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FL Claims EDI Release 3 Training 2007

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Title: FL Claims EDI Release 3 Training 2007 Subject: Claims EDI Release 3 Training Author: FL DWC EDI Team Last modified by: Tonya Granger Created Date – PowerPoint PPT presentation

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Title: FL Claims EDI Release 3 Training 2007


1
Electronic First Reports of Injury or Illness
(EDI DWC-1 Equivalent)
2
  • Electronic First Report of Injury or Illness
  • (EDI DWC-1 Equivalent)
  • The most typical EDI DWC-1 filing is
  • FROI 00 SROI IP
  • Required to be filed with DWC per Rule
    69L-56.301, F.A.C.

3
Electronic First Report of Injury or Illness
  • A SROI IP sent in combination with a FROI 00
    reports the Claim Administrators initial payment
    on a lost time claim.

4
  • Electronic First Report of Injury or Illness
  • Electronic First Reports of Injury or Illness
    are also represented by the following other EDI
    DWC-1 equivalent MTCs to report lost time claims
    and are also required to be filed with DWC

5
  • Electronic First Report of Injury or Illness
  • Other SROIs Sent with FROI 00
  • CD Compensable Death with no Known
    Dependents/Payees
  • EP Employer Paid
  • PD Partial Denial
  • PY Lump Sum Payment/Settlement
  • VE Volunteer (covered under FL law)
  • FROI Only
  • 04 Full (Total Denial)


6
Electronic First Report of Injury or Illness
  • Please note that we will be deferring discussion
    on AU/AP EDI DWC-1 equivalents and other
    Acquired Claims issues until tomorrow.

7
Pop Quiz
8
If a Compensable Volunteer also had non-volunteer
concurrent employment
9
What MTCs should be sent to report the
Electronic First Report of Injury or Illness?
10
Answer FROI 00 SROI IP To report payment of
indemnity based on wages from concurrent
employment.
11
SROI MTC IP (Initial Payment)
The SROI MTC IP (Initial Payment) transaction
implies that indemnity benefits are on-going
until suspended.
12
POP QUIZ Conversely, what transaction/MTC
is used when the first payment on the claim
is for a one-time lump sum payment or
settlement?
13
ANSWER MTC 00/PY
14
Lump sum payments / settlements will be discussed
in more detail during tomorrows training.
15
Another POP Quiz When is the 00/IP considered
timely filed with the Division?
16
  • Electronic First Report of Injury or Illness
  • Answer It depends
  • For initial payments other than TP, IB or
    settlement, if LT is immediate and continuous,
    00/IP is timely filed when it is received by DWC
    and assigned TA on or before 21 days after
    Claim Admin.s knowledge of the injury.

17
Electronic First Report of Injury or Illness
Answer (contd)
  • If LT is delayed or non-consecutive, 00/IP is
    timely filed with DWC when it is received by DWC
    and assigned TA on or before 13 days after the
    Claim Admin.s knowledge of the 8th day of
    disability (a/k/a Initial Date of Lost Time.)

18
To avoid late filing penalties, the EDI First
Report of Injury or Illness (00/IP or equivalent)
should be triggered immediately upon the
Claim Admin.s disposition of the claim
(payment or denial.)
HELPFUL HINT
19
This will allow time for correction of
potential errors and subsequent
resubmission with eventual receipt/acceptance by
DWC within the filing due dates specified in Rule
69L-56, F.A.C.
HELPFUL HINT
20
Electronic First Report of Injury or Illness
  • The specific timeframes for the timely
    submission of the 00/IP and other required
    electronic filings are set out in Rule 69L-56,
    F.A.C., the Event Table, and the MTC Filing
    Instructions document (all available on the
    Claims EDI web page.)

21
Electronic First Report of Injury or Illness
  • For FROI 00 with SROI IP combos (or equivalent),
    the FROI Date and Time Transmission Sent on the
    Batch Header must be PRIOR to the SROI Date/Time
    Transmission Sent.
  • If the SROI is received and processed ahead of
    the FROI, both will reject.

22
Electronic First Report of Injury or Illness
  • Also, for processing FROI 00/SROI IP combos (or
    equivalent), the Match Data in the FROI to SROI
    column of the Edit Matrix Match Data Tab, must
    match exactly from FROI to SROI.

23
Electronic First Report of Injury or Illness
  • If the FROI 00 and SROI IP (or equivalent) do
    not combine as required in the previous 2 slides,
    the error messages in this case will be confusing

24
Electronic First Report of Injury or Illness
because if they do not combo, they are
processed separately as individual FROI SROI
filings, which have different requirements/errors.
Example Error JCN Missing - Even though JCN
is not required for an 00/IP, it IS required for
a standalone SROI IP.
25
Now lets take a detailed look at the Benefits
Segment on the SROI
26
The Benefits segment on the SROI consists of the
following data elements (DNs)
27
Although you may not see this exact layout of
data elements on your own system/screen, your
companys program or vendor software should
adhere to the submission requirements covered in
the next several slides.
28
  • SROI BENEFITS Segment
  • The Benefits segment of the SROI transaction is
    used to report indemnity benefits that are
    currently being paid or have been paid by the
    current Claim Administrator.

29
  • SROI BENEFITS Segment
  • If you have paid indemnity, a Benefits Segment
    for EVERY indemnity Benefit Type paid should be
    included on EVERY SROI transaction.

30
  • SROI BENEFITS Segment
  • Exception A Benefit Type Code (or Other
    Benefit Type Code) previously reported may be
    left off the current transaction if its
    disappearance is explained by the presence of
    certain other codes
  • Reduced Benefit Amount Code,
  • Recovery Code (will discuss in detail later.)

31
  • SROI BENEFITS Segment
  • Correspondingly, the Benefit Type Amount (and
    Other Benefit Type Amount) reported on the
    current transaction must not be less than the
    previously reported unless a Reduced Benefit
    Amount Code or Recovery Code is reported.

32
All Data elements contained in the SROI BENEFITS
Segment (e.g., Gross/Net Weekly Amounts,
Start Date) are defined in the
Data Dictionary, Section 6 of IAIABC R3
Implementation Guide.
33
The most current version of the IAIABC R3
Implementation Guide is located at IAIABC.org.
The Guide is available for download FREE of
charge to any employee of an IAIABC EDI Member.
If you are not an EDI Member, you can purchase
the Guide for 95.     
34
When and how data should be populated in the SROI
Benefits segment is in the Variable Segment
Population Rules, Section 4 of the IAIABC R3
Guide.
35
Variable Segment Population Rules for the SROI
Benefits Segment
36
  • SROI BENEFITS Segment
  • Only one Benefits segment per Benefit Type Code
    (BTC) is allowed.
  • The applicable BTC must be included when a
    Benefits segment is present in the transaction.

37
  • SROI BENEFITS Segment
  • The Benefits segment is populated with the
    current values at the time of transmission, based
    upon the Benefit Type Codes paid on the claim
    (snapshot).

38
  • SROI BENEFITS Segment
  • Exception Benefit Payment Issue Date.
  • If the 00/IP is filed late and multiple payments
    have been issued, the Benefit Payment Issue Date
    for the IP should correspond to the initial
    payment, not the current payment.

39
  • SROI BENEFITS Segment
  • When an MTC is required to be sent at the
    Benefits level on the SROI (i.e., in the
    Benefits segment itself), the same MTC must be
    sent at the Claim level on the SROI.

40
SROI BENEFITS Segment Example IP sent with 050
followed by 02 to change something in the 050
Benefits segment Do not leave MTC IP in 050
Benefits segment on the 02. The MTC in the
Benefits segment must match the MTC on the
transaction.
41
  • SROI BENEFITS Segment
  • 0 (zero) Benefits Segments are allowed for the
    following SROI MTCs
  • CD - Compensable Death with No Dependents
  • VE - Volunteers
  • PD - Indemnity Only (Partial) Denials.

42
  • SROI BENEFITS Segment
  • 0 (zero) Benefits Segments are also allowed if
    Reduced Benefit Amount Code is reported as
  • S (Settlement on Another DOI) or
  • N (No Money Settlement).

43
  • SROI BENEFITS Segment
  • Reduced Benefit Amount Code N was recently
    appropriated by the IAIABC for reporting
    settlements with no dollars paid, such as those
    due to waiver of a lien.

44
  • SROI BENEFITS Segment
  • Where Reduced Benefit Amount Code N is
    reported, a Benefits segment will only be present
    on the transaction if indemnity benefits had been
    paid for the DOI prior to the settlement.

45
  • SROI BENEFITS Segment
  • 0 (zero) Benefits Segments are also allowed if
    OBT 430 (Unallocated Indemnity) is reported and
    the acquiring Claim Admin. has not yet issued its
    initial payment at the time of filing (e.g.,
    SA.)

46
  • Event
  • Benefits
  • Segments

EVENT
47
Sweep DNs
Event DNs
48
EVENT BENEFITS SEGMENT RULES
A Claim Administrator must be prepared to send
all data elements in the Benefits Segment as
required per the Benefits Segment Req
worksheet of FLs Element Requirement Table.
49
EVENT BENEFITS SEGMENT RULES
Exception If the Date Claim Admin. Had
Knowledge of the Injury preceded its R3 go
live date, Gross and Net Amounts and Effective
Dates, and Benefit Period Start and Through Dates
are NOT required (nor edited), even for Event
Benefits Segments. (Since these data elements
were not previously required on legacy paper or
R1 filings)
50
EVENT BENEFITS SEGMENT RULES
  • Note (exception to the exception)
  • Benefit Period Start Date is required for BTC 020
    BTC 240, and
  • Benefit Period Through Date is required for BTC
    240
  • even if the Date Claim Admin. Had Knowledge of
    the Injury preceded its R3 go live date.

51
EVENT BENEFITS SEGMENT RULES MTC
When a Benefit Type is starting, being changed
from or to another benefit type being suspended
or reporting a lump sum payment for Benefit Type
Code 0XX, MTC must be sent in the Event
Benefits segment for the affected Benefit(s).
52
SROI Benefits segment
53
SROI Benefits segment
If MTC is sent in the Benefits segment, it will
be edited as an Event Benefits segment.
54
EVENT BENEFITS SEGMENT EXAMPLE
MTC is reported in the Benefits segment when a
benefit type is being initiated or terminated
(AB, AP, CB, CA, S1-8, P7, EP, ER, IP, or RB).
55
EVENT BENEFITS SEGMENT EXAMPLE
All Benefits data elements are populated. Benefit
Payment Issue Date is required for an IP, and
certain APs, PYs (0xx).
56
EVENT BENEFITS SEGMENT RULES
BENEFIT PERIOD START DATE DN0088 For all
MTCs that are initiating or reinstating a
Benefit Type Code (AB, IP, RB, EP, ER, and CB)
The Benefit Period Start Date is the first date
of the uninterrupted period of benefit payments
that corresponds to the Benefit Type Code.
57
EVENT BENEFITS SEGMENT RULES
BENEFIT PERIOD START DATE DN0088 For all
MTCs that are NOT initiating or reinstating a
Benefit Type Code (S1-8, P7, CA, PY with BTC
0XX) The Benefit Period Start Date is the
earliest date for that Benefit Type Code
regardless of whether or not multiple benefit
periods have been paid for that Benefit Type Code.
58
EVENT BENEFITS SEGMENT RULES
For MTC AP and all subsequent MTCs filed on
acquired claims, the Benefit Period Start Date is
the first date of the uninterrupted period of
benefit payments by the acquiring Claim
Administrator that corresponds to the Benefit
Type Code.
59
HELPFUL HINT
  • Recap If you have paid indemnity, a Benefits
    Segment for EVERY indemnity Benefit Type paid
    should be included on EVERY SROI transaction
    (unless RBAC or Recovery applicable.)

60
HELPFUL HINT
An MTC previously reported at the Benefit level
that is not applicable to the current MTC being
reported should not be left in the Benefits
segment
61
HELPFUL HINT
For example Do not leave MTC IP in the 050
Benefits segment if you are now sending MTC PY to
report a full settlement (which will include a
500 Benefits segment). This will reject.
62
HELPFUL HINT
Recap In FL, if MTC is reported in any
Benefits segments, the segment will be considered
an Event Benefits segment, which means
all Event Benefits segment data elements will
be required to be
present
63
  • For example
  • TT (050) previously paid
  • Benefits subsequently changed from TP (070) to IB
    (030).
  • MTC CB is required in the 070 (TP) and the 030
    (IB) segments. These are both Event Benefits
    segments

64
Example (contd) If the MTC is also sent in
the old 050 TT segment, it too will be edited
as an Event Benefits Segment, and therefore all
data will be required and edited.
65
  • Sweep
  • Benefits
  • Segments

66
SWEEP BENEFITS SEGMENT RULES
  • A Sweep Benefits Segment(s) must be sent in
    addition to any Event Benefit Segment(s), for
    different Benefit Type Code(s) previously been
    paid but not part of the Event that is
    currently being reported.

67
SWEEP BENEFITS SEGMENT RULES
MTC is NOT included in the Benefits Segment for
the following Sweep MTCs
  • 02 (only if Benefits segment data is not changing
    and you dont want DWCs program to edit any
    BTCs),
  • 04
  • PD
  • PY reporting BTC 5XX
  • Periodics SA FN

68
SWEEP BENEFITS SEGMENT RULES
If the MTC is sent in a Sweep Benefits segment,
the Benefits Segment will be edited as an Event
Benefits segment. In this case,
certain data elements will be expected to be
present, and if not sent, will result in a
rejection.
69
SWEEP BENEFITS SEGMENT RULES
  • Example
  • 00/IP filed to report payment of TT
  • CB filed to report change in benefits from TT to
    TP
  • This CB reflects 2 Event Benefits segments for TT
    and TP (each contains MTC CB).
  • (continued next slide)

70
SWEEP BENEFITS SEGMENT RULES
  • Another CB is filed to report change from TP to
    IB this CB also reflects 2 Event Benefits for TP
    and IB (again, each segment would contain MTC
    CB).
  • The prior TT Benefits Segment is a Sweep
    Benefits Segment(s) that should be sent along
    with the two Event Benefits Segments (and would
    not contain MTC CB).

71
SWEEP BENEFITS SEGMENT RULES
A Sweep Benefits Segment must include the
following data elements
  • Benefit Type Code
  • Benefit Period Start Date
  • Benefit Period Through Date
  • Benefit Type Claim Weeks
  • Benefit Type Claim Days
  • Benefit Type Amount Paid

72
SWEEP BENEFITS SEGMENT RULES
A Sweep Benefits Segment will NOT include the
following
  • MTC (if sent would imply Event Segment)
  • Gross Weekly Amount
  • Gross Weekly Amount Effective Date
  • Net Weekly Amount
  • Net Weekly Amount Effective Date
  • Benefit Payment Issue Date

73
SWEEP BENEFITS SEGMENT RULES
BENEFIT PERIOD START DATE
  • For MTCs (on non-acquired claims) that are
    not initiating or reinstating a Benefit Type Code
    (PY with BTC 5XX, FN, SA, and 04 PD if preceded
    by payment) The Benefit Period Start Date is
    the earliest date for that Benefit Type Code,
    regardless of whether multiple benefit periods
    have been paid for that Benefit Type Code.

74
SWEEP BENEFITS SEGMENT RULES
When an MTC applies to the claim as a whole, the
MTC is sent at the Claim Level only (A49) and is
not populated in the Benefits segment.
MTC
If MTC sent it will be edited as an Event segment.
75
Sweep DNs
76
Questions?
77
Caveats and Tips for Successfully Filing 00/IP
78
Caveats and Tips for Successfully Filing 00/IP
  • If you receive the error,
  • BOTH FROI SROI MUST PASS EDITS TO ACCEPT FILING
  • this means there was a fatal error on either the
    FROI or SROI, so you must correct the error(s)
    and re-send BOTH the FROI and SROI.

79
Caveats and Tips for Successfully Filing 00/IP
  • We are also still seeing the following errors
    with great frequency
  • NO MATCHING FIRST REPORT
  • NO MATCHING SUBSEQUENT REPORT

80
Caveats and Tips for Successfully Filing 00/IP
  • These rejections are occurring when the FROI and
    SROI are not received and processed on the same
    day or when the FROI/SROI did not match, when a
    combo filing is required.

81
Caveats and Tips for Successfully Filing 00/IP
It is critical these errors are resolved asap to
avoid any resulting penalty for late filing with
the Division.
82
Other Errors Occurring on
00/IP Filings
83
Caveats and Tips for Successfully Filing 00/IP
  • We have been receiving DOBs yielding extremely
    young ages, which upon further investigation,
    were determined to be incorrect.
  • Currently, our program generates a TA-FL if the
    DOB sent yields an age less than 13 years or
    greater than 85 years

84
Caveats and Tips for Successfully Filing 00/IP
  • in which case the suspect DOB is not loaded to
    our database and you are expected to either
    revise your DOB or confirm if the DOB is correct.
  • But because the IAIABC standard requires DOB lt
    DOI, our program has not been rejecting filings
    where the DOB defaulted to DOI, therefore
    yielding an age of 0. So,

85
Caveats and Tips for Successfully Filing 00/IP
Beginning 4/30/10, DWCs program will now
reject filings where the DOB (at the time of the
DOI) yields an age lt 5, to minimize
truly incorrect DOBs and later
follow-up with our TPs. Note DWC already
returns a TR if the DOB yields an age of 100
years or more.
86
Caveats and Tips for Successfully Filing 00/IP
  • Discrepancies in the EMPLOYEE NAME will be
    brought to your attention for correction in your
    database (Employee First and Last Name are
    included in our programs match data criteria.)

87
Caveats and Tips for Successfully Filing 00/IP
  • DWC is statutorily required to collect the EEs
    address, so our program initially precludes the
    acceptance of filings where the EEs address
    EMPLRs address.
  • This edit is included in FLs requirements in
    part because EAO sends an initial contact letter
    to the EE therefore a proper address is needed
    (which is typically not the employers address.)

88
Caveats and Tips for Successfully Filing 00/IP
  • Filings that reject for this error can be
    re-loaded by DWC upon receipt of confirmation the
    EEs and EMPLRs address are indeed one in the
    same.
  • Prior to re-loading, the EDI Team will Google
    the EEs address and compare it to the nature of
    the employers business and the EEs occupation
    to determine if the addresses are likely the same.

89
Caveats and Tips for Successfully Filing 00/IP
  • In addition to a Benefits segment, FL also
    requires a Payment segment on the IP because we
    need to record the exact amount of the Claim
    Admin.s initial payment of indemnity (helpful to
    CPS.)

90
Caveats and Tips for Successfully Filing 00/IP
  • The R3 Payment Issue Date (a/k/a Date First
    Payment Mailed - paper term) must be the date
    the initial payment was actually mailed (or left
    the Claim Administrators control.)

91
Caveats and Tips for Successfully Filing 00/IP
If you are reporting the day the check is issued
by your system, you must ensure the check is
actually mailed that same day. The audit team
WILL validate.
92
Caveats and Tips for Successfully Filing 00/IP
  • If filing late, or re-sending an 00/IP that
    previously rejected, AND another indemnity check
    has been issued since the first installment

93
Caveats and Tips for Successfully Filing 00/IP
the Benefit Type Amount Paid should reflect
the total cumulative amount of ALL
indemnity paid to date at the time of filing, not
just the amount of the initial indemnity (IP)
check.
94
Caveats and Tips for Successfully Filing 00/IP
However, the Payment Segment should only
reflect the initial payment information, not
subsequent payment information. Again, this
is the segment from which DWC loads Date First
Payment Mailed to its claims system, utilized by
CPS.
95
Caveats and Tips for Successfully Filing 00/IP
  • Do not pay the waiting week only and therefore
    prematurely report the 00/IP to avoid potential
    late payment and/or filing penalties
    This will reject

96
Caveats and Tips for Successfully Filing 00/IP
Payment of the waiting week early is
gratuitous, and the claim is considered a
medical only claim and not reportable until the
employee has been disabled at least 8 days.
97
Caveats and Tips for Successfully Filing 00/IP
  • Accuracy of Claim Type is extremely important.
    Claim Type must be correct in relation to the
    Initial Date Disability Began and RTW information

98
Caveats and Tips for Successfully Filing 00/IP
  • If disability is NOT immediate and continuous
    (broken periods or delayed dis), Claim Type must
    be L (Became LT), which requires Initial Date
    of Lost Time and Date Claim Administrator Had
    Knowledge of Lost Time.
  • Also, if the Employee RTWd within the waiting
    wk, Claim Type must L.

99
Caveats and Tips for Successfully Filing 00/IP
  • Claim Type (continued)
  • If the Initial Date Disability Began is the same
    as the DOI (or DOI 1) and the Employee has not
    RTWd, Claim Type must be I (LT/indemnity
    immediate and continuous)

100
Caveats and Tips for Successfully Filing 00/IP
  • If Claim Type was incorrectly sent as I but
    should have been L, even if 8th Day data was
    included on the filing, such will not be
    edited/loaded and therefore not available to CPS.
  • The filing will be treated as a straight lost
    time case (and you may need to file 02 to have
    penalty revoked.)

101
Pop Quiz
102
What does the data element ,
Initial Date of Lost Time represent?
103
ANSWER Employees 8th Day of Disability
104
Caveats and Tips for Successfully Filing 00/IP
  • Initial Date of Lost Time is not the same as
    Initial Date Disability Began.
  • These are two different data elements.

105
Caveats and Tips for Successfully Filing 00/IP
  • Since the Initial Date of Lost Time equates to
    the 8th day of disability, it must always be sent
    as a date that is at least equal to, or more than
    the Initial Date Disability Began 7 days.

106
Caveats and Tips for Successfully Filing 00/IP
  • If the amount of time represented by the Start
    and Through Dates is more than the amount of
    Weeks/Days reported, a Non-Consecutive Period
    Code will be expected.
  • Note This code is not required on a SROI MTC
    RB, or an IB only First Report.

107
Caveats and Tips for Successfully Filing 00/IP
  • Non-Consecutive Period Code is often
    misunderstood.
  • It is used to report if the disability period
    for a particular benefit type was
    non-consecutive, i.e., broken periods of
    disability within one Benefit Type.

108
Caveats and Tips for Successfully Filing 00/IP
  • Reduced Benefit Amount Code DWCs program now
    precludes this code from being sent on the first
    report of injury (since it is never applicable on
    the initial payment.)

109
Caveats and Tips for Successfully Filing 00/IP
  • If 00/EP is initially reported, after which a
    SROI IP is sent to report the Claim Admin.'s
    Initial Payment of indemnity, Reduced Benefit
    Amount Code R must be reported if BTC 2xx is
    not included on the SROI IP.

110
Caveats and Tips for Successfully Filing 00/IP
We will discuss Reduced Benefit Amount Codes in
more detail relative to other SROI MTCs later
in the training.
111
Caveats and Tips for Successfully Filing 00/IP
  • We continue to see errors involving the Net
    Weekly Amount sent on the IP (as well as other
    SROIs).
  • Remember, the Net Weekly Amount should represent
    the weekly rate at which a particular BTC is
    being paid.
  • It is NOT necessarily the Comp Rate.

112
Caveats and Tips for Successfully Filing 00/IP
  • If you are receiving errors for
  • NET lt FL CALC GROSS AMT MINUS ADJ/CREDIT AMTS
  • This means the Net Weekly Amount you are sending
    is not in line with the amount calculated by
    DWCs program (within 5).

113
Caveats and Tips for Successfully Filing 00/IP
  • The FL CALC GROSS AMT is determined for each
    BTC in accordance with the Average Wage reported
    on the SROI our program next subtracts any
    weekly adjustment or credit amount reported (if
    still being applied).

114
Caveats and Tips for Successfully Filing 00/IP
  • The FL CALC GROSS AMT formula (pre-adjustment
    or credit) for each BTC is set out in the Edits
    Matrix, specifically, the FL Calculation
    (Proprietary) tab.

115
Caveats and Tips for Successfully Filing 00/IP
  • The expected FL CALC GROSS AMOUNT computed by
    DWCs program is displayed on the Errors tab in
    the data warehouse under Comparison Amount Per
    Edit.
  • Just scroll to right while on a particular error
    row (see next slide.)

116
Caveats and Tips for Successfully Filing 00/IP
117
Caveats and Tips for Successfully Filing 00/IP
  • If you are receiving errors for
  • NET .05 OVER FL CALC GROSS MINUS ADJ/CREDIT AMTS
  • This means that the Net Weekly Amount you are
    sending is more than 5 over the amount
    calculated by our program.

118
Caveats and Tips for Successfully Filing 00/IP
Example FL CALC GROSS AMT for a TT Cat (051)
Benefits segment would be determined as 80 of
AWW (subject to Max CR). If you instead reported
66 2/3 of AWW, this edit would be invoked.
119
Caveats and Tips for Successfully Filing 00/IP
  • Also, if your SROI contains two Benefits
    Segments, one for TT (050) and one for IB (030),
    there should be a different Gross and Net Weekly
    Amounts for each segment, since each of these
    benefit types are paid at different weekly rates.

120
Caveats and Tips for Successfully Filing 00/IP
  • Again, the Gross and Net Weekly Amounts are not
    the Comp Rate.
  • For TT, the weekly rate happens to be the same
    amount as the Comp Rate (66 2/3 of AWW). But
    you would not necessarily report this same amount
    for all other BTCs.

121
  • POP QUIZ
  • True or False
  • DWC defaults to a value of 5 if Number of Days
    Worked Per Week is not sent.

122
  • Answer
  • False
  • Number of Days Worked Per Week is required
    unless BTC 030 (IB) is the only benefit reported
    on an IP or AP.
  • Since IBs are paid in whole weeks only, a daily
    rate is not computed.

123
Caveats and Tips for Successfully Filing 00/IP
  • If you are receiving errors for
  • WKLY COMP AMT NOT CORRECT FOR
    AWW
  • The Weekly Comp Amount (Comp Rate) is statutory
    should be always be reported as 66 2/3 of the
    AWW ( or 5) for DOIs on or after 8/1/79.
  • Even if you were ordered to pay a higher
    weekly rate for TT (050).

124
Caveats and Tips for Successfully Filing 00/IP
  • If the 00/IP reports TP (070) benefits, Initial
    RTW Date (and other related RTW fields,
    including RTW Type Code A or R) must be sent
    since a return to work release is required to
    establish eligibility for TP benefits.

125
Caveats and Tips for Successfully Filing 00/IP
  • The Initial RTW Date represents the first day
    the EE actually RTW (A) or was released to RTW
    ( R) after the accident, not following the
    initial period of disability.

126
Caveats and Tips for Successfully Filing 00/IP
  • If the EE continued to work restricted duty
    following the accident and TP was effective
    immediately (no days off work), the Initial RTW
    would be either the DOI or DOI 1 (depending if
    Empr paid for DOI.)

127
Caveats and Tips for Successfully Filing 00/IP
  • If the 00/IP reports BTC 030 IB Only, the
    Initial RTW Date with the applicable RTW Type
    Code (A- Actual or R- Released) are required...

128
Caveats and Tips for Successfully Filing 00/IP
  • This will ensure DWC applies the correct IB
    payment rate (i.e., the FL Calc Gross Amt.)
  • If Actual RTW Date is not sent when applicable,
    DWCs program will compute the full IB rate.

129
Caveats and Tips for Successfully Filing 00/IP
  • The calculation for determining FL Calc Gross
    Amt for IBs (030) was recently amended to allow
    for the payment of EITHER a 37.5 or a 75 rate
    when the EE has actually returned to
    work, based on recent
    court case.

130
  • The First DCA found in the case of Seminole
    County Govt v. Eric Baumgardner (2/5/10), that
    F. S. 440.15(3)(c) does not allow the Claim
    Admin. to reduce IBs by 50 if the Claimant is
    working but not earning 100 of the AWW, even if
    the reason for the reduced earnings is unrelated
    to the accident.

131
Caveats and Tips for Successfully Filing 00/IP
  • If the initial payment is for Impairment Income
    Benefits (030) paid in a lump sum, you would send
    a SROI PY (with FROI ) instead of a SROI IP.
  • Lump Sum Payment/Settlement Code (i.e. A
    Advance) is not required here because lump sum
    payments of IBs are sometimes made in arrears
    for back IBs due versus an advance of future
    IBs due and owing.

132
Caveats and Tips for Successfully Filing 00/IP
  • BTC 030 IB Only paid in a lump sum via 00/PY
    will be discussed in more detail when we cover
    SROI MTC PY filings.

133
Acknowledgement Free Form Text
Messages for
Claim Administrators
Free Form Text
134
Where applicable, the following additional
information is provided by DWC on the
Acknowledgement in the 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 Exemptions
  • Go to Proof of Coverage database on web
    https//secure.fldfs.com/WCAPPS/Compliance_poc/wPa
    ges/query.asp
  • Search by the EE Name or SSN.
  • Review Exemption on file to see if the Employer
    listed on the Exemption is the same as the
    accident Employer. If so, the EE should
    technically not be receiving WC benefits.

136
Lets complete a SROI for
Scenario 1-A-8 (New) in your Handouts
137
Electronic First Report of Injury or
Illness Initial Payment 00/IP BTC 070 with
Multiple Initial RTW Dates on same IP (Scenario
1-A-8)
138
Relative to this scenario, an IRR was recently
submitted requesting clarification/modification
of DP Rule in order to address the correct
Initial RTW date that should be reported if
both a Released and Actual RTW Date occur
before the first payment.
139
Currently, there is no clear guidance from the
IAIABC as to how to report multiple Initial RTW.
The following scenario presents FLs current
position until we receive further direction from
the IAIABC.
140
  • The SROI IP will contain partial data excerpted
    from the SROI, and includes
  • 1 Benefits Segment and
  • 1 Payments Segment.

141
0001 Transaction Set ID
A9 Subsequent Report
0002 Maint. Type Code
IP Initial Payment
0003 MTC Date
20100123 Jan.23, 2010
0004 Jurisdiction Code
FL
0006 Insurer FEIN
785902378
0014 Claim Administrator Postal Code
379921223
0056 Initial Date Disability Began
20100101 Jan. 1, 2010
0072 Current Return to Work Date
N/A
142
0063 Wage Period Code
01 Weekly
0064 Number of Days Worked Per Week
5
0031 Date of Injury
20100101 Jan. 1, 2010
0015 Claim Admin. Claim Number
WC1256782
0005 Jurisdiction Claim Number N/A
0074 Claim Type Code
I Indemnity/ Lost Time
143
R22 Data Elements
0001 Transaction Set ID
R22
N/A
Date Claim Administrator Had Knowledge of Lost
Time (Clm Admins Knowledge of 8th Day of Dis for
FL)
0298
0015 Claim Administrator Claim Number
WC1256782
0187 Claim 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
S Social Security Number
0270 Employee ID Type Qualifier
0042 Employee SSN
324556745
145
0043 Employee Last Name
SMITH
0044 Employee First Name
JOHN
0045 Employee Middle Name/Initial
J
0255 Employee Last Name Suffix
JR
19530501 May 1, 1953
0052 Employee Date of Birth
0202 Reduced Benefit Amount Code N/A
146
0228 Return To Work With Same Employer Ind
Y Yes
N/A
Non-Consecutive Period Code
0212
N/A
Current Date Last Day Worked
0145
N/A
Current Date Disability Began
0144
0065 Initial Date Last Day Worked
20100101 Jan. 1, 2010
0189 Return To Work Type Code
A Actual
147
0224 Physical Restrictions Ind.
Y Yes
0134 Calculated Weekly Compensation Amount
00000040000 400.00
0256 Wage Effective Date
20100101 Jan. 1, 2010
01 Trauma
0290 Type of Loss Code
0058 Employment 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
0297 Initial Date of Lost Time (8th Day)
N/A
993574528
0200 Claim Admin. Alternate Postal Code (Mailing)
149
Variable Segment Counters
0288 Number of Benefits
01 1 Occurrence
0283 Number of Payments
01 1 Occurrence
0282 Number of Other Benefits
02 2 Occurrences
0289 Number of Benefit ACR
00
0284 Number of Recoveries
00
150
0285 Number of Reduced Earnings
00
0275 Number of Concurrent Employers
00
0277 Number of Full Denial Reason Code
00
0276 Number 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
0211 Net Weekly Amount Effective Date
N/A for TP
152
0088 Benefit Period Start Date
20100101 Jan. 1, 2010
0089 Benefit Period Through Date
20100121 Jan. 21, 2010
0090 Benefit Type Claim Weeks
0003
0091 Benefit Type Claim Days
0
0086 Benefit Type Amount Paid
00000115200 1152.00
0192 Benefit Payment Issue Date
20100123 Jan. 23, 2010
153
Payments
1 Occ
0222 Payment Reason Code
070 Temporary Partial
0217 Payee
JOHN J SMITH JR
0218 Payment Amount
00000115200 1152.00
0219 Payment Covers Period Start Date
20100101 Jan. 1, 2010
0220 Payment Covers Period Through Date
20100121 Jan. 21, 2010
0195 Payment Issue Date
20100123 Jan. 23, 2010
PI reported under OBT 311 and 321
154
Questions?
155
More on Other First Report /
EDI DWC-1 Equivalent MTCs
156
Other First Report/EDI DWC-1 Equivalents Recap
EDI DWC-1 Equivalent MTCs other than 00/IP are
used when indemnity benefits are not initially
being paid by the Claim Admin., but a report of
injury is due to DWC for a lost time case (e.g.,
FROI 04.)
157
  • EDI DWC-1 Equivalents
  • The following SROIs (sent with FROI 00), will
    still require a Benefits segment
  • EP Employer Paid
  • PY Lump Sum Payment/Settlement

158
  • Initial Payment Equivalents (Sent with FROI 00 or
    AU)
  • However, there will not be any Benefits Segments
    on the following SROI MTCs (sent with FROI 00),
    since no indemnity was paid on the claim.
  • CD (Compensable Death,
  • VE (Compensable Volunteer, and
  • PD (Partial/Indemnity Only Denial).

159
POP QUIZ Which MTC(s) are sent to report an
Electronic First Report of Injury or Illness
where salary was paid in lieu of compensation?
160
AnswerMTC 00/EP EMPLOYER PAID BENEFITS
161
EMPLOYER PAID BENEFITS
  • 69L-56.002(22), F.A.C. defines Employer Paid
    Salary in Lieu of Compensation as the employer
    paid the employee salary, wages, or other
    remuneration for a period of disability for
    which the insurer would have otherwise been
    obligated to pay indemnity benefits.

162
EMPLOYER PAID BENEFITS
  • This does NOT include the waiting week if the
    employee was not disabled for 22 or more days.

163
EMPLOYER PAID BENEFITS
  • 00/EP Initial Payment Equivalent
  • Represents the first report of payment of an
    indemnity benefit other than a lump sum
    payment/settlement that has been paid by
    the employer in lieu of compensation.

164
EMPLOYER PAID BENEFITS
00/EP Initial Payment Equivalent
  • The EE has received only salary in lieu of
    compensation from the employer at the time of
    filing.
  • The Claim Administrator has not paid any
    indemnity benefits at the time of filing.

165
A 00/EP filing must contain only 2xx benefits
segment(s).
EMPLOYER PAID BENEFITS
  • 240 Employer Paid Unspecified Indemnity
    benefits
  • 250 Employer Paid TT benefits
  • 270 Employer Paid TP benefits

166
EMPLOYER PAID BENEFITS
  • Also valid, but not as typical
  • 210 Employer Paid Death benefits
  • 230 Employer Paid Impairment Income benefits
  • 242 Employer Paid Voc Rehab (TT RE)
  • 251 Employer Paid TT Catastrophic (80)

167
EMPLOYER PAID BENEFITS
If the initial payment of indemnity benefits are
paid by the Employer as a full settlement, BTC
524 would be reported via MTC 00/PY (vs.
00/EP).
168
EMPLOYER PAID BENEFITS
  • Benefit Type Codes 210, 230, 242, 250, 251, 270
    should be used if the Claim Admin. knows the
    specific benefit type for which the injured
    worker was paid salary in lieu of comp (Benefit
    Type Amount Paid is reqd for these BTCs.)
  • If the specific benefit type is unknown, BTC 240
    should be used.

169
Data Population Rules for Employer Paid Benefits
170
Caveats and Tips for Successfully Filing 00/EP
171
Caveats and Tips for Successfully filing 00/EP
  • Do not send SROI EP if, at the time of filing,
    the only compensation the EE received was salary
    in lieu of comp (BTC 2xx) for the waiting week
    (Days 1-7).

172
Caveats and Tips for Successfully filing 00/EP
POP QUIZ If the EE has received payment
from the Employer for Days 1 thru 7 and
payment from the Claim Admin. for Days 8 thru
14, what MTC(s) should be filed w/DWC?
173
Caveats and Tips for Successfully filing 00/EP
ANSWER 00/IP
174
Caveats and Tips for Successfully filing 00/EP
  • Here, the 00/IP (sent at Day 14) may include the
    2xx Benefits segment for Days 1 thru 7.
  • But because salary was not paid beyond the
    waiting week, it cannot be considered salary in
    lieu of comp (since Days 1-7 were not yet payable
    at the time of filing.)

175
Caveats and Tips for Successfully filing 00/EP
  • If BTC 2xx was not included on the 00/IP and the
    EE was eventually disabled for 22 or more days
    such that the waiting week does become
    payable/reportable

176
Caveats and Tips for Successfully filing 00/EP
  • BTC 2xx should appear on the next SROI to
    account for payment of the waiting week.
  • In this situation, a SROI CB is not
    required to introduce the new 2xx
    benefits (so long as the Start Date of
    the 2xx segment is the earliest Start Date of all
    benefits reported.)

177
Caveats and Tips for Successfully filing 00/EP
  • If you issue payment after the Empr, where the EE
    was disabled for 22 days or more, but the 00/IP
    is being filed late, the IP should include both
    the 2xx segment along with the segment reporting
    benefits paid by the Claim Admin (providing you
    did not fully reimburse the employer for all
    salary paid.)

178
Caveats and Tips for Successfully filing 00/EP
  • Here, Days 1 thru 7 paid by the Employer
    does constitute salary in lieu of compensation
    that the Claim Administrator would have otherwise
    had to pay (since the EE was
    disabled for 22 or more days.)

179
Caveats and Tips for Successfully filing 00/EP
  • If you receive a penalty because you incorrectly
    filed an 00/IP and meant to file 00/EP, you can
    send a SROI 02 to revise the benefit picture
    and change the earliest paid indemnity to BTC
    2xx

180
Caveats and Tips for Successfully filing 00/EP
  • however, the SROI 02 must be the next accepted
    filing.
  • Also, MTC 02 must be included in the Benefits
    segment. Otherwise, DWCs program will not
    edit/load the Benefits segment(s).

181
Caveats and Tips for Successfully filing 00/EP
  • Also, Reduced Benefit Amount Code R must be
    present on the 02 to explain the disappearance
    of the previously reported BTC 2xx.

182
Caveats and Tips for Successfully filing 00/EP
  • After you confirm the 02 was accepted (see
    filing results in Data Warehouse next day), you
    can request a re-evaluation of a penalty that may
    have resulted from the incorrect initial
    benefit information.

183
Caveats and Tips for Successfully filing 00/EP
  • If the 02 is the next accepted filing, the
    following fields will be updated in DWCs
    database automatically (so the Claims EDI Team
    will not have to manually revise DWCs claim
    record prior to CPS re-evaluation)

184
DNs Changed by 02 if Next Accepted Filing
  • Salary Contd in Lieu of Comp Ind.
  • BTC 240 (Salary) Through Date
  • Original BTC
  • Claim Admin. Knowledge of Injury
  • Payment Issue Date
  • Pen Int Amount Paid in 1st Payment (OBTs
    311 and 321)

185
Caveats and Tips for Successfully filing 00/EP
  • If the 02 is not the next accepted filing after
    the 00/IP, these fields will need to be manually
    updated by the EDI Team (upon request by
    the CPS Admin.) to replace the initial
    payment data with the correct information.

186
Caveat sand Tips for Successfully filing 00/EP
  • Employer Paid Salary In Lieu of Compensation
    Indicator (DN-273) should be reported as Y only
    if Employer is currently paying salary in lieu of
    comp.
  • If Employer discontinues salary and Claim Admin.
    picks up payment, the Indicator should be changed
    to N.

187
Caveats and Tips for Successfully filing 00/EP
  • If you subsequently reimburse the employer for
    all salary paid in lieu compensation, Reduced
    Benefit Amount Code R Reclassification should
    be sent on the next transaction to explain why
    the 2xx Benefits segment is no longer present.

188
Caveats and Tips for Successfully filing 00/EP
  • If the employer actually paid salary in lieu of
    comp (for more than the ww), but the 00/IP was
    filed late and the Claim Admin. has already
    reimbursed the employer for all prior employer
    paid benefits, there will never be a 2xx segment
    on any EDI transaction. As a result,

189
  • you will need to supply other documentation
    to satisfy the CPS Specialist that salary was
    initially paid and that the initial payment was
    not late.
  • Afterwards, the EDI Team will be asked by CPS
    Admin. to update DWCs system to reflect the
    initial payment of indemnity as salary in lieu of
    comp.

190
Caveats and Tips for Successfully filing 00/EP
  • If salary in lieu of comp was initially reported
    in error or mis-coded from a paper DWC-1 or R1
    EDI filing
  • Rather than sending Reduced Benefit Amount Code
    R to reconcile the problem, contact the EDI
    Team, which can manually modify the initial
    filing information on DWCs database.

191
Caveats and Tips for Successfully filing 00/EP
  • Recap For R3 EDI filings
  • An MTC 02 is required to report corrected initial
    payment information.
  • If intervening EDI transactions were accepted
    prior to the 02, an EDI Team member will need to
    manually update DWCs database upon verification
    of the corrected data on the 02.

192
Caveats and Tips for Successfully filing 00/EP
  • We are seeing many rejections of 00/EP filings
    that appear to be medical only.
  • Remember, the Start Date of 2xx must be at least
    Day 8 of disability. You may need to either
    change an inaccurate Initial Date Disability
    Began or Start and Through Dates.

193
POP Quiz What MTC should be filed with DWC if
the employer ceases to pay salary in lieu of
compensation and you start paying instead?
194
Answer SROI MTC IP
195
IP after EP
  • If you are making your initial
    payment of indemnity (not a lump sum
    payment/settlement) after Empr paid salary in
    lieu of comp
  • A SROI MTC IP must be sent after the MTC EP that
    reported the initial payment of Employer Paid
    benefits.

196
  • If your initial payment, after the Employer paid
    benefits, is for a Final Settlement, send SROI PY
    (instead of IP.)

197
  • And if your initial payment, after the Employer
    paid benefits, is a lump sum payment that is not
    a final settlement (e.g., advance),
    send PY followed by an IP to show payment of
    ongoing benefits (EP PY IP.)

198
  • Also, if you will be continuing payment (after
    the Employer paid) and a SX was previously filed
    that reported the suspension of employer paid
    benefits, a SROI IP (vs. RB) should be filed with
    DWC to report your initial payment of indemnity
    (EP Sx - IP.)

199
  • In these cases, the standalone SROI MTC IP, PY
    represent an Electronic Notice of Action/Change,
    EDI DWC-4 equivalent, required in Rule
    69L-56.304(3), F.A.C.
  • DWC-4 or explanatory letter is required to be
    sent to the EE and Employer.

200
EP after IP
  • If the Employer elects to pay indemnity
    benefits, e.g., Impairment Income benefits, AFTER
    the Claim Administrator paid indemnity benefits,
    a SROI EP must be filed after MTC IP.
  • See Rule 69L-56.304(5), F.A.C. (No DWC-4 or
    letter required.)

201
EP after Sx
  • EP is also required if the employer paid
    benefits after an Sx that reported suspension of
    indemnity benefits previously paid by the Claim
    Admin (IP Sx - EP)
  • See Rule 69L-56.304(5), F.A.C. (No DWC-4 or
    letter required.)

202
SROI ER would only be applicable in this
situation if the employer had previously paid (EP
IP Sx ER.) See Rule 69L-56.3045(6), F.A.C.
(No DWC-4 or letter required.)
203
  • Exception to filing an EP or ER
  • If the employer elects to pay a lump sum
    payment/settlement, you would send MTC PY with
    BTC 524 (Employer Paid Lump Sum
    Payment/Settlement.)

204
Questions?
205
POP QUIZ What MTC is used to report a Totally
Denied Electronic First Report of Injury or
Illness?
206
ANSWER FROI MTC 04 Full (Total) Denial EDI DWC-1
Equivalent required to be filed with DWC per Rule
69L-56.301(2).
207
FROI MTC 04 Full (Total) Denial
  • FROI 04 represents a total denial of all
    indemnity and medical benefits, including denials
    based on compensability.

208
FROI MTC 04 Full (Total) Denial
  • This is the only EDI DWC-1 equivalent that does
    not require a corresponding SROI MTC to be paired
    with a FROI MTC.

209
FROI MTC 04 Full (Total) Denial
  • Even if a claim is classified as medical only
    in your system, if compensability of the claim is
    being denied, you must still report the
    claim to DWC, since the entire claim,
    including any potential indemnity, is
    denied.

210
FROI MTC 04 Full (Total) Denial
  • The corresponding Electronic Notice of Denial,
    EDI DWC-12 equivalent, is also due, and
    reported on the same FROI 04.

211
  • FROI MTC 04 - Full (Total) Denial
  • To report the EDI DWC-12 equivalent, the FROI 04
    must contain
  • Full Denial Reason Code,
  • Full Denial Effective Date, and
  • Denial Reason Narrative.
  • Note A paper copy of DWC-1 and DWC-12 must be
    produced for the EE Employer.

212
  • FROI MTC 04 - Full (Total) Denial
  • Full Denial Reason Code should identify all of
    the reasons the claim was denied (up to five
    different codes can be sent.)
  • Code 3F (Statute of limitations expired) is
    precluded unless MTC Date is gt one year after
    the DOI.

213
  • FROI MTC 04 - Full (Total) Denial
  • Also, Full Denial Reason Code 5B (Right to
    Reserve) can not be the only Full Denial Reason
    Code sent.

214
  • FROI MTC 04 - Full (Total) Denial
  • Full Denial Effective Date is the date from
    which the Claim Admin. is denying all benefits
    for the claim (e.g., DOI).
  • Can not be sent as a future date (i.e., later
    than the date the 04 was received by DWC.)

215
  • FROI MTC 04 - Full (Total) Denial
  • Denial Reason Narrative is required and must
    contain supporting documentation for the denial
    and must not repeat the text description of the
    Denial Reason Code.
  • EAO will require an 02 Change transaction if the
    Denial Reason Narrative is insufficient.

216
  • FROI MTC 04 - Full (Total) Denial
  • If a Full Denial Claim (FROI 04) begins as a
    Medical Only case, Claim Type M should be
    sent to represent a Medical Only Case for which
    compensability is being denied

217
FROI MTC 04 - Full (Total) Denial
  • Claim Type M should only be sent on a FROI 04
    where initial disposition was a compensable
    medical only claim that was subsequently denied
    in full (e.g., 3 months after the DOI).
  • It should not be sent on a FROI 04 for which
    indemnity was claimed at the time of initial
    disposition (14 days of knowledge.) 

218
FROI MTC 04 - Full (Total) Denial
  • If denials are ever re-included in CPS in the
    future, Claim Type M may
    serve to differentiate this type of denial from a
    straight lost time denial that can be evaluated
    for timely filing.  

219
FROI MTC 04 - Full (Total) Denial
Note Claim Type L (MO to LT) would not be
applicable in this situation because there may
not be any actual or claimed disability dates
to report if compensability is being denied in
general, so ...
220
FROI MTC 04 - Full (Total) Denial
  • there would not be any associated 8th day of
    disability information to report, which is
    required if Claim Type L.   

221
FROI MTC 04 - Full (Total) Denial
  • We inspected FROI 04 filings that reported Claim
    Type M and found that many were sent within 14
    days of the DOI, in which case Claim Type M is
    not applicable.
  • We will therefore be implementing a new edit
    effective Sept. 1, 2010 that will preclude this.

222
Filing Caveats and Tips for Successfully Filing
FROI 04
223
Caveats and Tips for Successfully Filing 04
  • We dont see that many rejections associated
    with FROI 04s since there arent as many data
    elements on the FROI compared to the SROI, but
    the next few slides will identify the most
    frequently occurring types of errors for FROI
    04s..

224
Caveats and Tips for Successfully Filing 04
  • Mainly, we are seeing potential duplication of
    denials, where a FROI 04 was sent, but either a
    DWC-1 or SROI (from same Claim Admin.) was
    already filed.
  • If the denial is not a duplicate and still needs
    to be filed, it must be sent as a SROI 04 (not
    another FROI 04.)

225
Caveats and Tips for Successfully Filing 04
  • Duplicate Denial errors are also occurring when
    more than one FROI 04 is sent in the same batch.
  • Note Unnecessary SROI 04s are also being sent
    after a FROI 04 was already filed, where no
    intervening MTC was filed to accept liability
    after the FROI 04 and before the SROI 04.

226
Caveats and Tips for Successfully Filing 04
  • FROI 04s are also rejecting where Nature of
    Injury Code 60 80 (Occupational Disease or
    Cumulative Injury), but Type of Loss Code 01
    (Traumatic).
  • Here, Type of Loss Code should 02
    (Occupational Disease) or 03 (Cumulative Injury
    - Other than Disease).

227
Caveats and Tips for Successfully Filing 04
  • Some FROI 04s are missing the Employers
    Address and FEIN, which are excused only if you
    are denying the claim on grounds of no coverage
    (Full Denial Reason Code 3A-H.)

228
Caveats and Tips for Successfully Filing 04
  • Recap Full Denial Reason Code 5B (Right to
    Reserve) cannot be the only Full Denial Reason
    Code sent.
  • Also, Full Denial Reason Code 3F (Statute of
    limitations expired) cannot be reported unless
    MTC Date is at least 1 year after the DOI.

229
Questions?
230
POP QUIZ What MTC is used to report an Indemnity
Only Denied Electronic First Report of Injury or
Illness?
231
ANSWER FROI 00 SROI PD (Partial Denial)
EDI DWC-1 Equivalent required to be filed with
DWC per Rule 69L-56.301(2)(c), F.A.C.
232
  • Partial (Indemnity Only) Denial
  • EDI DWC-1 Equivalent
  • A FROI 00 and SROI PD should be filed when the
    claim is found to be compensable, but indemnity
    benefits are denied in whole and only medical
    benefits will be paid.

233
  • Partial (Indemnity Only) Denial
  • EDI DWC-1 Equivalent
  • The same SROI PD sent with FROI 00 will also
    accomplish the reporting of the Electronic Notice
    of Denial, EDI DWC-12 equivalent, since it must
    contain
  • Partial Denial Code (A or E only), and
  • Denial Reason Narrative to provide details about
    why indemnity benefits will not be paid.

234
  • Partial (Indemnity Only) Denial
  • EDI DWC-1 Equivalent
  • PARTIAL DENIAL CODE identifies which portion of
    the claim is being denied (not the reason it is
    denied).

235
Partial Denial Codes for FL
A Denying Indemnity in whole, but not Medical
(Indemnity Only Denied Case) B Denying
Indemnity in part, but not Medical E Denying
Indemnity in whole and Medical in part (Indemnity
Only Denial) G Denying both Indemnity and
Medical in part
236
  • Partial (Indemnity Only) Denial
  • EDI DWC-1 Equivalent
  • The Partial Deni
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