “Days 8 thru 14” from “Days 8 thru 14” from the Claim Admin., this is the Claim Admin., this is notnot a ‘salary in lieu of a ‘salary in lieu of comp’ filing situation. comp’ filing situation.

In this case, the claim In this case, the claim administrator administrator maymay include include the 2xx benefit segment for the 2xx benefit segment for day 1 thru 7 on the 00/IP day 1 thru 7 on the 00/IP that is sent at “Day 14”; but that is sent at “Day 14”; but because salary was not paid because salary was not paid beyond the waiting week, it beyond the waiting week, it cannot be considered as cannot be considered as salary salary in lieu of in lieu of compensationcompensation (since that (since that period of time was not yet period of time was not yet payable at the time of payable at the time of filing .)filing .)


But if the 00/IP is sent late and at the But if the 00/IP is sent late and at the time of filing, the EE has been disabled time of filing, the EE has been disabled for 22 days or more, then the 2xx for 22 days or more, then the 2xx segment for employer paid salary for segment for employer paid salary for the waiting week (“Days 1 thru 7”) the waiting week (“Days 1 thru 7”) should be included on the IP (if the should be included on the IP (if the employer has not been reimbursed.) employer has not been reimbursed.)

Here, “Days 1 thru 7” paid by the Here, “Days 1 thru 7” paid by the Empr would constitute salary in lieu of Empr would constitute salary in lieu of compensation the Claim Administrator compensation the Claim Administrator would have otherwise had to pay.would have otherwise had to pay.


If BTC 2xx was not included If BTC 2xx was not included on the IP and it was later on the IP and it was later confirmed the employee confirmed the employee was disabled for 22 or was disabled for 22 or more days and the waiting more days and the waiting week is actually week is actually payable/reportable…payable/reportable…


……the addition of BTC 2xx the addition of BTC 2xx on the next R3 filing will be on the next R3 filing will be accepted without an accepted without an intervening MTC to intervening MTC to ‘introduce’ the 2xx benefits ‘introduce’ the 2xx benefits (where the Start Date of (where the Start Date of the 2xx benefit segment is the 2xx benefit segment is the earliest Start Date of the earliest Start Date of benefits reported.)benefits reported.)

A A 00/EP00/EP filing must filing must contain contain onlyonly 2xx benefits 2xx benefits segment(s). segment(s). BTC 240BTC 240 – Employer Paid – Employer Paid Unspecified Unspecified indemnity indemnity benefitsbenefitsBTC 250BTC 250 – Employer Paid TT – Employer Paid TT benefitsbenefitsBTC 270BTC 270 – Employer Paid TP – Employer Paid TP benefitsbenefits

……

Also valid, but not as Also valid, but not as typical:typical:

210210 – – Employer Paid DeathEmployer Paid Death benefitsbenefits230230 – Employer Paid – Employer Paid Impairment Impairment Income Income benefitsbenefits242242 – Employer Paid Voc – Employer Paid Voc Rehab Rehab (TT – R&E) (TT – R&E)251251 – – Employer Paid TT Employer Paid TT Catastrophic Catastrophic (80%) (80%)

Note: If the initial Note: If the initial payment of indemnity payment of indemnity benefits are paid by the benefits are paid by the Employer as a full Employer as a full settlement, BTC 524 settlement, BTC 524 would be reported via would be reported via MTC 00/PY (vs. 00/EP).MTC 00/PY (vs. 00/EP).


Benefit Type Codes 210, 230, 242, Benefit Type Codes 210, 230, 242, 250, 251, 270 should be used if 250, 251, 270 should be used if the Claim Admin. knows the the Claim Admin. knows the specific benefit type for which the specific benefit type for which the injured worker was paid salary in injured worker was paid salary in lieu of comp lieu of comp (Benefit Type Amount (Benefit Type Amount Paid is req’d for these BTC’s.)Paid is req’d for these BTC’s.)

If the specific benefit type is If the specific benefit type is unknown, BTC 240 should be used. unknown, BTC 240 should be used.

If the Claim Admin. If the Claim Admin. receives a penalty because receives a penalty because they they incorrectly filed an incorrectly filed an 00/IP vs. 00/EP00/IP vs. 00/EP (where the (where the Empr actually paid salary Empr actually paid salary in lieu of comp beyond the in lieu of comp beyond the waiting week and was waiting week and was notnot reimbursed), the Claim reimbursed), the Claim Admin. can file a Admin. can file a SROI 02SROI 02 to revise the ‘benefit to revise the ‘benefit picture’ to report the picture’ to report the earliest paid indemnity as earliest paid indemnity as 2xx. 2xx.

In this case, the In this case, the SROI SROI 0202 must include must include “MTC “MTC 02”02” in the Benefits in the Benefits segments. segments.

Otherwise, the EDI Otherwise, the EDI program will not detect program will not detect that the claim that the claim administrator is making administrator is making a change to the ‘benefit a change to the ‘benefit picture’. picture’.

After the Claim Admin. After the Claim Admin. confirms the confirms the MTC 02MTC 02 accepted, it should accepted, it should request a re-evaluation request a re-evaluation of their EDI DWC-1 filing of their EDI DWC-1 filing penalty that resulted penalty that resulted from the incorrect initial from the incorrect initial benefit information.benefit information.

If the If the MTC 02MTC 02 is the is the next next filing acceptedfiling accepted after the after the 00/IP, it will also update 00/IP, it will also update the the “Salary continued “Salary continued information” in information” in IntegratedIntegrated on the on the Disability Information Disability Information Tab. Tab.

If it is not the first If it is not the first accepted filing after the accepted filing after the 00/IP, the “salary in lieu 00/IP, the “salary in lieu of comp” info must be of comp” info must be updated manually by the updated manually by the EDI Team.EDI Team.

If the If the MTC 02MTC 02 is the is the next next accepted filingaccepted filing after the EDI after the EDI DWC-1,DWC-1, the following fields the following fields will be automaticallywill be automatically updated in the Division’s updated in the Division’s database and it is not database and it is not necessary to contact the necessary to contact the Claims EDI Team for Claims EDI Team for assistance in updating the assistance in updating the Division’s claim record prior Division’s claim record prior to requesting a to requesting a reevaluation by CPS: reevaluation by CPS:

Salary Cont’d in Lieu of Salary Cont’d in Lieu of Comp Ind.Comp Ind.

BTC 240 (Salary) Through BTC 240 (Salary) Through DateDate

Original BTC Original BTC

Claim Admin Knowledge of Claim Admin Knowledge of InjuryInjury

Benefit Payment Issue Date Benefit Payment Issue Date

Pen & Int Amount Paid in 1Pen & Int Amount Paid in 1stst Payment Payment (OBT’s 311 and (OBT’s 311 and 321)321)


Employer Paid Salary In Lieu Employer Paid Salary In Lieu of Compensation Indicator of Compensation Indicator (DN-273) should be reported (DN-273) should be reported as “Y” only if Employer is as “Y” only if Employer is currently currently paying salary in lieu paying salary in lieu of comp. of comp.

If Employer discontinues If Employer discontinues salary and Claim Admin. picks salary and Claim Admin. picks up payment, the Indicator up payment, the Indicator should be set to “N”.should be set to “N”.


If the Claim Administrator If the Claim Administrator reimburses the employer for reimburses the employer for salary paid in lieu salary paid in lieu compensation, and the compensation, and the employer is no longer paying employer is no longer paying salary, the salary, the Reduced Benefit Reduced Benefit Amount Code “R” – Amount Code “R” – ReclassificationReclassification should be sent should be sent to explain why the 2xx to explain why the 2xx Benefits segment is no longer Benefits segment is no longer on the current transaction.on the current transaction.


In situations where the In situations where the employer actually paid employer actually paid salary in lieu of comp (for salary in lieu of comp (for more than just the waiting more than just the waiting week), but the 00/IP was week), but the 00/IP was filed late and the Claim filed late and the Claim Admin. has already fully Admin. has already fully reimbursed the employer, reimbursed the employer, there will never be a 2xx there will never be a 2xx segment on any EDI segment on any EDI transaction. As a result, …transaction. As a result, …


… … the Claim Admin. will the Claim Admin. will need to supply other need to supply other documentation to satisfy documentation to satisfy the CPS Specialist that the CPS Specialist that salary was initially paid, salary was initially paid, after which an EDI Team after which an EDI Team member can update DWC’s member can update DWC’s system to reflect that the system to reflect that the initial payment of initial payment of indemnity was salary in lieu indemnity was salary in lieu of comp.of comp.

EMPLOYER PAID BENEFITSEMPLOYER PAID BENEFITSFor For paper DWC-1 or R1 EDI paper DWC-1 or R1 EDI filingsfilings: : If salary in lieu of comp was If salary in lieu of comp was incorrectly reported or mis-incorrectly reported or mis-coded when the record was coded when the record was first established, rather than first established, rather than sending Reduced Benefit sending Reduced Benefit Amount Code “R” to reconcile Amount Code “R” to reconcile the problem, contact the EDI the problem, contact the EDI Team to modify the initial Team to modify the initial filing information on the DWC filing information on the DWC database.database.


Recap:Recap: For R3 EDI filings:For R3 EDI filings: The claim administrator must The claim administrator must file an MTC 02 to report file an MTC 02 to report corrected initial payment corrected initial payment information. If there have information. If there have been intervening EDI been intervening EDI transactions that accepted, an transactions that accepted, an EDI Team member may need EDI Team member may need to manually update Integrated to manually update Integrated after confirming the after confirming the information on the accepted information on the accepted MTC 02.MTC 02.

For example, if the Claim For example, if the Claim Admin. needs to report a Admin. needs to report a corrected ‘Date First corrected ‘Date First Payment Mailed” Payment Mailed” and the and the 02 is 02 is notnot the next the next accepted filing,accepted filing, manual manual intervention will need to intervention will need to be requested of the EDI be requested of the EDI Team. Team.

Data Population Rules for Data Population Rules for Employer Paid BenefitsEmployer Paid Benefits

IP after EPIP after EPIf the Claim Admin. is making If the Claim Admin. is making its initial payment of indemnity its initial payment of indemnity (other than for a lump sum (other than for a lump sum payment/settlement) payment/settlement) afterafter the the employer has paid salary in lieu employer has paid salary in lieu of comp:of comp:

A SROI MTC A SROI MTC IPIP must be sent must be sent following the MTC following the MTC EPEP that that reportedreported the initial payment of, the initial payment of, or MTC Sx thator MTC Sx that reported the reported the suspension of, Employer Paid suspension of, Employer Paid benefits.benefits.

EP after IP

MTC EP must be filed after MTC EP must be filed after MTC IP if MTC IP if the Employer the Employer elects to pay indemnity elects to pay indemnity benefits, e.g., Impairment benefits, e.g., Impairment Income benefits, AFTER Income benefits, AFTER the Claim Administrator the Claim Administrator paid indemnity benefits.paid indemnity benefits.

EDI Contacts at EDI Contacts at [email protected]@myfloridacfo.comKaren Kubie (EDI Team Karen Kubie (EDI Team Administrator)Administrator)POC & Claims EDIPOC & Claims EDI [email protected]

Tonya GrangerTonya GrangerPOC & Claims EDI POC & Claims EDI [email protected]

Margaret ForsmanMargaret ForsmanClaims EDIClaims EDI [email protected]

R3 EDI Contacts at R3 EDI Contacts at DWCDWCDebra LeeDebra LeeClaims EDIClaims EDI [email protected]

Laura CotnerLaura CotnerClaims & POC EDIClaims & POC EDI [email protected]

Vickie FieldsVickie FieldsClaims EDI Claims EDI [email protected]

Amanda LoveAmanda LoveClaims EDIClaims EDI [email protected]

Florida Division of Workers’ Compensation Claims EDI Release 3 Update August 2009.

Documents

Transcript of Florida Division of Workers’ Compensation Claims EDI Release 3 Update August 2009.