Florida Division of Workers’ Compensation Claims EDI Release 3

Florida Division of Workers’ Compensation Claims EDI Release 3
Training WELCOME

Your Trainer Linda Yon FL DWC EDI Coordinator

Additional DWC Staff Karen Kubie - DWC Claims EDI Lead Business Analyst Kim Wiley – DWC EDI IT Project Manager Janice Youngblood – DWC EDI IT Consultant/Programmer Margaret Forsman - DWC Claims EDI Business Analyst

Additional DWC Staff Tonya Granger - DWC Lead EDI POC Analyst & Claims Analyst Debra Lee – DWC EDI Claims Analyst Laura Cotner - DWC EDI Claims and POC Analyst

Rule Chapter 69L of the Florida Administrative Code is the EDI Rule for Proof of Coverage and Claims (non-medical)

EDI Rule 69L-56,F.A.C. was effective January 7, 2007.
It requires all insurers to implement the IAIABC Claims EDI Release 3 electronic format.

EDI Rule 69L-56 F.A.C. This EDI Implementation applies to all required form filings for all Dates of Injuries, and not just those injuries that occur after the Insurer’s EDI Implementation date. This includes legacy claims.

So Here’s A Little Background On EDI …

On a National level, in 1990 the IAIABC spearheaded a program
to utilize the concept of EDI for Workers’ Compensation data.

What is the IAIABC? The International Association of Industrial Accident Boards and Commissions. A 93-year-old organization of jurisdictional workers’ compensation administrators and others interested in WC.

What is EDI? Electronic Data Interchange is the electronic exchange of data between business trading partners (i.e., claim administrators to state agencies), in a standardized format. This does not include reporting by Injured Workers! EDI

Bringing Together the Important Participants
Developing an Electronic Standard Bringing Together the Important Participants Jurisdictions Carriers Vendors TPA’s

Developing a National Standard through the IAIABC EDI Development Committees was a “consensus development” process that required “give” and “take” from all participants.

The end result is a national standard format for the reporting of workers’ compensation data electronically.

IAIABC EDI Project Background
1990: IAIABC membership adopted IAIABC Committee’s proposal to develop standards for communicating data electronically between providers, payers, and state administrators via EDI. 1993: Claims Release 1 2000: Claims Release 2 (Iowa) 2005: Claims Release 3 Culmination of 4 yrs of work – list how many people have been involved – level of care & detail

Where can you find the IAIABC R3 Implementation Guide & Codes?

The Release 3 Claims Implementation Guide can be purchased for $95 from the IAIABC’s website: or it is free if your company is an IAIABC EDI Member. The latest R Guide is dated January 1, 2008

The Release 3 Claims Implementation Guide contains the transaction record layouts, data dictionary, business and technical rules, national scenarios, etc.

STANDARD USAGE FOR ALL PRODUCTS
Error Message Dictionary Glossary Country Codes State Codes Industry Codes (NAICS 2002 or 2007) Nature of Injury Codes Cause of Injury Codes Part of Body Codes Permanent Impairment Body Part Codes

Glossary Glossary

Glossary The purpose of the Glossary is to acquaint the reader with easy-to-understand definitions of workers' compensation terms that are not defined in the R3 Dictionary as Data Elements.

Glossary The Glossary defines terms that are common to FROI/SROI, MED, and POC EDI reporting. Not all of the terms are directly related to one of the IAIABC EDI reporting products, but they are commonly used in the business and data reporting environment.

Glossary Alphabetical by term

However, terms that are specific to ‘approved’ Data Elements for Claims, POC and Med reporting will be found in the Data Dictionary section of the respective IAIABC Implementation Guide.

Acronyms (see your handout)

ACRONYMS EDI Committee participants frequently use acronyms in their discussions, and newcomers (and veterans, too!) can easily lose their place in what is going on if they don’t understand what the acronyms stand for.

ACRONYM Examples: FTP File Transfer Protocol FEIN
Federal Employer Identification Number FROI First Report of Injury GUI Graphical User Interface HTTP Hyper Text Transfer Protocol SROI Subsequent Report of Injury URL Uniform Resource Locator

RELEASE 3 RELEASE 3

Release 3 Combined Business & Technical Data Dictionary

The Release 3 Data Dictionary Section 6 in the Implementation Guide

Release 3 Data Dictionary
Identifies the Data Number (DN) Gives the Definition of the Data Element Gives the Last Revision Date of the Data Element

Gives the Format (i.e. 2 A/N = two characters alpha/numeric) Lists the Valid Values for the DN Gives DP (Data Population) Rule to Help Identify the Correct Use of the Data Element

FL’s Claims EDI Webpage

FL Supplement Overview:
Tracks all monthly additions or corrections to the requirement tables.

If you haven’t already, begin reviewing FL’s requirement tables (including updated supplement) immediately to determine: When each transaction must be sent (Event Table) Data Elements required for each transaction / MTC (Element Requirement Table)

(Cont’d)… Review FL’s requirement tables (including updated supplement) immediately to determine: Edits that will reject the record (Edit Matrix)

The FL Claims EDI Webpage contains helpful resource documents including: FL EDI Migration Strategies MTC Filing Instructions FL R3 Business Scenarios FL Quick Code Reference Guide Training Questions & Answers MTC to Form Crosswalk Crosswalks of paper DWC Claims Forms to EDI Data Elements

Questions?

In R3 EDI, all WC data is sent electronically via a
FROI or SROI transaction.

What Is A ? FROI

First Report of Injury (FROI)

Release 3 FROI Transaction
Originally, the EDI First Report of Injury Record was identified by a Transaction Set ID of '148' and had a specific Record Layout. In Release 3, the 148 record must be paired with a companion record - R21, FROI Companion Record to complete the First Report of Injury transaction.

Release 3 FROI Transaction
This means the Release 3 FROI transaction requires 2 records to communicate the First Report event, the “148” & “R21” records.

First Report of Injury FROI =148 + R21

Section 2 in the Release 3 Implementation Guide
The FROI Flat File Section 2 in the Release 3 Implementation Guide

FROI Flat File Record Layout

FROI Flat File (148) Record Layout
Data Elements Filler

FROI Companion Flat File (R21) Record Layout
Data Elements Filler

FROI R21 Variable Segments

POP QUIZ If the Accident Description Narrative segments are 50 characters each, and this Accident Description is 161 characters…

…how many segments must be sent to report the entire Accident Description Narrative?

ANSWER = d (4 segments) DN Data Element Name Data Beg End 0038
Accident/Injury Description Narrative AS HELEN WAS LEAVING HER WORK SITE (BLDG 500) SHE 1601 1650 WAS WAITING FOR HER HUSBAND TO PICK HER UP ON THE 1651 1700 STEPS OF THE BLDG. AS SHE LEANED AGAINST THE RAIL 1701 1750 ING & FELL. 1751 1800

What Is A ? SROI

Subsequent Report of Injury
(SROI)

Release 3 SROI Transaction
Originally, the EDI Subsequent Report of Injury Record was identified by a Transaction Set ID of ‘A49' and had a specific Record Layout. In Release 3, the A49 must be paired with a companion record - R22, SROI Companion Record, to complete the SROI transaction.

Release 3 SROI Transaction
This means the Release 3 SROI transaction requires 2 records to communicate the Subsequent Report event, the “A49” & “R22” records.

Subsequent Report of Injury SROI = A49+R22

Section 2 in the Implementation Guide
The SROI Flat File Section 2 in the Implementation Guide

SROI Flat File Record Layout

Now Let’s Discuss Important Codes Common To EDI Transactions

Important Codes Maintenance Type Codes
R3 Quick Code Reference Guide (see handout) Maintenance Type Codes Benefit Type Codes Other Benefit Type Codes

R3 Quick Code Reference Included with your handouts One Stop Shopping

What Is An ? MTC MTC

Maintenance Type Code

Maintenance Type Code A code that defines the specific purpose of each transaction being transmitted.

Maintenance Type Code DWC Forms required to be filed with the Division are replaced by EDI filings identified by MTC codes.

Maintenance Type Code Most MTC codes equate to a specific DWC Form that will no longer be required to be filed with DWC. However the DWC Form may still be required to be sent to other parties (e.g., DWC-1, DWC-4).

First Report of Injury MTC’s

FL FROI MTC’s Include : 00 – Original 04 – Total Denial
01 – Cancel (Claim Filed in Error) AQ – Acquired Claim AU – Acquired First Report

FL FROI MTC’s: Changes 02 – Change

Subsequent Report MTC’s

Initial Payment Equivalents: EP – Employer Paid Salary in Lieu of Comp
FL SROI MTC’s: Initial Payment Equivalents: IP - Initial Payment PY – Payment EP – Employer Paid Salary in Lieu of Comp AP - Acquired First Payment

FL SROI MTC’s: Initial Payment Equivalents (cont’d):
CD – Compensable Death-No Known Dependents/Payees VE - Volunteer

Denials: FL SROI Report MTC’s: 04 – Full Denial
PD – Partial Denial (Indemnity Only & other required partial denials).

Additions/Changes FL SROI MTC’s: AB – Add Concurrent Benefit
CA – Change in Benefit Amount CB – Change in Benefit Type

Reinstatements FL SROI MTC’s: ER – Employer Reinstatement
RB – Reinstatement of Benefits ER – Employer Reinstatement

Full Suspensions (of all Indemnity)
FL SROI MTC’s: Full Suspensions (of all Indemnity) S1 – RTW or Released to RTW S2 - Medical Non-Compliance S3 – Administrative Non-Compliance

FL SROI MTC’s: Full Suspensions (of all Indemnity) S4 – Claimant Death S5 - Incarceration S6 – Claimant’s Whereabouts Unknown

FL SROI MTC’s: Full Suspensions (of all Indemnity) S7 – Benefits Exhausted S8 – Jurisdiction Change You should recognize these from the DWC-4 Form

Partial Suspension (of a concurrent benefit)
FL SROI MTC’s: Partial Suspension (of a concurrent benefit) P7 – Benefits Exhausted FL’s only concurrent benefit type is PT and PT Supplemental Benefits. If one benefit is suspended but the other benefit continues, a Partial Suspension is filed.

Periodic Reports FL SROI MTC’s: SA – Sub Annual
For EDI R3, the Annual Claim Cost Report has been replaced with a Sub Annual report, due every 6 months from the Date of Injury until the claim is closed.

FL SROI MTC’s: Periodic Reports (cont’d)… FN – Final

FL SROI MTC’s: Changes 02 – Changes EDI

Benefit Type Codes (BTC) ?
What are Benefit Type Codes (BTC) ?

codes that identify the type of indemnity benefits being paid.
TT - 050 TP - 070 IB - 030 BTC’s are codes that identify the type of indemnity benefits being paid.

Benefit Type Codes 010 – Fatal/Death 020 – Permanent Total
021 – Permanent Total Supplemental 030 – Perm Partial Scheduled (Impairment Income) 040 – Perm Partial Unscheduled (Supplemental Income) 050 – Temporary Total

Benefit Type Codes 051 – Temporary Total Catastrophic
070 – Temporary Partial 090 – Permanent Partial Disfigurement 410 – Voc Rehab Maintenance 500 – Unspecified Lump Sum Pmt/Settlement 5XX – Specific Lump Sum Pmt/Settlement per Benefit Type Code (e.g., 510, 550, etc.)

Benefit Type Codes 210 – Employer Paid Fatal (Death)
230 – Employer Paid Perm Partial (IB’s) 240 - Employer Paid Unspecified 242 – Employer Paid Voc Rehab Maintenance 250 – Employer Paid Temporary Total 251 – Employer Paid Temporary Total Catastrophic 270 – Employer Paid Temporary Partial

What are “Other Benefit Type” Codes (OBT’s)?

codes that represent the type of non-indemnity benefits being paid.
311 321 370 OBT’s are codes that represent the type of non-indemnity benefits being paid.

Other Benefit Type Codes (required by FL)
300 – Total Funeral Expenses 310 – Total Penalties 311 – Total Employee Penalties 320 – Total Interest 321 – Total Employee Interest 370 – Total Other Medical

Other Benefit Type Codes (required by FL)
380 – Total Voc Rehab Evaluation 390 – Total Voc Rehab Education 400 – Total Other Voc Rehab 430 – Total Unallocated Prior Indemnity Benefits (acquired claims) 475 – Total Medical Travel Expenses

300 400 475 FL has reduced the amount of OBT Codes required to be reported for R3, because the majority of medical information is already being reported to the Division via another electronic format.

Other Benefit Type Codes (not required by FL)
FL no longer requires the reporting of Physician (Medical), Hospital, or Pharmacy/Durable Medical Paid To Date on the EDI Claim Cost “Periodic” report.

Questions?

What Is The Claims EDI Mandate All About ?
How Does It Affect FL WC Insurers?

Rule 69L-56 Rule Section Overview
69L Forms and Instructions 69L Definitions

69L-56.100 Proof of Coverage (POC) Electronic Reporting Requirements
69L Technical Requirements for POC EDI Transmissions 69L Policy Cancellation or Non-renewal Requirements 69L Time Periods for Filing Electronic Policy Information

69L-56. 300. Claims EDI Reporting. Requirements and
69L Claims EDI Reporting Requirements and Implementation Schedules 69L Electronic First Report of Injury or Illness 69L Electronic Notice of Denial and Rescinded Denial 69L Electronic Periodic Claim Cost Reports

69L-56. 304 Electronic Notice of Action or. Change, Including
69L Electronic Notice of Action or Change, Including Change in Claims Administration, Required by the Insurer’s Primary Implementation Schedule 69L Electronic Notice of Action or Change, Suspensions, and Reinstatement of Indemnity Benefits Required by the Insurer’s Secondary Implementation Schedule

69L-56.307 Electronic Cancellation of Claim
69L Technical Requirements for Claims EDI Transmissions 69L Claims EDI Test to Production Status Requirements

69L-56. 330. Electronic Formats for. Reporting the Employee’s 8th
69L Electronic Formats for Reporting the Employee’s 8th Day of Disability and the Claim Administrator’s Knowledge of 8th Day of Disability (This section will eventually be repealed after all current R1 trading partners implement R3) 69L Insurer Responsibilities Where Third Party Services are Utilized

The following DWC paper forms currently being filed with the Division will be replaced by electronic transactions: DWC-1 First Report Of Injury or Illness DWC-12 Notice of Denial DWC-13 Claim Cost Report DWC-4 Notice of Action/Change DWC-49 Aggregate Claims Administration Change Report

EDI filing requirements (i. e
EDI filing requirements (i.e., when a claim administrator must file these EDI transactions with DWC) are in Rule 69L-56, F.A.C. Paper form copies required to be sent to other parties will still be required per Rule 69L-3, F.A.C.

How Will MTC’s and Insurers Be “Phased In” for Implementing EDI R3?

EDI Claims R3 Implementation
The Division has established by rule two implementation schedules for “phasing in” all of the MTC’s required for R3 reporting: The Primary Implementation Schedule includes MTC’s for reporting the electronic equivalent of the DWC-1, 12, 13 & 49 & some DWC-4 data. The Secondary Implementation Schedule includes MTC’s that equate to most DWC-4’s.

Again, implementation of EDI R3 applies to all MTC’s required by rule for all Dates of Injuries, not just for dates of injuries occurring after the Insurer’s R3 production implementation date. Legacy claims are included in the mandate.

Paper forms previously filed do NOT need to be re-submitted electronically.

The Division has divided insurers/self-insurers into three ‘test to production’ periods (tiers), based on Insurer Code #. Insurer Code #’s and current R1 Trading Partners will implement first. Insurer Code #’s will implement next. Insurer Code #’s and will implement last.

If there are multiple subsidiary insurer entities within an insurer’s corporate structure / organization, the insurer’s compliance date for the Primary Implementation Schedule will be based on the lowest numeric value assigned to any of the subsidiary insurer entities in the group.

For Example (Old Reliable Group): Old Reliable Ins Co. = # 145
Old Reliable P&C Co. = # 328 Old Reliable of Illinois = # 733 All insurers in the Old Reliable Group are required to file electronically in the first group of the Primary Implementation Schedule. They must begin testing on

Third Party Administrators (TPAs) are not included in this list because they are not ‘Insurers’. However, a TPA must be ready to comply with the EDI filing requirements as soon as their first Insurer client is required to comply.

Third Party Administrators (TPAs) are not required to implement all of their insurer clients at the same time, but….

…the 30 day initial late filing penalty waiver in rule 69L (d), is only applicable to the “claim administrator” as a whole at the time it first implements R3 EDI filings.

Therefore, if a claim administrator implements R3 EDI for different clients at different times, the subsequent clients will not be granted a separate 30 day late filing penalty waiver.

Claims EDI Primary Implementation Schedule Phase In:
The first group (Insurer Code #s ) began testing November 1, 2007, and are being phased in to production beginning First Group Must Begin Testing: First Group Phased In Production:

The second group (Insurer Code #s ) must begin testing February 1, 2008, and be in production no later than the last day of the 3rd month after the testing period begins. Second Group Must Begin Testing: Second Group Must Be In Production:

The third group (Insurer Code #s and ) must begin testing May 1, 2008, and be in production no later than the last day of the 3rd month after the testing period begins. Third Group Must Begin Testing: Third Group Must Be In Production:

What ‘Forms’ Will Be Required To Be Electronically Submitted In The Claims EDI Release 3 Primary Implementation Schedule?

The Claims EDI R3 Primary Implementation Schedule will include the electronic form equivalents for:
First Report of Injury (DWC-1) Notice of Denial (DWC-12) Claim Cost Report (DWC-13) Aggregate Claims Administration Change Report (DWC-4 or DWC-49) Notice of Action/Change (certain fields) (DWC-4)

What MTC’s Will Be Required in the Claims EDI Release 3 Primary Implementation Schedule?

Claims EDI R3 Required MTC’s First Report of Injury (FROI):
The following Maintenance Type Codes (MTC’s) are required to be implemented during the Primary Implementation Schedule for the First Report of Injury (FROI): MTC’s 00, 01, 02, 04, AQ, & AU (Definitions of MTC’s are in the IAIABC R3 Implementation Guide/Data Dictionary).

Claims EDI R3 Required MTC’s
The following Maintenance Type Codes (MTC’s) are required to be implemented for the Primary Implementation Schedule for the Subsequent Report (SROI): MTC’s IP, EP, AP, PY, PD, CD, VE, 02, 04, SA & FN

FL requires both the FROI and SROI combination filing to constitute the electronic form equivalent of a DWC-1 reporting initial payment or ‘equivalent’ information.

Claims EDI R3 Required MTC’s
SROI Maintenance Type Codes (MTC’s) required by FL to be filed with a FROI MTC (00 or AU) to report the initial payment or equivalent are: IP, EP, PY, PD, CD, VE, & AP

Some data elements from the DWC-4 will be required to be sent during the Primary Implementation Schedule, because of the design of the record layout.

These required DWC-4 data elements are identified in the EDI Rule 69L , F.A.C., and some examples follow….

Example DWC-4 Changes Required in Primary Implementation
Claim Administrator Postal Code not due to change in claims administration Industry Code Manual Classification Code Employee SSN Employee First/Last Name, Last Name Suffix, Middle Name/Initial Date of Injury

Claims EDI R3 Secondary Implementation Schedule Phase In:
The insurer should begin testing the remainder of DWC-4 related MTC’s no later than 9 months after the its compliance date associated with the Primary Implementation Schedule, and be in production status no later than 1 quarter after the required testing start date.

Claims EDI R3 Secondary Implementation Schedule Phase In:
1st Group’s (Insurer Code #s ) Primary Implementation Schedule compliance date = First Group Must Begin Testing for the Secondary Implementation Schedule: First Group Must Be in Production for the Secondary Implementation Schedule:

Claims EDI Secondary Implementation Schedule Phase In:
2nd Group’s (Insurer Code # ) Primary Implementation Schedule compliance date = Second Group Must Begin Testing for the Secondary Implementation Schedule: Second Group Must Be in Production for the Secondary Implementation Schedule:

Claims EDI Secondary Implementation Schedule Phase In:
3rd Group’s (Insurer Code #s and ) Primary Implementation Schedule compliance date = Third Group Must Begin Testing for the Secondary Implementation Schedule: Third Group Must Be in Production for the Secondary Implementation Schedule:

Claim Administrator’s can voluntarily send MTC’s required in the Secondary Implementation Schedule (most DWC-4’s) during the Primary Implementation Schedule.

What MTC’s Will Be Required in the Claims EDI Release 3 Secondary Implementation Schedule?

Claims EDI MTC’s Required Subsequent Report (SROI):
The following Maintenance Type Codes (MTC’s) are required to be implemented for the Secondary Implementation Schedule for the Subsequent Report (SROI): 02, P7, S1-S8, CA, CB, AB, RB, & ER

Crosswalk of MTC’s to DWC Forms

MTC’s to DWC Forms

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

Questions?

How Will EDI Errors Be Communicated to Claim Administrators?

The Division will acknowledge every EDI R3 transaction received with the standard EDI Acknowledgement format: ‘AKC’. AKC Report

Transmissions received on or before 9:00 p. m. , E. S. T
Transmissions received on or before 9:00 p.m., E.S.T., will be processed by DWC the same day the transmission was sent. It will be acknowledged the next calendar day (morning).

Transmissions received after 9:00 p. m
Transmissions received after 9:00 p.m. EST will be processed by DWC the following calendar day. It will be acknowledged the day after the transmission is processed.

FL processes transmissions 7 days a week, including holidays.

The ‘AKC’ acknowledgement will identify how many transactions passed edits (TA -Transaction Accepted); how many failed edits (TR -Transaction Rejected); and the specific error(s) that caused the transaction to reject.

FL does not use the TE – “Transaction Accepted with Errors” Acknowledgement Code.

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

The Claim Administrator will receive credit for the date the transaction was originally received by the Division.

FL provides EDI Claim Administrators the capability of viewing all FROI’s & SROI’s received, via the on-line Claims EDI Data Warehouse.

The on-line Claims EDI Data Warehouse will assist claim administrators in resolving EDI errors faster, and may also assist in resolving issues with the Centralized Performance System (CPS). Claims EDI Warehouse

More detailed information regarding the on-line Claims EDI Data Warehouse will be provided later in the training. Claims EDI Warehouse

Questions?

FL Trading Partner Tables

FL EDI Reporting requirements are defined in the Trading Partner Tables:
Required Report(s) Data needed on the Report(s) Applied Editing

Trading Partner Tables
MTC Filing (FL Website) Reference (FL Website) FL Quick Code Instructions (

What is an Event?

Claim Business Events Claim Event Flow in FL 1. Establish Claim with
2. Initial Payment or Equivalent 9. Lump Sum Payment(s) 7. Suspend 10. Periodic Reports 3. Changes to Benefits/Amnts 5. Reinstate 11. Changes (Non-Indemnity) Benefits 6. Change 4. Suspension of all Benefits 12. Cancel 8. Claim Closure

An Event is a business circumstance that occurs in the life of a WC Claim which requires the reporting of EDI information to DWC. These circumstances reflect FL’s requirements, including: First Report of Injury events Subsequent Report events Periodic events

FL identifies all of the transactions (MTC’s) that are required for reporting specific business events on its Event Table.

Interpreting the FL Event Table
Example: Florida requires the submission of a FROI MTC 00 for First Reports of Injury or Illness based on the insurer’s mandate date …

… when disability is immediate & continuous & lost time is greater than seven (7) days.

The filing must receive a TA within 21 calendar days after the claim administrator’s knowledge of the injury.

A DWC-1 or IA-1 (ACORD 4) form must also be sent to the employee & employer

Periodic (Claim Cost) Reports
In addition to reporting “typical” business claim Events, FL requires the claim administrator to report the “cost status” of the claim via Periodic (Claim Cost) Reports

POP QUIZ

What is the Paper Equivalent of a
Periodic Report for FL?

Answer: DWC-13 Claim Cost Report

POP QUIZ

What are the Periodic MTC’s accepted by FL?

Answer: MTC SA & FN

Event Table FL Periodic Reports
SA Sub-Annual – Submitted every 6 months after the DOI, as defined on FL’s Event Table. FN Final – Submitted when Claim Administrator determines no further benefits will be paid.

Event Table In addition to the Event Table, FL describes its business events in the ‘MTC Filing Instructions’. This document assists claim administrators understand what MTC’s to use in reporting required business events to FL. MTC Filing Instructions

FL MTC Filing Instructions

Questions?

FL BUSINESS SCENARIOS

FL SCENARIO ASSUMPTIONS

General scenario assumptions are included in the scenarios to assist in understanding the sample data that is presented.

The FL Scenarios were enhanced from the IAIABC scenarios in the R3 Implementation Guide. All the 2001 dates were moved forward to 2007 (the next year where all dates fell on the same day of the week).

Calculated Weekly Compensation Amount is the Comp. Rate, and is 66 2/3% of the Average Wage. The statutory comp rate max is not accurate per FL law.

Scenarios are presented in uppercase text. However, data may be sent to FL in mixed case format. Payment of indemnity benefits is based upon a 5 day work week The Industry Code must be a 2002 or 2007 NAICS code.

FL Scenarios contain required sample data elements pertinent to the scenario. These data are identified as “M” (Mandatory) or “MC” (Mandatory/Conditional) on the FL Element Requirement Table.

Additional data elements may be present in the scenario if they are identified as “IA” (If Applicable/Available) on the Element Requirement Table (e.g., Middle Initial and Suffix).

Although Claim Administrators may send additional data elements marked “NA” (Not Applicable), such data will not be edited or loaded by FL, and therefore not presented in the scenarios.

FL SCENARIO PROFILES

FL Scenario Profiles Unless otherwise noted in the scenario narrative, the basic scenario profile information for all scenarios will be as follows….

FL Scenario Profiles Description Data Name: John James Smith, Jr.
Injured Employee Description Data Name: John James Smith, Jr. SSN: DOI: June 15, 2007 DOB: May 1, 1953 Empmnt Status: Full Time

FL Scenario Profiles Description Data Class Code: 2802 (Carpenter)
Injured Employee Description Data Class Code: (Carpenter) Days Worked/Week: 5 Wage: $15.00 Wage Period: Hourly (FROI)

FL Scenario Profiles Employer/Insured Description Data
Employer: Acme Construction Inc. FEIN: Physical Location: 32 Meadowbrook Lane Anytown, FL 32399 Industry (NAICS):

Insurer/Claim Administrator
FL Scenario Profiles Insurer/Claim Administrator Description Data Insurer: Old Reliable Ins. Co. FEIN: Average Wage: $600.00 Wage Period: Weekly (SROI)

FL SCENARIOS A FROI must be paired with the applicable SROI that is reporting the initial payment or equivalent, unless the FROI is reporting a Full Denial (MTC 04), Cancel (MTC 01), Change (MTC 02) or Acquired Claim (MTC AQ).

Questions?

FL SCENARIOS FOR MTC’s REQUIRED IN THE PRIMARY IMPLEMENTATION SCHEDULE

Complete FROI/SROI Combo SCENARIO MTC “00” with “IP”
Disability Immediate & Continuous Rule 69L (1)(a)1., F.A.C.

Indemnity Benefits other than TP or IB or settlement will be paid, an
NEW CLAIM: Lost Time Case Where Disability is Immediate and Continuous If the Initial Payment of Indemnity Benefits will be made by the Claim Administrator, and Indemnity Benefits other than TP or IB or settlement will be paid, an Electronic First Report of Injury or Illness is due.

Due: 21 Days after Claim Administrator’s Knowledge of the Injury
NEW CLAIM: Lost Time Case Where Disability is Immediate and Continuous Send: FROI 00 with SROI IP Due: 21 Days after Claim Administrator’s Knowledge of the Injury Note: Also provide FORM DWC-1 or IA-1 to the employee & employer.

To avoid late filing penalties for an Electronic First Report of Injury or Illness, the EDI DWC-1 should be triggered immediately upon the CA’s disposition of the claim (payment or denial), to allow time for correction of potential errors and resubmission, and for subsequent receipt/acceptance by the Division within the filing due dates specified in Rule 69L-56, F.A.C.

FROI “00” Scenario Narrative
Employee fell from ladder at employer’s warehouse on 6/15/07. Employee broke his leg. Foreman witnessed the accident. Employee treated and released from the Emergency Room.

FROI “00” Scenario Narrative
Employee earned $15.00 an hour working 40 hours a week. Employer reported injury to insurer on 6/17/07.

FROI MTC “00” SCENARIO Claim Administrator reported the loss to DWC on 6/29/07.

FROI MTC “00” SCENARIO Insurer is identified.
Claim Administrator details are provided (remainder are on R21).

FROI MTC “00” SCENARIO Employer/Insured information is reported.
The Employer’s name is on the R21 The rest of the Employer’s address is on the R21 NAICS Code

FROI MTC “00” SCENARIO If applicable, Policy Number should be reported, but Effective Date & Expiration Date are not required.

FROI MTC “00” SCENARIO Details of the accident are included.
Employee broke leg falling from a ladder.

FROI MTC “00” SCENARIO Employer reported injury to claim administrator on 6/17/07.

FROI MTC “00” SCENARIO Details about injured employee are sent.
The rest of the Employee’s name and address is on the R21

FROI MTC “00” SCENARIO Date the initial disability began & other FROI fields must be reported on the SROI. Manual “Risk” Class Code is only on the FROI.

FROI MTC “00” SCENARIO Employee earned $15.00 an hour and worked 5 days a week. Employee has not returned to work.

FROI MTC “00” SCENARIO FROI Companion Record - R21

FROI MTC “00” SCENARIO Claim Administrator Claim Number is repeated in the R21. It links the R21 companion to the related 148.

FROI MTC “00” SCENARIO Claim Administrator FEIN is sent.
Claim Administrator Name is sent, and rest of the Claim Admin Address. 456 Main St

FROI MTC “00” SCENARIO ID qualifier = S.
Positions 232 to 246 contain a Social Security Number.

FROI MTC “00” SCENARIO Remainder of Employee name, address fields and phone are here in the R21 record.

FROI MTC “00” SCENARIO Type of Loss Code is reported on the SROI.
Employee has not returned to work.

FROI MTC “00” SCENARIO Insured FEIN and Insured Name are reported.

FROI MTC “00” SCENARIO Insurer Name and Insurer Type Code are reported.

FROI MTC “00” SCENARIO Details of accident site:

FROI MTC “00” SCENARIO Employer Name, Physical address and contact information.

FROI MTC “00” SCENARIO Employer Mailing Address information is not required.

FROI MTC “00” SCENARIO Claim Type Code and EP Salary Indicator are to be reported on the SROI.

FROI MTC “00” SCENARIO Variable Segment Counters include:
Two Accident/Injury Narratives, and One Witness segment.

FROI MTC “00” SCENARIO Accident description exceeds 50 characters; two segments are needed to send entire narrative description.

Variable Segment Population Rules for FROI
ACCIDENT/INJURY DESCRIPTION NARRATIVES SEGMENT: No more than 10 (50 byte narrative text) segments per claim, and the number of segments sent must equal the “Number” of Accident/Injury Description Narratives segment counter.

FROI MTC “00” SCENARIO Foreman Jones was the only witness.

Variable Segment Population Rules for FROI
WITNESSES SEGMENT: No more than 5 witnesses per claim, and the number of segments sent must equal the “Number” of Witnesses segment counter.

Questions on the FROI?

Corresponding SROI MTC “IP”

MTC “IP” (Initial Payment)
The claim administrator has issued its first payment of indemnity benefits (not a lump sum payment/settlement.) The Initial Payment transaction implies that indemnity benefits are ongoing until suspended.

SROI IP Scenario Narrative
On 6/29/07, the Claim Administrator issued the first indemnity check. Check covered TTD benefits from 6/23/07 through 6/29/07 (Day 8-14).

SROI MTC “IP” SCENARIO Initial Payment transaction is sent to the Division on 6/29/07.

SROI MTC “IP” SCENARIO Initial Date Disability Began is the day after DOI because Employer paid for DOI. Employee was a 5 day per week worker.

SROI MTC “IP” SCENARIO Claim Admin Claim Number must be sent on every record.

SROI MTC “IP” SCENARIO No Jurisdiction Claim number required because IP SROI is filed with 00 FROI.

SROI MTC “IP” SCENARIO Claim Type indicates Lost Time case.

SROI MTC “IP” SCENARIO No variable segments; A49 ends at position 208.

SROI MTC “IP” SCENARIO Claim Administrator Claim Number is repeated in R22. It links the R22 companion to the related A49.

SROI MTC “IP” SCENARIO Claim Administrator information:

SROI MTC “IP” SCENARIO R22 includes additional employee information.

SROI MTC “IP” SCENARIO These fields are either not required, or they are reported on the FROI.

SROI MTC “IP” SCENARIO These fields are not applicable to this claim, except the Initial Date Last Day Worked.

SROI MTC “IP” SCENARIO Current Date Disability Began should NOT be defaulted to the same as the Initial Date Dis Began. This is only populated if you have a 2nd period of disability.

SROI MTC “IP” SCENARIO Weekly Compensation Rate is $400
based on Average Wage of $600 effective the Date of Injury.

SROI MTC “IP” SCENARIO Type of Loss Code and Employment Status Code are reported on the SROI.

SROI MTC “IP” SCENARIO Additional wage information:

SROI MTC “IP” SCENARIO One Benefits segment and one Payment segment are required on this claim.

SROI MTC “IP” SCENARIO Temporary Total was the only benefit paid. MTC is also in Ben segment for IP.

SROI MTC “IP” SCENARIO Gross & Net Weekly Amount = $400/week (comp rate), effective on the DOI.

SROI MTC “IP” SCENARIO Initial payment reflected benefits were paid
from June 23 through June 29, (Day 8-14) for 1 week in the amount of $400.

SROI MTC “IP” SCENARIO Ben Payment Issue Date is the date payment left the CA’s control, e.g., mailed ( ), not necessarily the system check issue date.

SROI MTC “IP” SCENARIO FL requires the reporting of the exact amount of the Claim Administrator’s initial payment of indemnity benefits on MTC IP; therefore, the Payment segment must also be sent on the SROI, in accordance with the Element Requirement table.

SROI MTC “IP” SCENARIO MTC IP requires a Payments segment.
Payment Reason Code = Benefit Type Code.

SROI MTC “IP” SCENARIO Payment information related to the Initial Payment is captured in the Payments segment.

SROI MTC “IP” SCENARIO Payment Issue Date = Benefit Payment Issue Date in Benefits Segment.

Questions?

Florida Division of Workers’ Compensation Claims EDI Release 3

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Florida Division of Workers’ Compensation Claims EDI Release 3

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