Electronic First Reports of Injury or Illness (EDI DWC-1 Equivalent)

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Electronic First Electronic First Reports of Injury Reports of Injury or Illness or Illness (EDI DWC-1 Equivalent)(EDI DWC-1 Equivalent)

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Electronic First Report of Injury Electronic First Report of Injury or Illnessor Illness

(EDI DWC-1 Equivalent)(EDI DWC-1 Equivalent)

The most typical EDI DWC-1 The most typical EDI DWC-1

filing is:filing is:

FROI 00 + SROI IPFROI 00 + SROI IP

Required to be filed with DWC Required to be filed with DWC per Rule 69L-56.301, F.A.C.per Rule 69L-56.301, F.A.C.

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A A SROI IPSROI IP sent in sent in combination with a FROI combination with a FROI 00 reports the Claim 00 reports the Claim Administrator’s Administrator’s initial initial paymentpayment on a lost time on a lost time claim. claim.


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Electronic First Reports of Electronic First Reports of Injury or IllnessInjury or Illness are also are also represented by the represented by the following other EDI DWC-1 following other EDI DWC-1 equivalent MTC’s to report equivalent MTC’s to report lost time claims and are also lost time claims and are also required to be filed with required to be filed with DWC:DWC:

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Other SROI’s Sent with FROI Other SROI’s Sent with FROI 00:00:

CDCD – Compensable Death with – Compensable Death with no no Known Known Dependents/PayeesDependents/Payees EPEP – Employer Paid – Employer Paid PDPD – Partial Denial – Partial Denial PYPY – Lump Sum – Lump Sum Payment/SettlementPayment/Settlement VEVE – Volunteer (covered – Volunteer (covered under FL law)under FL law)

FROI OnlyFROI Only 04 – Full (Total Denial)04 – Full (Total Denial)

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Please note that we will Please note that we will be deferring discussion on be deferring discussion on AU/AP EDI DWC-1 AU/AP EDI DWC-1 equivalents and other equivalents and other Acquired Claims issues Acquired Claims issues until tomorrow. until tomorrow.


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Pop Quiz: Pop Quiz:

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If a If a Compensable Compensable Volunteer also Volunteer also had non-had non-volunteer volunteer concurrent concurrent employment…employment…

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……What MTC’s What MTC’s should be sent should be sent to report the to report the

Electronic First Electronic First Report of Injury Report of Injury

or Illness?or Illness?

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Answer:Answer:

FROI 00 + SROI FROI 00 + SROI IPIP

To report payment of To report payment of indemnity based on indemnity based on

wages from concurrent wages from concurrent employment.employment.

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SROI MTCSROI MTC IP (Initial IP (Initial Payment)Payment)

The SROI MTC The SROI MTC IPIP (Initial (Initial Payment) transaction Payment) transaction implies that indemnity implies that indemnity benefits are benefits are on-goingon-going until until suspended.suspended.

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POP QUIZ:POP QUIZ:Conversely, what Conversely, what

transaction/MTC transaction/MTC is used is used when the first when the first payment on payment on the claim is the claim is for a for a one-timeone-time lump lump sum payment or sum payment or settlement?settlement?

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ANSWER: ANSWER:

MTC 00/PYMTC 00/PY

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Lump sum Lump sum payments / payments / settlements will be settlements will be discussed in more discussed in more detail during detail during tomorrow’s training.tomorrow’s training.

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Another POP Another POP Quiz:Quiz:

When is the 00/IP When is the 00/IP considered considered timely filed with timely filed with the Division?the Division?

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Answer: Answer: It depends – It depends –

For initial payments For initial payments other other than TP, IB or settlement,than TP, IB or settlement, if if LT is immediate and LT is immediate and continuouscontinuous,, 00/IP is timely 00/IP is timely filed when it is received by filed when it is received by DWC and assigned ‘TA’ on DWC and assigned ‘TA’ on or before or before 21 days21 days after after Claim Admin.’s knowledge Claim Admin.’s knowledge of the injury.of the injury.

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If LT is delayed or non-If LT is delayed or non-consecutiveconsecutive,, 00/IP is 00/IP is timely filed with DWC when timely filed with DWC when it is received by DWC and it is received by DWC and assigned ‘TA’ on or before assigned ‘TA’ on or before 13 days13 days after the Claim after the Claim Admin.’s knowledge of the Admin.’s knowledge of the 88thth day of disability day of disability (a/k/a (a/k/a Initial Date of Lost Time.)Initial Date of Lost Time.)

Electronic First Report of Injury Electronic First Report of Injury or Illnessor IllnessAnswer (cont’d):Answer (cont’d):

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To avoid late filing To avoid late filing penalties, the EDI First penalties, the EDI First Report of Injury or Illness Report of Injury or Illness (00/IP or equivalent) (00/IP or equivalent) should be triggered should be triggered immediately upon the immediately upon the Claim Admin.’s Claim Admin.’s disposition of the disposition of the claim (payment or claim (payment or denial.)denial.)

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

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The specific timeframes The specific timeframes for the timely submission for the timely submission of the 00/IP and other of the 00/IP and other required electronic filings required electronic filings are set out in are set out in Rule 69L-56, Rule 69L-56, F.A.C., the Event TableF.A.C., the Event Table, , and the and the MTC Filing MTC Filing InstructionsInstructions document (all document (all available on the Claims EDI available on the Claims EDI web page.)web page.)


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For FROI 00 with SROI IP For FROI 00 with SROI IP combos (or equivalent), the combos (or equivalent), the FROI FROI Date and Time Date and Time Transmission SentTransmission Sent on the on the Batch Header must be Batch Header must be PRIORPRIOR to the SROI Date/Time to the SROI Date/Time Transmission Sent.Transmission Sent.

If the SROI is received and If the SROI is received and processed ahead of the FROI, processed ahead of the FROI, both will reject.both will reject.


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Also, for processing FROI Also, for processing FROI 00/SROI IP combos (or 00/SROI IP combos (or equivalent), the equivalent), the Match DataMatch Data in in the FROI to SROI column of the the FROI to SROI column of the Edit Matrix Match Data Tab, Edit Matrix Match Data Tab, must match exactly from FROI must match exactly from FROI to SROI. to SROI.


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If the FROI 00 and If the FROI 00 and SROI IP (or equivalent) SROI IP (or equivalent) do not combine as do not combine as required in the required in the previous 2 slides, the previous 2 slides, the error messages in this error messages in this case will be confusing…case will be confusing…


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… … because if they do not because if they do not ‘combo’, they are processed ‘combo’, they are processed separately as individual FROI separately as individual FROI & SROI filings, which have & SROI filings, which have different different requirements/errors.requirements/errors.

Example Error:Example Error: “JCN Missing” “JCN Missing” - Even though JCN is not - Even though JCN is not required for an 00/IP, it required for an 00/IP, it ISIS required for a standalone required for a standalone SROI IP. SROI IP.


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Now let’s Now let’s take a take a detailed look detailed look at the at the BenefitsBenefits Segment on Segment on the SROI the SROI

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The The BenefitsBenefits segment on the segment on the SROI consists of the following SROI consists of the following data elements (DN’s):data elements (DN’s):

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Although you may not see Although you may not see this exact layout of data this exact layout of data elements on your own elements on your own system/screensystem/screen, your your company’s program or company’s program or vendor software should vendor software should adhere to the submission adhere to the submission requirements covered in requirements covered in the next several slides.the next several slides.

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SROI SROI BENEFITSBENEFITS SegmentSegment

The The BenefitsBenefits segment of segment of the SROI transaction is the SROI transaction is used to report used to report indemnityindemnity benefits that are currently benefits that are currently being paid or have been being paid or have been paid by the current Claim paid by the current Claim Administrator.Administrator.

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If you have paid If you have paid indemnity, a indemnity, a BenefitsBenefits Segment for Segment for EVERYEVERY indemnity Benefit Type indemnity Benefit Type paid should be included paid should be included on on EVERYEVERY SROI SROI transaction.transaction.

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Exception:Exception: A A Benefit Type Benefit Type CodeCode (or Other Benefit Type (or Other Benefit Type Code) previously reported Code) previously reported may be left off the current may be left off the current transaction if its transaction if its disappearance is ‘explained’ disappearance is ‘explained’ by the presence of certain by the presence of certain other codes: other codes:

• Reduced Benefit Amount Reduced Benefit Amount Code,Code,• Recovery CodeRecovery Code (will discuss in (will discuss in detail later.)detail later.)

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Correspondingly, the Correspondingly, the Benefit Type AmountBenefit Type Amount (and (and Other Benefit Type Other Benefit Type Amount) reported on the Amount) reported on the current transaction must current transaction must not be less than the not be less than the $$ previously reported unless previously reported unless a a Reduced Benefit Amount Reduced Benefit Amount CodeCode oror Recovery CodeRecovery Code is is reported.reported.

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All Data elements All Data elements contained in thecontained in the SROI SROI

BENEFITSBENEFITS SegmentSegment (e.g., Gross/Net Weekly Amounts, (e.g., Gross/Net Weekly Amounts,

Start Date)Start Date) are defined in are defined in thethe Data Data

Dictionary, Section 6Dictionary, Section 6 of IAIABC R3 of IAIABC R3

Implementation Implementation Guide.Guide.

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The most current version of The most current version of the the IAIABC R3 IAIABC R3 Implementation GuideImplementation Guide is is located at located at IAIABC.orgIAIABC.org. .

The Guide is available for The Guide is available for download FREE of charge to download FREE of charge to any employee of an IAIABC any employee of an IAIABC EDI Member. If you are not EDI Member. If you are not an EDI Member, you can an EDI Member, you can purchase the Guide for $95. purchase the Guide for $95.

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When and how data When and how data should be populated in the should be populated in the SROI SROI Benefits Benefits segment is segment is in the in the Variable Segment Variable Segment Population Rules, Section Population Rules, Section 44 of the IAIABC R3 Guide. of the IAIABC R3 Guide.

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Variable Variable Segment Segment

Population Population Rules for the Rules for the SROI SROI BenefitsBenefits

SegmentSegment

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Only Only oneone BenefitsBenefits segment segment per Benefitper Benefit Type CodeType Code (BTC) is allowed(BTC) is allowed..

The applicable BTC The applicable BTC mustmust be be included when a Benefits included when a Benefits segment is present in the segment is present in the transaction.transaction.

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SROI SROI BENEFITSBENEFITS SegmentSegment The The BenefitsBenefits segment is segment is

populated with the populated with the 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).

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Exception:Exception: Benefit Payment Issue Benefit Payment Issue Date. Date.

If the 00/IP is filed late and If the 00/IP is filed late and multiple payments have been multiple payments have been issued, the Benefit Payment Issue issued, the Benefit Payment Issue Date for the IP should correspond Date for the IP should correspond to the to the initial paymentinitial payment,, not the not the current payment.current payment.

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When an MTC is When an MTC is required to be sent at required to be sent at the ‘Benefits level’ on the ‘Benefits level’ on the SROI (i.e., in the the SROI (i.e., in the BenefitsBenefits segment segment itself), the same MTC itself), the same MTC must be sent at the must be sent at the ‘Claim level’ on the ‘Claim level’ on the SROI.SROI.

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Example:Example: IP sent with 050 IP sent with 050 followed by 02 to change followed by 02 to change something in the 050 something in the 050 Benefits segment – Do not Benefits segment – Do not leave MTC IP in 050 Benefits leave MTC IP in 050 Benefits segment on the 02. segment on the 02.

The MTC in the Benefits The MTC in the Benefits segment must match the segment must match the MTC on the transaction.MTC on the transaction.

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SROI SROI BENEFITSBENEFITS SegmentSegment0 (zero) Benefits0 (zero) Benefits Segments Segments are allowed for the following are allowed for the following SROI MTC’s:SROI MTC’s:

• CDCD - Compensable Death - Compensable Death with No Dependents; with No Dependents;

• VEVE - Volunteers; - Volunteers;

• PDPD - - Indemnity Only (Partial) Indemnity Only (Partial) Denials.Denials.

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0 (zero) Benefits 0 (zero) Benefits Segments are also Segments are also allowed if allowed if Reduced Reduced Benefit Amount CodeBenefit Amount Code is is reported as:reported as:

• SS (Settlement on Another (Settlement on Another DOI) or DOI) or

• NN (No Money Settlement). (No Money Settlement).

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Reduced Benefit Reduced Benefit Amount Code “N”Amount Code “N” was was recently appropriated recently appropriated by the IAIABC for by the IAIABC for reporting settlements reporting settlements with no dollars paid, with no dollars paid, such as those due to such as those due to waiver of a lien. waiver of a lien.

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Where Where Reduced Reduced Benefit Amount Code Benefit Amount Code “N”“N” is reported, a is reported, a BenefitsBenefits segment will segment will only be present on the only be present on the transaction if indemnity transaction if indemnity benefits had been paid benefits had been paid for the DOI prior to the for the DOI prior to the settlement. settlement.

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0 (zero) Benefits 0 (zero) Benefits Segments are also Segments are also allowed if allowed if OBT 430 OBT 430 (Unallocated Indemnity)(Unallocated Indemnity) is reported and the is reported and the acquiring Claim Admin. acquiring Claim Admin. has not yet issued its has not yet issued its initial payment at the initial payment at the time of filing time of filing (e.g., SA.)(e.g., SA.)

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““Event”Event”

BenefitsBenefits

SegmentsSegments

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Sweep DN’sSweep DN’sEvent DN’sEvent DN’s

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““EVENT”EVENT” BENEFITS BENEFITS SEGMENT SEGMENT RULESRULES

A Claim Administrator A Claim Administrator must be prepared to must be prepared to send send all data elementsall data elements in the in the BenefitsBenefits Segment as required Segment as required per the “Benefits per the “Benefits Segment Req” Segment Req” worksheet of FL’s worksheet of FL’s Element Requirement Element Requirement Table.Table.

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Exception:Exception: If the ‘Date Claim If the ‘Date Claim Admin. Had Knowledge of the Admin. Had Knowledge of the Injury’ preceded its R3 “go Injury’ preceded its R3 “go live” date,live” date, Gross and Net Gross and Net Amounts and Effective Dates, Amounts and Effective Dates, and Benefit Period Start and and Benefit Period Start and Through Dates are Through Dates are NOTNOT required (nor edited), even required (nor edited), even for Event for Event BenefitsBenefits Segments. Segments.

(Since these data elements were not (Since these data elements were not previously required on legacy paper previously required on legacy paper or R1 filings)or R1 filings)

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Note (exception to the Note (exception to the exception):exception):

1.1.Benefit Period Start Date is Benefit Period Start Date is required for BTC 020 & BTC required for BTC 020 & BTC 240, and240, and

2.2.Benefit Period Through Benefit Period Through Date is required for BTC Date is required for BTC 240240

……even ieven if the ‘Date Claim f the ‘Date Claim Admin. Had Knowledge of Admin. Had Knowledge of the Injury’ preceded its R3 the Injury’ preceded its R3 “go live” date.“go live” date.

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““EVENT”EVENT” BENEFITS BENEFITS SEGMENT SEGMENT RULESRULESMTCMTC

When a Benefit Type is When a Benefit Type is starting, being changed from starting, being changed from or to another benefit type or to another benefit type being suspended; or being suspended; or reporting a lump sum reporting a lump sum payment for Benefit Type payment for Benefit Type Code 0XX, Code 0XX, MTCMTC must be sent must be sent in the “Event” in the “Event” BenefitsBenefits segment for the segment for the affectedaffected Benefit(s).Benefit(s).

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SROI SROI BenefitsBenefits segmentsegment

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If MTC is sent in If MTC is sent in the Benefits the Benefits segment, it will segment, it will be edited as an be edited as an “Event” Benefits “Event” Benefits segment. segment.

SROI SROI BenefitsBenefits segmentsegment

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MTCMTC is reported in the is reported in the BenefitsBenefits segment segment when a benefit type is being when a benefit type is being initiated or terminated initiated or terminated (AB, AP, (AB, AP, CB, CA, S1-8, P7, EP, ER, IP, or RB).CB, CA, S1-8, P7, EP, ER, IP, or RB).

““EVENT”EVENT” BENEFITS BENEFITS SEGMENT SEGMENT EXAMPLEEXAMPLE

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All All BenefitsBenefits data elements are data elements are populated.populated.Benefit Payment Issue DateBenefit Payment Issue Date is is required for an IP, and certain required for an IP, and certain AP’s, & PY’s (0xx).AP’s, & PY’s (0xx).

““EVENT”EVENT” BENEFITS BENEFITS SEGMENT SEGMENT EXAMPLEEXAMPLE

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BENEFIT PERIOD START DATE – BENEFIT PERIOD START DATE – DN0088DN0088

For all MTC’s that are For all MTC’s that are initiating or reinstating a initiating or reinstating a Benefit Type Code (AB, IP, RB, Benefit Type Code (AB, IP, RB, EP, ER, and CB): The EP, ER, and CB): The Benefit Benefit Period Start DatePeriod Start Date is the first is the first date of the date of the uninterrupteduninterrupted period of benefit payments period of benefit payments that corresponds to the that corresponds to the Benefit Type Code.Benefit Type Code.

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BENEFIT PERIOD START DATE – BENEFIT PERIOD START DATE – DN0088DN0088

For all MTC’s that are For all MTC’s that are NOTNOT initiating or reinstating a Benefit initiating or reinstating a Benefit Type Code (S1-8, P7, CA, PY with Type Code (S1-8, P7, CA, PY with BTC 0XX): The BTC 0XX): The Benefit Period Benefit Period Start DateStart Date is the is the earliest dateearliest date for for that Benefit Type Code regardless that Benefit Type Code regardless of whether or not multiple benefit of whether or not multiple benefit periods have been paid for that periods have been paid for that Benefit Type Code.Benefit Type Code.

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For MTC AP and all For MTC AP and all subsequent MTC’s filed on subsequent MTC’s filed on acquired claims, the acquired claims, the Benefit Period Start DateBenefit Period Start Date is is the first date of the the first date of the uninterrupted period of uninterrupted period of benefit payments benefit payments by the by the acquiring Claim acquiring Claim AdministratorAdministrator that that corresponds to the Benefit corresponds to the Benefit Type Code.Type Code.

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Recap:Recap: If you have paid If you have paid indemnity, a indemnity, a BenefitsBenefits Segment for Segment for EVERYEVERY indemnity Benefit Type indemnity Benefit Type paid should be included paid should be included on on EVERYEVERY SROI SROI transaction (unless RBAC transaction (unless RBAC or Recovery applicable.)or Recovery applicable.)

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An An MTCMTC previously previously reported reported at the at the Benefit levelBenefit level that is that is not applicable to the not applicable to the currentcurrent MTC being MTC being reported should reported should notnot be left in the Benefits be left in the Benefits segment … segment …

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

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Recap:Recap: In FL, if In FL, if MTCMTC is is reported reported in any Benefits in any Benefits segmentssegments, the segment will , the segment will be considered an be considered an “Event”“Event” BenefitsBenefits segment, segment, which means which means allall “Event”“Event” BenefitsBenefits segment data segment data elements will be elements will be required to be required to be present…present…

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… … For eFor example:

TT (050) previously paid;TT (050) previously paid;

Benefits subsequently Benefits subsequently changed from TP (070) to changed from TP (070) to IB (030).IB (030).

MTC CB is required in the MTC CB is required in the 070 (TP) and the 030 (IB) 070 (TP) and the 030 (IB) segments. These are both segments. These are both EventEvent BenefitsBenefits segments… segments…

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Example Example (cont’d):(cont’d):

… … If the MTC is also If the MTC is also sent in the ‘old’ 050 TT sent in the ‘old’ 050 TT segment, it too will be segment, it too will be edited as an edited as an EventEvent Benefits Benefits Segment, and Segment, and therefore all data will therefore all data will be required and be required and edited. edited.

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““Sweep” Sweep”

BenefitsBenefits

SegmentsSegments

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““SWEEP”SWEEP” BENEFITS BENEFITS SEGMENT SEGMENT RULESRULES

A A “Sweep”“Sweep” Benefits Benefits Segment(s) must be sent in Segment(s) must be sent in addition to any addition to any “Event”“Event” Benefit Segment(s), for Benefit Segment(s), for different Benefit Type Code(s) different Benefit Type Code(s) previously been paid but not previously been paid but not part of the “Event” that is part of the “Event” that is currently being reported.currently being reported.

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• 0202 ((onlyonly if if BenefitsBenefits segment data is segment data is not changing and you don’t want not changing and you don’t want DWC’s program to edit any BTC’s), DWC’s program to edit any BTC’s),

• 0404• PDPD• PYPY reporting BTC reporting BTC 5XX5XX

• Periodics: Periodics: SASA & & FNFN

MTC is MTC is NOTNOT included in the included in the BenefitsBenefits Segment for the Segment for the following following “Sweep”“Sweep” MTC’s: MTC’s:

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If the MTC is sent in a If the MTC is sent in a “Sweep”“Sweep” BenefitsBenefits segment, segment, the the Benefits Benefits Segment will Segment will be edited as an “Event” be edited as an “Event” BenefitsBenefits segment. segment. In this case, certain data In this case, certain data elements will be expected elements will be expected to be present, and if not to be present, and if not sent, will result in a sent, will result in a rejection.rejection.

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““SWEEP”SWEEP” BENEFITS BENEFITS SEGMENT SEGMENT RULESRULESExample: Example:

00/IP00/IP filed to report payment of TT; filed to report payment of TT;

CBCB filed to report change in benefits filed to report change in benefits from TT to TP; from TT to TP;

This CB reflects 2 Event This CB reflects 2 Event BenefitsBenefits

segments for TT and TP segments for TT and TP (each contains (each contains

‘MTC CB’). ‘MTC CB’). (continued next slide)…(continued next slide)…

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““SWEEP”SWEEP” BENEFITS BENEFITS SEGMENT SEGMENT RULESRULES Another Another CBCB is filed to report is filed to report

change from TP to IB; this CB change from TP to IB; this CB also reflects 2 Event also reflects 2 Event BenefitsBenefits for for TP and IBTP and IB (again, each segment (again, each segment would contain ‘MTC CB’).would contain ‘MTC CB’).

The prior TT The prior TT Benefits Benefits Segment is Segment is a a “Sweep”“Sweep” BenefitsBenefits Segment(s) Segment(s) that should be sent along with that should be sent along with the two the two “Event”“Event” Benefits Benefits SegmentsSegments (and would (and would not not contain MTC CB).contain MTC CB).

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Benefit Type Code Benefit Type Code Benefit Period Start Date Benefit Period Start Date Benefit Period Through Date Benefit Period Through Date Benefit Type Claim Weeks Benefit Type Claim Weeks Benefit Type Claim Days Benefit Type Claim Days Benefit Type Amount PaidBenefit Type Amount Paid

A A “Sweep”“Sweep” BenefitsBenefits Segment Segment must must includeinclude the following data elements: the following data elements:

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MTC MTC (if sent would imply Event Segment)(if sent would imply Event Segment)

Gross Weekly AmountGross Weekly Amount Gross Weekly Amount Effective Gross Weekly Amount Effective

DateDate Net Weekly AmountNet Weekly Amount Net Weekly Amount Effective Net Weekly Amount Effective

DateDate Benefit Payment Issue DateBenefit Payment Issue Date

A A “Sweep”“Sweep” BenefitsBenefits Segment Segment will will NOTNOT include the following:include the following:

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For MTC’s (on non-acquired claims) For MTC’s (on non-acquired claims) that are not initiating or reinstating a that are not initiating or reinstating a Benefit Type Code (PY with BTC 5XX, Benefit Type Code (PY with BTC 5XX, FN, SA, and 04 & PD if preceded by FN, SA, and 04 & PD if preceded by payment): The payment): The Benefit Period Start Benefit Period Start DateDate is the is the earliest dateearliest date for that for that Benefit Type Code, regardless of Benefit Type Code, regardless of whether multiple benefit periods have whether multiple benefit periods have been paid for that Benefit Type Code.been paid for that Benefit Type Code.


BENEFIT PERIOD START DATE BENEFIT PERIOD START DATE

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MTCMTC

When an MTC applies to the claim When an MTC applies to the claim as a whole, the MTC is sent at the as a whole, the MTC is sent at the Claim LevelClaim Level only (A49) and is not only (A49) and is not populated in the Benefits segment.populated in the Benefits segment.

If MTC sent it If MTC sent it will be edited will be edited as an Event as an Event segment.segment.

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Sweep DN’sSweep DN’s

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Questions?

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Caveats Caveats and and

Tips for Tips for Successfully Successfully Filing 00/IP Filing 00/IP

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If you receive the error,If you receive the error,

BOTH FROI & SROI MUST BOTH FROI & SROI MUST PASS EDITS TO ACCEPT PASS EDITS TO ACCEPT

FILINGFILING

this means there was a this means there was a fatal error on either the fatal error on either the FROI or SROI, so you must FROI or SROI, so you must correct the error(s) and re-correct the error(s) and re-send send BOTHBOTH the FROI and the FROI and SROI.SROI.

Caveats and Tips for Successfully Caveats and Tips for Successfully Filing 00/IPFiling 00/IP

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We are also still seeing We are also still seeing the following errors the following errors with great frequency:with great frequency:

• NO MATCHING FIRST REPORTNO MATCHING FIRST REPORT

• NO MATCHING SUBSEQUENT NO MATCHING SUBSEQUENT REPORTREPORT


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These rejections are These rejections are occurring when the FROI occurring when the FROI andand SROI are not received SROI are not received and processed on the and processed on the same day or when the same day or when the FROI/SROI did not FROI/SROI did not ‘match’, when a ‘combo’ ‘match’, when a ‘combo’ filing is required.filing is required.


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It is critical these It is critical these errors are resolved errors are resolved asap to avoid any asap to avoid any resulting penalty resulting penalty for late filing with for late filing with

the Division.the Division.


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Other Errors Other Errors Occurring on Occurring on

00/IP 00/IP FilingsFilings

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We have been receiving We have been receiving DOB’s yielding extremely DOB’s yielding extremely young ages, which upon young ages, which upon further investigation, were further investigation, were determined to be incorrect. determined to be incorrect.

Currently, our program Currently, our program generates a TA-FL if the generates a TA-FL if the DOB sent yields an age less DOB sent yields an age less than 13 years or greater than 13 years or greater than 85 years…than 85 years…


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… … in which case the suspect in which case the suspect DOB is not loaded to our DOB is not loaded to our database and you are expected database and you are expected to either revise your DOB or to either revise your DOB or confirm if the DOB is correct. confirm if the DOB is correct.

But because the IAIABC But because the IAIABC standard requires ‘DOB < = standard requires ‘DOB < = DOI’, our program has DOI’, our program has not not been rejecting filings where the been rejecting filings where the

DOB defaulted to DOI,DOB defaulted to DOI, therefore therefore yielding an yielding an age of ‘0’. So, …age of ‘0’. So, …


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… … Beginning 4/30/10, DWC’s Beginning 4/30/10, DWC’s program will now program will now rejectreject filings filings where the DOB (at the time of where the DOB (at the time of the DOI) yields an the DOI) yields an age < = 5, to minimize age < = 5, to minimize

truly incorrect DOB’s truly incorrect DOB’s and and later follow-later follow-up with our TP’s. up with our TP’s.

Note:Note: DWC already returns a DWC already returns a TRTR if the DOB yields an age of if the DOB yields an age of 100 years or more. 100 years or more.


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Discrepancies in the Discrepancies in the EMPLOYEE NAMEEMPLOYEE NAME will be will be brought to your attention brought to your attention for correction in your for correction in your database (Employee First database (Employee First and Last Name are and Last Name are included in our program’s included in our program’s match data criteria.)match data criteria.)


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DWC is statutorily required to DWC is statutorily required to collect the collect the EE’s address,EE’s address, so our so our program initially precludes the program initially precludes the acceptance of filings where the acceptance of filings where the EE’s address = EMPLR’s address. EE’s address = EMPLR’s address.

• This edit is included in FL’s This edit is included in FL’s requirements in part because requirements in part because EAO sends an initial contact EAO sends an initial contact letter to the EE; therefore a letter to the EE; therefore a proper address is needed proper address is needed (which is typically not the (which is typically not the employer’s address.) employer’s address.)


88

• Filings that reject for this Filings that reject for this ‘error’ can be re-loaded by ‘error’ can be re-loaded by DWC upon receipt of DWC upon receipt of confirmation the EE’s and confirmation the EE’s and EMPLR’s address are indeed EMPLR’s address are indeed one in the same. one in the same.

• Prior to re-loading, the EDI Prior to re-loading, the EDI Team will ‘Google’ the EE’s Team will ‘Google’ the EE’s address and compare it to the address and compare it to the nature of the employer’s nature of the employer’s business and the EE’s business and the EE’s occupation to determine if the occupation to determine if the addresses are likely the same.addresses are likely the same.


89

In addition to a In addition to a BenefitsBenefits segment, FL also requires a segment, FL also requires a PaymentPayment segment on the IP segment on the IP because we need to record because we need to record the exact amount of the the exact amount of the Claim Admin.’s initial Claim Admin.’s initial payment of indemnity payment of indemnity (helpful to CPS.)(helpful to CPS.)


90

The R3 The R3 Payment Payment Issue DateIssue Date (a/k/a (a/k/a “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 actually mailed mailed (or (or left the Claim left the Claim Administrator’s Administrator’s control.)control.)


91

If you are reporting the If you are reporting the day the check is issued day the check is issued by your system, you by your system, you must ensure the check must ensure the check is actually mailed that is actually mailed that same day. same day.

The audit team The audit team WILLWILL validate.validate.


92

If filing late, or re-If filing late, or re-sending an 00/IP that sending an 00/IP that previously rejected, previously rejected, AND another AND another indemnity check has indemnity check has been issued since the been issued since the first installment…first installment…


93

… … the the Benefit Type Benefit Type Amount PaidAmount Paid should should reflect the reflect the total total cumulative amount of cumulative amount of ALL indemnity paid ALL indemnity paid to dateto date at the time of at the time of filing, not just the filing, not just the amount of the initial amount of the initial indemnity (IP) check.indemnity (IP) check.


94

However, theHowever, the PaymentPayment Segment should only Segment should only reflect the initial payment reflect the initial payment information, not information, not subsequent payment subsequent payment information. information.

Again, this is the segment Again, this is the segment from which DWC loads from which DWC loads ‘Date First Payment ‘Date First Payment Mailed’ to its claims Mailed’ to its claims system, utilized by CPS.system, utilized by CPS.


95

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


96

… … 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 and not reportable and not reportable until the employee until the employee has been disabled at has been disabled at least 8 days.least 8 days.


97

Accuracy of Claim Accuracy of Claim Type is extremely Type is extremely important.important. Claim Claim Type must be correct Type must be correct in relation to the in relation to the Initial Date Disability Initial Date Disability Began and RTW Began and RTW information…information…


98

• If disability is NOT If disability is NOT immediate and continuousimmediate and continuous (broken periods or delayed dis),(broken periods or delayed dis), Claim TypeClaim Type must be must be “L”“L” (Became LT),(Became LT), which requires which requires “Initial Date of Lost Time”“Initial Date of Lost Time” and “Date Claim and “Date Claim Administrator Had Administrator Had Knowledge of Lost Time”. Knowledge of Lost Time”.

•Also, if the Employee RTW’d Also, if the Employee RTW’d within the waiting wk, Claim within the waiting wk, Claim Type must = L. Type must = L.


99

Claim TypeClaim Type (continued): (continued):

• If the Initial Date If the Initial Date Disability Began is the Disability Began is the same as the DOI (or DOI + same as the DOI (or DOI + 1) and the Employee has 1) and the Employee has not RTW’d, Claim Type not RTW’d, Claim Type must be must be ‘I’‘I’ (LT/indemnity (LT/indemnity immediate and immediate and continuous); continuous);


100

• If Claim Type was If Claim Type was incorrectly sent as “I”incorrectly sent as “I” but but should have been “L”, should have been “L”, even if “8th Day” data was even if “8th Day” data was included on the filing, such included on the filing, such will will notnot be be edited/loaded and edited/loaded and therefore not available to therefore not available to CPS. CPS. • The filing will be treated The filing will be treated as a straight lost time case as a straight lost time case (and you may need to file 02 to (and you may need to file 02 to have penalty revoked.) have penalty revoked.)


101

Pop Quiz: Pop Quiz:

102

What does the data What does the data element , element , ‘Initial Date of Lost ‘Initial Date of Lost Time’Time’ represent? represent?

103

ANSWER:ANSWER:

‘‘Employee’sEmployee’s 88thth Day Day of Disabilityof Disability’’

104

‘‘Initial Date of Lost Initial Date of Lost Time’Time’ is is notnot the same as the same as ‘Initial Date Disability ‘Initial Date Disability Began’. Began’.

These are two These are two different data different data

elements.elements.


105

Since the ‘Initial Date of Since the ‘Initial Date of Lost Time’ equates to the Lost Time’ equates to the 88thth day of disability, it day of disability, it must always be sent as a must always be sent as a date that is at least equal date that is at least equal to, or more than the Initial to, or more than the Initial Date Disability Began + 7 Date Disability Began + 7 days.days.


106

If the amount of time If the amount of time represented by the Start represented by the Start and Through Dates is and Through Dates is more than the amount of more than the amount of Weeks/Days reported, a Weeks/Days reported, a Non-Consecutive Period Non-Consecutive Period CodeCode will be expected. will be expected.

Note:Note: This code is not required This code is not required on a SROI MTC RB, or an ‘IB only’ on a SROI MTC RB, or an ‘IB only’ First Report. First Report.


107

Non-Consecutive Period Non-Consecutive Period CodeCode is often is often misunderstood. misunderstood.

• It is used to report if the It is used to report if the disability period for a disability period for a particular benefit type particular benefit type was non-consecutive, i.e., was non-consecutive, i.e., “broken” periods of “broken” periods of disabilitydisability within one within one Benefit TypeBenefit Type..


108

Reduced Benefit Amount Reduced Benefit Amount CodeCode – DWC’s program – DWC’s program now precludes this code now precludes this code from being sent on the first from being sent on the first report of injury (since it is report of injury (since it is never applicable on the never applicable on the initial payment.)initial payment.)


109

If 00/EP is initially If 00/EP is initially reported, after which a reported, after which a SROI IP is sent to report SROI IP is sent to report the Claim Admin.'s Initial the Claim Admin.'s Initial Payment of indemnity, Payment of indemnity, Reduced Benefit Amount Reduced Benefit Amount Code “R”Code “R” must be must be reported if BTC 2xx is not reported if BTC 2xx is not included on the SROI IP.included on the SROI IP.


110

We will discuss We will discuss Reduced Benefit Reduced Benefit Amount CodesAmount Codes in in more detail relative more detail relative to other SROI MTC’s to other SROI MTC’s later in the training. later in the training.


111

We continue to see errors We continue to see errors involving the involving the Net Weekly Net Weekly AmountAmount sent on the IP (as well sent on the IP (as well as other SROI’s). as other SROI’s).

• Remember, the Net Weekly Remember, the Net Weekly Amount should represent the Amount should represent the weekly rate at which a weekly rate at which a particular BTC is being paid. particular BTC is being paid.

• It is It is NOT necessarilyNOT necessarily the the Comp Rate.Comp Rate.


112

If you are receiving errors If you are receiving errors for:for:

NETNET << FL CALC GROSS FL CALC GROSS AMT AMT MINUS ADJ/CREDIT MINUS ADJ/CREDIT AMTSAMTS

This means the Net Weekly This means the Net Weekly Amount you are sending is Amount you are sending is not in line with the amount not in line with the amount calculated by DWC’s calculated by DWC’s program (within 5¢). program (within 5¢).


113

•The The ‘FL CALC GROSS AMT’‘FL CALC GROSS AMT’ is determined for each BTC is determined for each BTC in accordance with the in accordance with the Average Wage reported on Average Wage reported on the SROI; our program next the SROI; our program next subtracts any weekly subtracts any weekly adjustment or credit adjustment or credit amount reported (if still amount reported (if still being applied). being applied).


114

•The The ‘FL CALC GROSS AMT’‘FL CALC GROSS AMT’ formula (pre-adjustment or formula (pre-adjustment or credit)credit) for each BTC is set for each BTC is set out in the Edits Matrix, out in the Edits Matrix, specifically, the specifically, the ‘FL ‘FL Calculation (Proprietary)’ Calculation (Proprietary)’ tab.tab.


115

•The expected FL CALC The expected FL CALC GROSS AMOUNT computed GROSS AMOUNT computed by DWC’s program is by DWC’s program is displayed on the ‘Errors displayed on the ‘Errors tab’ in the data warehouse tab’ in the data warehouse under under “Comparison Amount “Comparison Amount Per Edit”.Per Edit”.

Just scroll to right while on Just scroll to right while on a particular error row (see a particular error row (see next slide.)next slide.)


116


117


NET $.05NET $.05 OVEROVER FL CALC FL CALC GROSS MINUS ADJ/CREDIT GROSS MINUS ADJ/CREDIT

AMTSAMTS

This means that the Net This means that the Net Weekly Amount you are Weekly Amount you are sending is more than 5¢ sending is more than 5¢ over the amount calculated over the amount calculated by our program. by our program.


118

Example:Example:

‘‘FL CALC GROSS AMT’FL CALC GROSS AMT’ for a for a TT Cat (051) Benefits TT Cat (051) Benefits segment would be segment would be determined as 80% of AWW determined as 80% of AWW (subject to Max CR). If you (subject to Max CR). If you instead reported 66 2/3% of instead reported 66 2/3% of AWW, this edit would be AWW, this edit would be invoked. invoked.


119

Also, if your SROI contains Also, if your SROI contains two Benefits Segments, one two Benefits Segments, one for TT (050) and one for IB for TT (050) and one for IB (030), there should be a (030), there should be a different Gross and Net different Gross and Net Weekly Amounts for each Weekly Amounts for each segment, since each of segment, since each of these benefit types are paid these benefit types are paid at different weekly rates. at different weekly rates.


120

• Again, the Gross and Net Again, the Gross and Net Weekly Amounts are Weekly Amounts are notnot the Comp Rate. the Comp Rate.

• For TT, the weekly rate For TT, the weekly rate happens to be the same happens to be the same amount as the Comp Rate amount as the Comp Rate (66 2/3% of AWW). But you (66 2/3% of AWW). But you would not necessarily report would not necessarily report this same amount for all this same amount for all other BTC’s.other BTC’s.


121

POP QUIZ: POP QUIZ:

True or False:True or False:

DWC defaults to a DWC defaults to a value of ‘5’ if value of ‘5’ if ‘Number ‘Number of Days Worked Per of Days Worked Per Week’Week’ is not sent. is not sent.

122

Answer:Answer:

FalseFalse‘‘Number of Days Worked Per Number of Days Worked Per Week’Week’ is is requiredrequired unless BTC unless BTC 030 (IB) is the only benefit 030 (IB) is the only benefit reported on an IP or AP.reported on an IP or AP.

Since IB’s are paid in whole Since IB’s are paid in whole weeks only, a daily rate is not weeks only, a daily rate is not computed.computed.

123


WKLY COMP AMT WKLY COMP AMT NOT CORRECT FOR AWW NOT CORRECT FOR AWW

The Weekly Comp Amount (Comp The Weekly Comp Amount (Comp Rate) is statutory & should be Rate) is statutory & should be always be reported as 66 2/3 % always be reported as 66 2/3 % of the AWW (+ or – 5¢) for DOI’s of the AWW (+ or – 5¢) for DOI’s on or after 8/1/79. on or after 8/1/79.

*** *** Even if you were ordered to pay Even if you were ordered to pay a higher weekly rate for TT (050).a higher weekly rate for TT (050).


124

If the 00/IP reports If the 00/IP reports TP TP (070)(070) benefits, benefits, “Initial RTW “Initial RTW Date”Date” (and other related (and other related RTW fields, including RTW RTW fields, including RTW Type Code “A” or “R”) Type Code “A” or “R”) must be sent since a return must be sent since a return to work release is required to work release is required to establish eligibility for to establish eligibility for TP benefits. TP benefits.


125

The The “Initial RTW Date”“Initial RTW Date” represents the first day represents the first day the EE actually RTW (“A”) the EE actually RTW (“A”) or was released to RTW or was released to RTW ( “R”) ( “R”) after the accidentafter the accident, , not following the initial not following the initial period of disability.period of disability.


126

• If the EE continued to If the EE continued to work restricted duty work restricted duty following the accident following the accident and TP was effective and TP was effective immediately (no days off immediately (no days off work), the work), the Initial RTWInitial RTW would be either the DOI would be either the DOI or DOI +1or DOI +1 (depending if Empr (depending if Empr paid for DOI.) paid for DOI.)


127

If the 00/IP reports If the 00/IP reports BTC BTC 030 ‘IB Only’,030 ‘IB Only’, the the “Initial RTW Date”“Initial RTW Date” with with the applicable the applicable “RTW “RTW Type Code”Type Code” ( (A- ActualA- Actual or or R- ReleasedR- Released) are ) are required...required...


128

•……This willThis will ensure DWC ensure DWC applies the correct IB applies the correct IB payment rate (i.e., the payment rate (i.e., the ‘FL ‘FL Calc Gross Amt’.)Calc Gross Amt’.)

•If Actual RTW Date is not If Actual RTW Date is not sent when applicable, sent when applicable, DWC’s program will DWC’s program will compute the full IB rate.compute the full IB rate.


129

The calculation for The calculation for determining determining ‘FL Calc ‘FL Calc Gross Amt’Gross Amt’ for for IB’s (030)IB’s (030) was recently amended to was recently amended to allow for the payment of allow for the payment of EITHEREITHER a a 37.5%37.5% or a or a 75%75% rate when the EE has rate when the EE has “actually” returned to “actually” returned to work,work, based on recent based on recent court case…. court case….


130

• … …The First DCA found in The First DCA found in the case of the case of Seminole County Seminole County Gov’t v. Eric Baumgardner Gov’t v. Eric Baumgardner (2/5/10)(2/5/10),, that F. S. 440.15(3) that F. S. 440.15(3)(c) does (c) does notnot allow the Claim allow the Claim Admin. to reduce IBs by Admin. to reduce IBs by 50% if the Claimant is 50% if the Claimant is working but not earning working but not earning 100% of the AWW,100% of the AWW, even if even if the reason for the reduced the reason for the reduced earnings is unrelated to the earnings is unrelated to the accident.accident.

131

If the initial payment is for If the initial payment is for Impairment Income Benefits Impairment Income Benefits (030) (030) paid in a lump sum,paid in a lump sum, you you would send a would send a SROI PYSROI PY (with (with FROI ) instead of a SROI IP. FROI ) instead of a SROI IP.

• Lump Sum Lump Sum Payment/Settlement Code (i.e. Payment/Settlement Code (i.e. A – Advance) is A – Advance) is not not required required here because lump sum here because lump sum payments of IB’s are payments of IB’s are sometimes made in arrears for sometimes made in arrears for back IB’s due versus an back IB’s due versus an advance of future IB’s due and advance of future IB’s due and owing.owing.


132


BTC 030 ‘IB Only’ BTC 030 ‘IB Only’ paid in a paid in a lump sumlump sum via via 00/00/PYPY will be discussed will be discussed in more detail when we in more detail when we cover SROI MTC cover SROI MTC PYPY filings.filings.

133

Acknowledgement Acknowledgement ‘Free Form Text’ ‘Free Form Text’

Messages for Messages for Claim Claim

AdministratorsAdministrators

134

Where applicable, the Where applicable, the following additional following additional information is provided by information is provided by DWC on the DWC on the Acknowledgement in the Acknowledgement in the ‘Free Form Text’ field: ‘Free Form Text’ field:

POSSIBLE COVERAGE EXEMPTION ON FILE FOR

SSN and NO 02

IN BEN SEG-NOT EDITED/LOADED

135

To Follow-up on Possible To Follow-up on Possible Exemptions:Exemptions: Go to Proof of Coverage Go to Proof of Coverage

database on web:database on web: https://secure.fldfs.com/WCAPPS/Compliance_poc/wPages/query.asp

Search by the EE Name or SSN.Search by the EE Name or SSN.

Review Exemption on file to see Review Exemption on file to see if the Employer listed on the if the Employer listed on the Exemption is the same as the Exemption is the same as the accident Employer. If so, the EE accident Employer. If so, the EE should technically not be receiving should technically not be receiving

WC benefits.WC benefits.

136

Let’s complete a Let’s complete a SROI for SROI for Scenario 1-A-8 Scenario 1-A-8

(New)(New) in your in your Handouts…Handouts…

137

Electronic First Electronic First Report of Injury or Report of Injury or

IllnessIllness

Initial Payment – 00/IPInitial Payment – 00/IP

BTC 070 with Multiple Initial BTC 070 with Multiple Initial RTW Dates on same IPRTW Dates on same IP

(Scenario 1-A-8)(Scenario 1-A-8)

138

Relative to this scenario, an Relative to this scenario, an IRR was recently submitted IRR was recently submitted requesting requesting clarification/modification of clarification/modification of DP Rule DP Rule in order to in order to address the correct address the correct Initial RTW date that should Initial RTW date that should

be reported be reported if both a if both a ‘Released’ and ‘Actual’ ‘Released’ and ‘Actual’ RTW Date occur before the RTW Date occur before the first payment. first payment.

139

Currently, there is no Currently, there is no clear guidance from the clear guidance from the IAIABC as to how to report IAIABC as to how to report multiple Initial RTW. multiple Initial RTW.

The following scenario The following scenario presents FL’s current presents FL’s current position until we receive position until we receive further direction from the further direction from the IAIABC.IAIABC.

140

The SROI IP will contain The SROI IP will contain partial data excerpted partial data excerpted from the SROI, and from the SROI, and includes:includes:

1 1 BenefitsBenefits Segment Segment andand 1 1 PaymentsPayments Segment. Segment.

141

0001 Transaction Set ID A9 Subsequent Report

0002 Maint. Type Code IP Initial Payment0003 MTC Date 20100123 Jan.23, 2010

0004 Jurisdiction Code FL

0006 Insurer FEIN 785902378

0014Claim Administrator Postal Code 379921223

0056Initial Date Disability Began 20100101 Jan. 1, 2010

0072Current Return to Work Date N/A

142

0063 Wage Period Code 01 Weekly

0064Number of Days Worked Per Week 5

0031 Date of Injury 20100101Jan. 1, 2010

0015Claim Admin. Claim Number WC1256782

0005Jurisdiction Claim Number N/A

0074 Claim Type Code IIndemnity/ Lost Time

143

R22 Data Elements

0001 Transaction Set ID R22

N/A

Date Claim Administrator Had Knowledge of Lost Time (Clm Admin’s Knowledge of 8th Day of Dis for FL)

0298

0015Claim Administrator Claim Number WC1256782

0187Claim Administrator FEIN 785902378

144

0188 Claim Administrator Name

OLD RELIABLE INSURANCE COMPANY

0140 Claim Administrator Claim Rep Name

Angie,,Adjuster Angie Adjuster

0137 Claim Admin. Claim Rep Phone Number

8505551111 (850) 555-1111

0270 Employee ID Type Qualifier

S Social Security Number

0042 Employee SSN 324556745

145

0043 Employee Last Name SMITH

0044Employee First Name JOHN

0045Employee Middle Name/Initial J

0255Employee Last Name Suffix JR

0052Employee Date of Birth 19530501

May 1, 1953

0202Reduced Benefit Amount Code N/A

146

0228Return To Work With Same Employer Ind Y Yes

N/ANon-Consecutive Period Code0212

N/ACurrent Date Last Day Worked0145

N/ACurrent Date Disability Began0144

0065Initial Date Last Day Worked 20100101

Jan. 1, 2010

0189Return To Work Type Code A Actual

147

0224Physical Restrictions Ind. Y Yes

0134

Calculated Weekly Compensation Amount 00000040000 $400.00

0256 Wage Effective Date 20100101Jan. 1, 2010

0290 Type of Loss Code 01 Trauma

0058Employment Status Code 1

Full Time

148

0068 Initial Return to Work Date 20100110

Jan. 10, 2010

0066 Full Wages Paid For Date Of Injury Indicator N No

0273 Employer Paid Salary in Lieu of Comp. Indicator N No

0286 Average Wage 00000060000 $600.00

0297Initial Date of Lost Time (8th Day) N/A

0200

Claim Admin. Alternate Postal Code (Mailing) 993574528

149

Variable Segment Counters

0288Number of Benefits 01

1 Occurrence

0283Number of Payments 01

1 Occurrence

0282Number of Other Benefits

02

2 Occurrence

s

0289Number of Benefit ACR 00

0284Number of Recoveries 00

150

0285Number of Reduced Earnings 00

0275

Number of Concurrent Employers 00

0277

Number of Full Denial Reason Code 00

0276Number of Denial Reason Narratives 00

0287

Number of Suspension Narratives 00

151

Variable Segments

Benefits 1 Occ

0085 Benefit Type Code 070 Temporary Partial

0002 Maint. Type Code IP Initial Payment

0174 Gross Weekly Amt N/A for TP

0175

Gross Weekly Amount Effective Date N/A for TP

0087 Net Weekly Amount N/A for TP

0211Net Weekly Amount Effective Date N/A for TP

152

0088Benefit Period Start Date 20100101

Jan. 1, 2010

0089Benefit Period Through Date 20100121

Jan. 21, 2010

0090Benefit Type Claim Weeks 0003

0091Benefit Type Claim Days 0

0086Benefit Type Amount Paid 00000115200 $1152.00

0192Benefit Payment Issue Date 20100123

Jan. 23, 2010

153

Payments 1 Occ

0222Payment Reason Code 070

Temporary Partial

0217 Payee JOHN J SMITH JR

0218 Payment Amount 00000115200 $1152.00

0219Payment Covers Period Start Date 20100101

Jan. 1, 2010

0220Payment Covers Period Through Date 20100121

Jan. 21, 2010

0195Payment Issue Date 20100123

Jan. 23, 2010

P&I reported under OBT 311 and 321

154

Questions?Questions?

155

More on More on Other First Other First

Report / EDI Report / EDI DWC-1 DWC-1

Equivalent MTC’sEquivalent MTC’s

156

Other First Report/EDI Other First Report/EDI DWC-1 EquivalentsDWC-1 Equivalents

Recap:Recap: EDI DWC-1 Equivalent EDI DWC-1 Equivalent MTC’s other than 00/IP areMTC’s other than 00/IP are used when indemnity used when indemnity benefits are not initially benefits are not initially being paid by the Claim being paid by the Claim Admin., but a report of Admin., but a report of injury is due to DWC for a injury is due to DWC for a lost time case (e.g., FROI lost time case (e.g., FROI 04.)04.)

157

EDI DWC-1 EquivalentsEDI DWC-1 Equivalents

The following SROI’s (sent with The following SROI’s (sent with FROI 00), will still require a FROI 00), will still require a BenefitsBenefits segment: segment:

EPEP – Employer Paid – Employer Paid PYPY – Lump Sum – Lump Sum Payment/SettlementPayment/Settlement

158

Initial Payment Initial Payment Equivalents Equivalents (Sent with (Sent with

FROI 00 or AU):FROI 00 or AU):

However, there will However, there will notnot be any be any Benefits Benefits Segments on the Segments on the following SROI MTC’s (sent with following SROI MTC’s (sent with FROI 00),FROI 00), since no indemnity since no indemnity was paid on the claim.was paid on the claim.

CD CD (Compensable Death,(Compensable Death,

VE VE (Compensable Volunteer, (Compensable Volunteer, andand

PDPD (Partial/Indemnity Only (Partial/Indemnity Only Denial).Denial).

159

POP QUIZ:POP QUIZ:Which MTC(s) are sent Which MTC(s) are sent to report an Electronic to report an Electronic First Report of Injury or First Report of Injury or Illness where Illness where salary was salary was

paid in lieu of paid in lieu of compensation?compensation?

160

Answer:Answer:MTC 00/EPMTC 00/EP

EMPLOYER PAID EMPLOYER PAID BENEFITSBENEFITS

161

69L-56.002(22), F.A.C. 69L-56.002(22), F.A.C. defines defines Employer Paid Employer Paid Salary in Lieu of Salary in Lieu of CompensationCompensation as “the as “the employer paid the employer paid the employee salary, wages, or employee salary, wages, or other remuneration other remuneration for a for a period of disability for period of disability for which the insurer would which the insurer would have otherwise been have otherwise been obligated to pay indemnity obligated to pay indemnity benefits.”benefits.”

EMPLOYER PAID BENEFITSEMPLOYER PAID BENEFITS

162

This does This does NOTNOT include the waiting include the waiting week if the employee week if the employee was not disabled for was not disabled for 22 or more days22 or more days”.”.


163


00/EP00/EP – Initial Payment – Initial Payment Equivalent:Equivalent:

Represents the first Represents the first report of payment of an report of payment of an indemnity benefit other indemnity benefit other than a lump sum than a lump sum payment/settlement that payment/settlement that has been has been paid by the paid by the employer employer in lieu of in lieu of compensationcompensation..

164


The EE has received The EE has received only only salary in lieu of salary in lieu of compensationcompensation from the from the employer at the time of employer at the time of filing.filing.

The Claim Administrator The Claim Administrator has not paid any has not paid any indemnity benefits at the indemnity benefits at the time of filing. time of filing.

00/EP00/EP – Initial Payment – Initial Payment Equivalent:Equivalent:

165

A A 00/EP00/EP filing must filing must contain contain onlyonly 2xx benefits 2xx benefits segment(s). segment(s). 240 240 Employer Paid Employer Paid Unspecified Unspecified Indemnity benefitsIndemnity benefits


250 250 Employer Paid TT Employer Paid TT benefitsbenefits

270 270 Employer Paid TP Employer Paid TP benefitsbenefits

166

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

210 210 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%)


167

If the initial payment of If the initial payment of indemnity benefits are indemnity benefits are paid by the Employer paid by the Employer as a as a full settlement,full settlement, BTC BTC 524524 would be would be reported via MTC reported via MTC 00/PY00/PY (vs. 00/EP). (vs. 00/EP).


168

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 complieu 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.


169

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

170


Tips for Tips for Successfully Successfully Filing 00/EP Filing 00/EP

171

Do Do notnot send SROI EP send SROI EP if, at the time of filing, if, at the time of filing, the the only only compensation compensation the EE received was the EE received was salary in lieu of comp salary in lieu of comp (BTC 2xx) for the (BTC 2xx) for the waiting week (Days 1-waiting week (Days 1-7).7).

Caveats and Tips for Successfully Caveats and Tips for Successfully filing 00/EPfiling 00/EP

172

POP QUIZ:POP QUIZ: If the EE has If the EE has received payment from received payment from the the EmployerEmployer for for “Days 1 thru 7” “Days 1 thru 7” andand payment from the payment from the Claim Claim Admin.Admin. for “Days 8 thru for “Days 8 thru 14”, what MTC(s) should 14”, what MTC(s) should be filed w/DWC?be filed w/DWC?


173

ANSWER:ANSWER:

00/IP00/IP


174

Here, the 00/IP (sent at Here, the 00/IP (sent at Day 14) Day 14) maymay include the include the 2xx 2xx Benefits Benefits segment for segment for Days 1 thru 7. Days 1 thru 7.

But because salary was not But because salary was not paid beyond the waiting paid beyond the waiting week, it cannot be week, it cannot be considered salary considered salary in lieu of in lieu of compcomp (since Days 1-7 were (since Days 1-7 were not yet payable at the time not yet payable at the time of filing.)of filing.)


175

If BTC 2xx was If BTC 2xx was notnot included on the 00/IPincluded on the 00/IP and the EE was and the EE was eventually disabled for eventually disabled for 22 or more days such 22 or more days such that the waiting week that the waiting week does become does become payable/reportable… payable/reportable…


176

… … BTC 2xx BTC 2xx shouldshould appear on appear on the next SROI to account for the next SROI to account for payment of the waiting week. payment of the waiting week.

In this situation, aIn this situation, a SROI CB is SROI CB is notnot required to ‘introduce’ required to ‘introduce’ the new 2xx benefits the new 2xx benefits (so long as the Start (so long as the Start Date of the 2xx segment is the Date of the 2xx segment is the earliest Start Date of all earliest Start Date of all benefits reported.)benefits reported.)


177

If you issue payment If you issue payment after the after the EmprEmpr, where the EE was , where the EE was disabled for disabled for 22 days or more, 22 days or more, but the 00/IP is being filed but the 00/IP is being filed latelate, the IP should include , the IP should include both the 2xx segment along both the 2xx segment along with the segment reporting with the segment reporting benefits paid by the Claim benefits paid by the Claim Admin Admin (providing you did not (providing you did not fully reimburse the employer for fully reimburse the employer for all salary paid.) …all salary paid.) …


178

… … Here, “Days 1 thru 7” Here, “Days 1 thru 7” paid by the Employer paid by the Employer doesdoes constitute salary in lieu of constitute salary in lieu of compensation that the compensation that the Claim Administrator would Claim Administrator would have otherwise had to pay have otherwise had to pay (since the EE was (since the EE was disabled for 22 or disabled for 22 or more days.)more days.)


179

If you receive a penalty If you receive a penalty because you because you incorrectly incorrectly filed an 00/IP and meant filed an 00/IP and meant to file 00/EPto file 00/EP,, you can you can send a send a SROI 02SROI 02 to revise to revise the ‘benefit picture’ and the ‘benefit picture’ and change the earliest paid change the earliest paid indemnity to BTC 2xx; …indemnity to BTC 2xx; …


180

… … however, the however, the SROI 02SROI 02 must be the next accepted must be the next accepted filing.filing.

• Also, Also, “MTC 02”“MTC 02” must be must be included in the included in the BenefitsBenefits segment. Otherwise, segment. Otherwise, DWC’s program will not DWC’s program will not edit/load the edit/load the Benefits Benefits segment(s). segment(s).


181

• Also, Also, Reduced Benefit Reduced Benefit Amount Code “R”Amount Code “R” must must be present on the 02 to be present on the 02 to explain the explain the ‘disappearance’ of the ‘disappearance’ of the previously reported BTC previously reported BTC 2xx.2xx.


182

• After you confirm the After you confirm the 0202 was accepted (see was accepted (see filing results in Data filing results in Data Warehouse next day), Warehouse next day), you can request a re-you can request a re-evaluation of a penalty evaluation of a penalty that may have that may have resulted from the resulted from the incorrect initial benefit incorrect initial benefit information.information.


183

If the If the 0202 is the is the next next accepted filingaccepted filing, the, the following fields will be following fields will be updated in DWC’s database updated in DWC’s database automatically (so the automatically (so the Claims EDI Team will not Claims EDI Team will not have to manually revise have to manually revise DWC’s claim record DWC’s claim record prior to CPS re-evaluation): prior to CPS re-evaluation):


184

• 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

• Payment Issue Date 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)

DN’s Changed by 02 DN’s Changed by 02 if Next if Next Accepted FilingAccepted Filing::

185

If the 02If the 02 isis notnot the next the next accepted filing after the accepted filing after the 00/IP, these fields will 00/IP, these fields will need to be manually need to be manually updated by the EDI updated by the EDI Team (upon request by Team (upon request by the CPS Admin.) to the CPS Admin.) to replace the initial replace the initial payment data with the payment data with the correct information.correct information.


186

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

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

Caveat sand Tips for Successfully Caveat sand Tips for Successfully filing 00/EPfiling 00/EP

187

If you subsequently reimburse If you subsequently reimburse the employer for the employer for allall salary paid salary paid in lieu compensation, in lieu compensation, Reduced Reduced Benefit Amount Code “R” – Benefit Amount Code “R” – ReclassificationReclassification should be sent should be sent on the next transaction to on the next transaction to explain why the 2xx Benefits explain why the 2xx Benefits segment is no longer present.segment is no longer present.


188

If the employer actually paid If the employer actually paid salary in lieu of comp (for more salary in lieu of comp (for more than the ww), than the ww), but the 00/IP was but the 00/IP was filed late and the Claim Admin. filed late and the Claim Admin. has already reimbursed the has already reimbursed the employer for all prior employer employer for all prior employer paid benefits,paid benefits, there will never there will never be a 2xx segment on any EDI be a 2xx segment on any EDI transaction. As a result, …transaction. As a result, …


189

… … you will need to supply you will need to supply other documentation to other documentation to satisfy the CPS Specialist that satisfy the CPS Specialist that salary was initially paid and salary was initially paid and that the initial payment was that the initial payment was not late. not late.

Afterwards, the EDI Team will Afterwards, the EDI Team will be asked by CPS Admin. to be asked by CPS Admin. to update DWC’s system to update DWC’s system to reflect the initial payment of reflect the initial payment of indemnity as salary in lieu of indemnity as salary in lieu of comp.comp.

190

If salary in lieu of comp was If salary in lieu of comp was initially reported in error or initially reported in error or mis-coded mis-coded from a from a paperpaper DWC-1 DWC-1 or or R1R1 EDI filing: EDI filing:

Rather than sending Reduced Rather than sending Reduced Benefit Amount Code “R” to Benefit Amount Code “R” to reconcile the problem, contact reconcile the problem, contact the EDI Team, which can the EDI Team, which can manually modify the initial filing manually modify the initial filing information on DWC’s database.information on DWC’s database.


191

Recap:Recap: For R3 EDI filings:For R3 EDI filings: An MTC 02 is required to An MTC 02 is required to

report corrected initial report corrected initial payment information.payment information.

If intervening EDI transactions If intervening EDI transactions were accepted prior to the 02, were accepted prior to the 02, an EDI Team member will an EDI Team member will need to manually update need to manually update DWC’s database upon DWC’s database upon verification of the corrected verification of the corrected data on the 02.data on the 02.


192

We are seeing many We are seeing many rejections of rejections of 00/EP00/EP filings that filings that appear to be ‘medical only’. appear to be ‘medical only’.

Remember, the Start Date of Remember, the Start Date of 2xx must be at least ‘Day 8’ 2xx must be at least ‘Day 8’ of disability. You may need of disability. You may need to either change an to either change an inaccurate Initial Date inaccurate Initial Date Disability Began or Start and Disability Began or Start and Through Dates. Through Dates.


193

POP Quiz:POP Quiz:

What MTC should be What MTC should be filed with DWC if the filed with DWC if the employer ceases to employer ceases to pay salary in lieu of pay salary in lieu of compensation and compensation and you start paying you start paying

instead?instead?

194

Answer: Answer:

SROI MTC IPSROI MTC IP

195

IP after EPIP after EP If you are making your If you are making your initial payment of initial payment of indemnity (not a lump indemnity (not a lump sum payment/settlement) sum payment/settlement) afterafter Empr paid salary in lieu Empr paid salary in lieu of comp:of comp:

A SROI MTC A SROI MTC IPIP must be sent must be sent after the MTC EP that after the MTC EP that reported the initial payment reported the initial payment of Employer Paid benefits.of Employer Paid benefits.

196

If your initial If your initial payment, after the payment, after the Employer paid Employer paid benefits, benefits, isis for a for a Final Final Settlement,Settlement, send send SROI SROI PYPY (instead of IP.) (instead of IP.)

197

And if your initial And if your initial payment, after the payment, after the Employer paid benefits, Employer paid benefits, is a lump sum payment is a lump sum payment that is that is not a finalnot a final settlement (e.g., settlement (e.g., advance),advance), send send PY PY followed by an IPfollowed by an IP to to show payment of show payment of ongoing benefits (EP – ongoing benefits (EP – PY – IP.)PY – IP.)

198

Also, if you will be Also, if you will be continuing payment (after continuing payment (after the Employer paid) and a the Employer paid) and a SX was previously filed that SX was previously filed that reported the reported the suspension of suspension of employer paid benefitsemployer paid benefits, a , a SROI SROI IPIP (vs. RB) should be (vs. RB) should be filed with DWC to report filed with DWC to report your initial payment of your initial payment of indemnity (EP – Sx - IP.)indemnity (EP – Sx - IP.)

199

In these cases, the In these cases, the ‘standalone’ SROI MTC ‘standalone’ SROI MTC IP, PYIP, PY represent an represent an Electronic Notice of Electronic Notice of Action/Change, EDI Action/Change, EDI DWC-4 equivalent,DWC-4 equivalent, required in required in Rule 69L-Rule 69L-56.304(3), F.A.C.56.304(3), F.A.C.DWC-4 or explanatory letter is DWC-4 or explanatory letter is required to be sent to the EE and required to be sent to the EE and Employer.Employer.

200

EP after IPEP after IP If the If the Employer elects to Employer elects to paypay indemnity benefits, indemnity benefits, e.g., Impairment Income e.g., Impairment Income benefits, benefits, AFTER the Claim AFTER the Claim AdministratorAdministrator paid paid indemnity benefitsindemnity benefits, a SROIa SROI EPEP must be filed after must be filed after MTC IP.MTC IP.

See Rule 69L-56.304(5), See Rule 69L-56.304(5), F.A.C.F.A.C. (No DWC-4 or letter (No DWC-4 or letter required.)required.)

201

EP after SxEP after Sx EPEP is also required if the is also required if the employer paid benefits after employer paid benefits after an Sx that reported an Sx that reported suspension of indemnity suspension of indemnity benefits previously paid by benefits previously paid by the Claim Admin (IP – Sx - the Claim Admin (IP – Sx - EP) …EP) …

See Rule 69L-56.304(5), See Rule 69L-56.304(5), F.A.C.F.A.C. (No DWC-4 or letter (No DWC-4 or letter required.)required.)

202

… … SROI SROI ER ER would only be would only be applicable in this situation applicable in this situation if if the employer had previously the employer had previously paidpaid (EP – IP – Sx – ER.) (EP – IP – Sx – ER.)

See Rule 69L-56.3045(6), See Rule 69L-56.3045(6), F.A.C. F.A.C. (No DWC-4 or letter (No DWC-4 or letter required.)required.)

203

Exception to filing an EP Exception to filing an EP or ER:or ER:

• If the employer elects to If the employer elects to pay a pay a lump sum lump sum payment/settlementpayment/settlement, you , you would send MTC would send MTC PY with PY with BTC 524BTC 524 (Employer Paid (Employer Paid Lump Sum Lump Sum Payment/Settlement.)Payment/Settlement.)

204


205

POP QUIZ:POP QUIZ:What MTC is used to What MTC is used to

report a report a Totally Totally DeniedDenied Electronic Electronic

First Report of Injury First Report of Injury or Illness?or Illness?

206

ANSWER:ANSWER:

FROI MTC 04FROI MTC 04

Full (Total) DenialFull (Total) Denial

EDI DWC-1 Equivalent required EDI DWC-1 Equivalent required to beto be filed with DWC per Rule filed with DWC per Rule

69L-56.301(2).69L-56.301(2).

207

FROI MTC 04 FROI MTC 04 Full (Total) Denial Full (Total) Denial

FROI 04 FROI 04 represents a represents a total total denial of all denial of all indemnity and indemnity and medicalmedical benefits, benefits, including denials including denials based on based on compensability.compensability.

208


This is the only EDI This is the only EDI DWC-1 equivalent that DWC-1 equivalent that does not require a does not require a corresponding SROI MTC corresponding SROI MTC to be paired with a FROI to be paired with a FROI MTC. MTC.

209

Even if a claim is Even if a claim is classified as “medical classified as “medical only” in your system, if only” in your system, if compensability of the claim compensability of the claim is being deniedis being denied, you must , you must still report the still report the claim claim to DWC, since the to DWC, since the entire claim, including any entire claim, including any potential indemnity, is potential indemnity, is denied. denied.


210

The corresponding The corresponding Electronic Notice of Electronic Notice of Denial, EDI DWC-12 Denial, EDI DWC-12 equivalent,equivalent, is also is also due, and reported on due, and reported on the same FROI 04.the same FROI 04.


211

FROI MTC 04 - Full (Total) FROI MTC 04 - Full (Total) DenialDenial

To report the EDI DWC-12 To report the EDI DWC-12 equivalent, the FROI 04 equivalent, the FROI 04 must contain:must contain:

• “ “Full Denial Reason Full Denial Reason Code”, Code”, • “ “Full Denial Effective Full Denial Effective Date”, andDate”, and• “ “Denial Reason Denial Reason Narrative”.Narrative”.

Note:Note: A paper copy of DWC-1 and A paper copy of DWC-1 and DWC-12 must be produced for the DWC-12 must be produced for the EE & Employer.EE & Employer.

212


““Full Denial Reason Full Denial Reason Code”Code” should identify all of should identify all of the reasons the claim was the reasons the claim was denied (up to five different denied (up to five different codes can be sent.)codes can be sent.)

• Code “3F”Code “3F” (Statute of (Statute of limitations expired) is limitations expired) is precluded unless MTC Date precluded unless MTC Date is >= one year after the DOI.is >= one year after the DOI.

213


• Also, Full Denial Reason Also, Full Denial Reason Code Code “5B”“5B” (Right to (Right to Reserve) can not be the Reserve) can not be the only Full Denial Reason only Full Denial Reason Code sent.Code sent.

214


““Full Denial Effective Full Denial Effective Date”Date” is the date from is the date from which the Claim Admin. is which the Claim Admin. is denying all benefits for the denying all benefits for the claim (e.g., DOI).claim (e.g., DOI).

• Can not be sent as a Can not be sent as a future date (i.e., later than future date (i.e., later than the date the 04 was the date the 04 was received by DWC.) received by DWC.)

215


““Denial Reason Narrative” Denial Reason Narrative” is required and must contain is required and must contain supporting documentation supporting documentation for the denial and for the denial and must not must not repeat the text description of repeat the text description of the Denial Reason Code.the Denial Reason Code.

• EAO will require an 02 EAO will require an 02 Change transaction if the Change transaction if the Denial Reason Narrative is Denial Reason Narrative is insufficient.insufficient.

216


If a Full Denial Claim (FROI If a Full Denial Claim (FROI 04) begins as a “Medical 04) begins as a “Medical Only” case, Only” case, Claim Type “M”Claim Type “M” should be sent to represent should be sent to represent a a Medical Only Case for Medical Only Case for which compensability is which compensability is being denied…being denied…

217

• Claim Type “M”Claim Type “M” should should onlyonly be sent on a FROI 04 be sent on a FROI 04 where where initial disposition was a initial disposition was a compensable ‘medical only’compensable ‘medical only’ claim that was claim that was subsequently subsequently denied in fulldenied in full (e.g., 3 months (e.g., 3 months after the DOI). after the DOI).

It should It should notnot be sent on a be sent on a FROI 04 for which indemnity FROI 04 for which indemnity was claimed at the time of was claimed at the time of initial disposition (14 days of initial disposition (14 days of knowledge.) knowledge.)

FROI MTC 04 - Full (Total) FROI MTC 04 - Full (Total)

DenialDenial

218

• If “denials” are ever re-If “denials” are ever re-included in CPS in the included in CPS in the future, Claim Type future, Claim Type “M” may serve to “M” may serve to differentiate this type of differentiate this type of denial from a ‘straight’ denial from a ‘straight’ lost time denial that can lost time denial that can be evaluated for timely be evaluated for timely filing. filing.


DenialDenial

219

Note:Note: Claim Type “L” (MO Claim Type “L” (MO to LT) would not be to LT) would not be applicable in this situation applicable in this situation because there may not be because there may not be any actual or ‘claimed’ any actual or ‘claimed’ disability dates to report if disability dates to report if compensability is being compensability is being denied in general, so ... denied in general, so ...


DenialDenial

220

• ……there would not be there would not be any associated ‘8th day any associated ‘8th day of disability’ information of disability’ information to report, which is to report, which is required if Claim Type = required if Claim Type = “L”. “L”.


DenialDenial

221

We inspected FROI 04 We inspected FROI 04 filings that reported Claim filings that reported Claim Type “M” and found that Type “M” and found that many were sent within 14 many were sent within 14 days of the DOI, in which days of the DOI, in which case Claim Type “M” is case Claim Type “M” is notnot applicable. applicable.

We will therefore be We will therefore be implementing a new editimplementing a new edit effective Sept. 1, 2010effective Sept. 1, 2010 that that will preclude this. will preclude this.


DenialDenial

222

Filing Caveats Filing Caveats and and

Tips for Tips for Successfully Successfully

Filing FROI 04 Filing FROI 04

223

We don’t see that many We don’t see that many rejections associated with rejections associated with FROI 04’s since there aren’t FROI 04’s since there aren’t as many data elements on the as many data elements on the FROI compared to the SROI, FROI compared to the SROI, but the next few slides will but the next few slides will identify the most frequently identify the most frequently occurring types of errors for occurring types of errors for FROI 04’s..FROI 04’s..

Caveats and Tips for Successfully Caveats and Tips for Successfully

Filing 04:Filing 04:

224

Mainly, we are seeing Mainly, we are seeing potential duplication of potential duplication of denials, where a FROI 04 denials, where a FROI 04 was sent, but either a DWC-was sent, but either a DWC-1 or SROI (from same Claim 1 or SROI (from same Claim Admin.) was already filed. Admin.) was already filed.

• If the denial is not a If the denial is not a duplicate and still needs to duplicate and still needs to be filed, it must be sent as be filed, it must be sent as a a SROISROI 04 04 (not another FROI 04.) (not another FROI 04.)



225

‘‘Duplicate Denial” errors are Duplicate Denial” errors are also occurring when more also occurring when more than one FROI 04 is sent in than one FROI 04 is sent in the same batch.the same batch.

Note:Note: Unnecessary Unnecessary SROISROI 04’s 04’s are also being sent after a are also being sent after a FROI 04 was already filed, FROI 04 was already filed, where no intervening MTC was where no intervening MTC was filed to accept liability after filed to accept liability after the FROI 04 and before the the FROI 04 and before the SROI 04.SROI 04.



226

FROI 04’s are also rejecting FROI 04’s are also rejecting where Nature of Injury Code = where Nature of Injury Code = “60 – 80”“60 – 80” ( (Occupational Occupational Disease or Cumulative InjuryDisease or Cumulative Injury), ), but Type of Loss Code = “01”but Type of Loss Code = “01” (Traumatic).(Traumatic).

• Here, Type of Loss Code Here, Type of Loss Code should = “02” should = “02” (Occupational (Occupational Disease)Disease) or “03” or “03” (Cumulative (Cumulative Injury - Other than Disease).Injury - Other than Disease).



227

Some FROI 04’s are Some FROI 04’s are missing the Employer’s missing the Employer’s Address and FEIN, which Address and FEIN, which are excused only if you are are excused only if you are denying the claim on denying the claim on grounds of no coverage grounds of no coverage (Full Denial Reason Code (Full Denial Reason Code 3A-H.)3A-H.)



228

Recap:Recap: Full Denial Reason Full Denial Reason CodeCode 5B (Right to Reserve)5B (Right to Reserve) cannot be the only Full cannot be the only Full Denial Reason Code sent.Denial Reason Code sent.

Also, Also, Full Denial Reason Full Denial Reason CodeCode 3F (Statute of 3F (Statute of limitations expired)limitations expired) cannot cannot be reported unless MTC be reported unless MTC Date is at least 1 year after Date is at least 1 year after the DOI.the DOI.



229


230

POP QUIZ:POP QUIZ:

What MTC is used to What MTC is used to report an report an Indemnity Indemnity

Only DeniedOnly Denied Electronic First Electronic First

Report of Injury or Report of Injury or Illness?Illness?

231

ANSWER:ANSWER:

FROI 00 + SROI PDFROI 00 + SROI PD

(Partial Denial)(Partial Denial)EDI DWC-1 Equivalent EDI DWC-1 Equivalent

required to berequired to be filed with filed with DWC per RuleDWC per Rule 69L-69L-

56.301(2)(c), F.A.C.56.301(2)(c), F.A.C.

232

Partial (Indemnity Only) Partial (Indemnity Only) DenialDenial

EDI DWC-1 EquivalentEDI DWC-1 Equivalent

A A FROI 00 and SROI FROI 00 and SROI PDPD should be filed when should be filed when the claim is found to be the claim is found to be compensable, but compensable, but indemnity benefits are indemnity benefits are denied in wholedenied in whole and and only medical benefits only medical benefits will be paid.will be paid.

233

Partial (Indemnity Only) DenialPartial (Indemnity Only) DenialEDI DWC-1 EquivalentEDI DWC-1 Equivalent

The same The same SROISROI PD PD sent with sent with FROIFROI 00 00 will also accomplish the will also accomplish the reporting of the reporting of the Electronic Electronic Notice of DenialNotice of Denial,, EDI DWC-12 EDI DWC-12 equivalent, since it must equivalent, since it must contain: contain: Partial Denial CodePartial Denial Code (A or E (A or E only),only), and and Denial Reason NarrativeDenial Reason Narrative to to provide details about why provide details about why indemnity benefits will not be indemnity benefits will not be paid.paid.

234



PARTIAL DENIAL CODEPARTIAL DENIAL CODE identifies which portion of identifies which portion of the claim is being denied the claim is being denied (not the reason it is (not the reason it is denied).denied).

235

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

236



The The Partial Denial CodePartial Denial Code should identify which should identify which portion of the claim is portion of the claim is currentlycurrently being denied being denied (vs. evaluating if any (vs. evaluating if any indemnity and medical indemnity and medical benefits have been paid in benefits have been paid in the past). the past).

237



•For example:For example: If indemnity If indemnity benefits were previously benefits were previously paid and the Claim Admin. paid and the Claim Admin. decided to deny all future decided to deny all future indemnity but not deny all indemnity but not deny all medical, they would send medical, they would send a a Partial Denial Code Partial Denial Code “A” “A” or “E”or “E” … …

238

Partial (Indemnity Partial (Indemnity Only) DenialOnly) Denial


… to indicate that o indicate that ALL ALL indemnity is currently indemnity is currently being deniedbeing denied (and not (and not Partial Denial Code “B” or Partial Denial Code “B” or “G” on the basis that “G” on the basis that some indemnity had been some indemnity had been paid in the past.) paid in the past.)

239



Denial Reason NarrativeDenial Reason Narrative is required to convey the is required to convey the specific benefits and specific benefits and reasons for the denial, reasons for the denial, and should not repeat and should not repeat the information already the information already represented by the code represented by the code itselfitself..

240


EDI DWC-1 EquivalentEDI DWC-1 EquivalentAgain, the narrative Again, the narrative should should NOTNOT be defaulted to be defaulted to the text description of the the text description of the code. code.

•This will result in This will result in additional correspondence additional correspondence from EAO and you will be from EAO and you will be required to send another required to send another transaction (MTC 02).transaction (MTC 02).

241



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

•Full Denial Reason CodeFull Denial Reason Code•Full Denial Effective DateFull Denial Effective Date

DENIEDENIEDD

242

If indemnity benefits If indemnity benefits were previously paid were previously paid and you and you later changed later changed dispositiondisposition and denied and denied ALL future indemnity ALL future indemnity and ALL future medical, and ALL future medical, you would report a you would report a SROI 04 – Full (Total) SROI 04 – Full (Total) Denial.Denial.


243


Tips for Tips for Successfully Successfully

Filing Filing FROI 00 + FROI 00 + SROI PDSROI PD

244

If a First Report of Injury If a First Report of Injury or Illness is not already on or Illness is not already on file with DWC (paper or file with DWC (paper or EDI), a Partial (Indemnity EDI), a Partial (Indemnity Only) Denial 00/PD can Only) Denial 00/PD can only be sent with only be sent with Partial Partial Denial Code A or E.Denial Code A or E.

• Only Codes A and E Only Codes A and E represent represent ALL ALL indemnity is being denied.indemnity is being denied.

Caveats and Tips for Successfully Caveats and Tips for Successfully Filing 00/PDFiling 00/PD

245

Partial Denial Codes C or D Partial Denial Codes C or D are never applicable in FL are never applicable in FL because they represent a because they represent a denial of medical in whole denial of medical in whole or part, but not indemnity. or part, but not indemnity.

• Partial Denial Codes used Partial Denial Codes used for FL filings must address for FL filings must address some aspect of indemnity some aspect of indemnity denial (all or part).denial (all or part).


246

Partial Denial Code F Partial Denial Code F should also never be sent should also never be sent because it represents a because it represents a denial of all medical where denial of all medical where indemnity will continue to indemnity will continue to be paid.be paid.

• This is N/A in FL since This is N/A in FL since indemnity can’t be paid indemnity can’t be paid without on-going medical without on-going medical substantiation.substantiation.


247

If you originally filed a If you originally filed a 00/PD with PD Code A 00/PD with PD Code A or Eor E & you & you subsequently subsequently decide to paydecide to pay some or some or all indemnityall indemnity, you must , you must file a file a SROI IP with a SROI IP with a Denial Rescission Date.Denial Rescission Date.

Caveats and Tips for Successfully Caveats and Tips for Successfully filing 00/PDfiling 00/PD

248

If some indemnity If some indemnity benefits are benefits are still being still being partially denied after the partially denied after the IPIP,, another another PDPD will also will also need to be filed after the need to be filed after the IP to indicate that IP to indicate that some some indemnity is still being indemnity is still being denied.denied.


249

If you need to report a If you need to report a change in disposition, change in disposition, e.g., e.g., going fromgoing from Partial Denial Partial Denial Code B or G (some Code B or G (some indemnity denied) to A or E indemnity denied) to A or E (all indemnity denied) and (all indemnity denied) and no new benefits are being no new benefits are being initiated, you would file initiated, you would file another PD with the new another PD with the new PD Code.PD Code.


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However, if disposition However, if disposition changes from “A” or “E” changes from “A” or “E” (full indemnity denial) to (full indemnity denial) to “B” or “G” (denying “B” or “G” (denying indemnity in part), you indemnity in part), you will need to also file an will need to also file an IPIP (or PY) right behind the (or PY) right behind the PD PD to report the initiation to report the initiation of indemnity benefitsof indemnity benefits (since (since you are no longer denying all you are no longer denying all indemnity.)indemnity.)


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If a Partial Denial If a Partial Denial Code needs to be Code needs to be changedchanged because the because the previous PD Code was previous PD Code was sent incorrectly, sent incorrectly, this this can be done with can be done with MTC MTC 0202 (e.g., changing A to E (e.g., changing A to E or B to G.)or B to G.)


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However, if you are However, if you are sending ansending an 0202 to change to change the PD Code to B or G the PD Code to B or G (indemnity denied in (indemnity denied in part) part) andand indemnity indemnity benefits will be benefits will be commencing for the first commencing for the first time,time, both of these both of these actions cannot be actions cannot be communicated on the 02 communicated on the 02 alone…alone…


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……You will need to also You will need to also send another transaction send another transaction (e.g., IP, PY) to (e.g., IP, PY) to communicate the initiation communicate the initiation of indemnity benefits of indemnity benefits since since neither an 02 or PD neither an 02 or PD can initiate benefits.can initiate benefits.

• If the claim is still being If the claim is still being partially denied, another partially denied, another PD (after IP, PY, etc.) will PD (after IP, PY, etc.) will have to be sent.have to be sent.


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


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There is no specific DN There is no specific DN for ‘partial denial date”, for ‘partial denial date”, so FL uses the MTC Date so FL 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


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Denial Rescission DateDenial Rescission Date represents an ‘action represents an ‘action date’ (i.e., the date you date’ (i.e., the date you took the action to took the action to rescind benefits), not an rescind benefits), not an effective date of the effective date of the rescinded benefits. rescinded benefits.


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POP QUIZ: POP QUIZ:

If an EDI DWC-1 If an EDI DWC-1 equivalent has been equivalent has been

filed and you filed and you subsequently deny subsequently deny

indemnity,indemnity, what MTC what MTC is used to report the is used to report the Electronic Notice of Electronic Notice of

Denial?Denial?

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ANSWER: ANSWER:

To report the To report the subsequent denial of subsequent denial of

indemnity: indemnity:

SROISROI 04 04 (if also denying (if also denying

medical)medical)

or or SROISROI PD PD

Documents

Electronic First Reports of Injury or Illness (EDI DWC-1 Equivalent)