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

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

The most typical EDI DWC-1 filing is: FROI 00 + SROI IP
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 , F.A.C.

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

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

Other SROI’s Sent with FROI 00:
Electronic First Report of Injury or Illness Other SROI’s 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)

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

Pop Quiz:

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

…What MTC’s should be sent to report the Electronic First Report of Injury or Illness?

Answer: FROI SROI IP To report payment of indemnity based on wages from concurrent employment.

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

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?

ANSWER: MTC 00/PY

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

Another POP Quiz: When is the 00/IP considered timely filed with the Division?

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.

Answer (cont’d): 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.)

HELPFUL HINT 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 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.

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.)

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.

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.

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…

… 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.

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

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

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

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.

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

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.)

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.

All Data elements contained in the SROI BENEFITS Segment (e. g
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.

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.

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.

Variable Segment Population Rules for the SROI Benefits Segment

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.

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).

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.

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.

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.

SROI BENEFITS Segment CD - Compensable Death with No Dependents;
0 (zero) Benefits Segments are allowed for the following SROI MTC’s: CD - Compensable Death with No Dependents; VE - Volunteers; PD - Indemnity Only (Partial) Denials.

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).

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.

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.

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.)

“Event” Benefits Segments EVENT

Sweep DN’s Event DN’s

“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 FL’s Element Requirement Table.

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)

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.

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).

SROI Benefits segment

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

“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).

“EVENT” BENEFITS SEGMENT EXAMPLE
All Benefits data elements are populated. Benefit Payment Issue Date is required for an IP, and certain AP’s, & PY’s (0xx).

BENEFIT PERIOD START DATE – DN0088 For all MTC’s 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.

BENEFIT PERIOD START DATE – DN0088 For all MTC’s 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.

For MTC AP and all subsequent MTC’s 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.

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.)

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 …

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.

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…

… 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…

Example (cont’d): … 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.

“Sweep” Benefits Segments

“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.

MTC is NOT included in the Benefits Segment for the following “Sweep” MTC’s: 02 (only if Benefits segment data is not changing and you don’t want DWC’s program to edit any BTC’s), 04 PD PY reporting BTC 5XX Periodics: SA & FN

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.

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)…

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).

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

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

BENEFIT PERIOD START DATE For MTC’s (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.

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.

Sweep DN’s

Questions?

Caveats and Tips for Successfully Filing 00/IP

BOTH FROI & SROI MUST PASS EDITS TO ACCEPT FILING
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.

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

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.

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

Other Errors Occurring on 00/IP Filings

We have been receiving DOB’s 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…

… 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 < = DOI’, our program has not been rejecting filings where the DOB defaulted to DOI, therefore yielding an age of ‘0’. So, …

… Beginning 4/30/10, DWC’s program will now reject filings where the DOB (at the time of the DOI) yields an age < = 5, to minimize truly incorrect DOB’s and later follow-up with our TP’s. Note: DWC already returns a TR if the DOB yields an age of 100 years or more.

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 program’s match data criteria.)

DWC is statutorily required to collect the EE’s address, so our program initially precludes the acceptance of filings where the EE’s address = EMPLR’s address. This edit is included in FL’s requirements in part because EAO sends an initial contact letter to the EE; therefore a proper address is needed (which is typically not the employer’s address.)

Filings that reject for this ‘error’ can be re-loaded by DWC upon receipt of confirmation the EE’s and EMPLR’s address are indeed one in the same. Prior to re-loading, the EDI Team will ‘Google’ the EE’s address and compare it to the nature of the employer’s business and the EE’s occupation to determine if the addresses are likely the same.

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.)

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 Administrator’s control.)

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.

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

… 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.

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.

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 …

… 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.

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

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 RTW’d within the waiting wk, Claim Type must = L.

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

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.)

Pop Quiz:

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

‘Employee’s 8th Day of Disability’
ANSWER: ‘Employee’s 8th Day of Disability’

‘Initial Date of Lost Time’ is not the same as ‘Initial Date Disability Began’. These are two different data elements.

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.

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.

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.

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

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.

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

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

If you are receiving errors for: NET < 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 DWC’s program (within 5¢).

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).

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.

The expected FL CALC GROSS AMOUNT computed by DWC’s 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.)

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.

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.

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.

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 BTC’s.

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

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

WKLY COMP AMT NOT CORRECT FOR AWW
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 DOI’s on or after 8/1/79. *** Even if you were ordered to pay a higher weekly rate for TT (050).

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.

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.

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.)

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...

…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, DWC’s program will compute the full IB rate.

The calculation for determining ‘FL Calc Gross Amt’ for IB’s (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….

…The First DCA found in the case of Seminole County Gov’t v
…The First DCA found in the case of Seminole County Gov’t v. Eric Baumgardner (2/5/10), that F. S (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.

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 IB’s are sometimes made in arrears for back IB’s due versus an advance of future IB’s due and owing.

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.

Acknowledgement ‘Free Form Text’ Messages for Claim Administrators

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

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

Let’s complete a SROI for Scenario 1-A-8 (New) in your Handouts…

Initial Payment – 00/IP BTC 070 with Multiple Initial RTW Dates on same IP (Scenario 1-A-8)

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.

Currently, there is no clear guidance from the IAIABC as to how to report multiple Initial RTW.
The following scenario presents FL’s current position until we receive further direction from the IAIABC.

The SROI IP will contain partial data excerpted from the SROI, and includes:
1 Benefits Segment and 1 Payments Segment.

Claim Administrator Postal Code 379921223
0001 Transaction Set ID A9 Subsequent Report 0002 Maint. Type Code IP Initial Payment 0003 MTC Date Jan.23, 2010 0004 Jurisdiction Code FL 0006 Insurer FEIN 0014 Claim Administrator Postal Code 0056 Initial Date Disability Began Jan. 1, 2010 0072 Current Return to Work Date N/A

Jan. 1, 2010 Indemnity/ Lost Time
0063 Wage Period Code 01 Weekly 0064 Number of Days Worked Per Week 5 0031 Date of Injury Jan. 1, 2010 0015 Claim Admin. Claim Number WC 0005 Jurisdiction Claim Number N/A 0074 Claim Type Code I Indemnity/ Lost Time

R22 Data Elements 0001 Transaction Set ID R22 0298 Date Claim Administrator Had Knowledge of Lost Time (Clm Admin’s Knowledge of 8th Day of Dis for FL) N/A 0015 Claim Administrator Claim Number WC 0187 Claim Administrator FEIN

Social Security Number
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 (850) 0270 Employee ID Type Qualifier S Social Security Number 0042 Employee SSN

0043 Employee Last Name SMITH 0044 Employee First Name JOHN 0045 Employee Middle Name/Initial J 0255 Employee Last Name Suffix JR 0052 Employee Date of Birth May 1, 1953 0202 Reduced Benefit Amount Code N/A

Non-Consecutive Period Code N/A
0228 Return To Work With Same Employer Ind Y Yes 0212 Non-Consecutive Period Code N/A 0145 Current Date Last Day Worked N/A 0144 Current Date Disability Began N/A 0065 Initial Date Last Day Worked Jan. 1, 2010 0189 Return To Work Type Code A Actual

0224 Physical Restrictions Ind. Y Yes 0134 Calculated Weekly Compensation Amount $400.00 0256 Wage Effective Date Jan. 1, 2010 0290 Type of Loss Code 01 Trauma 0058 Employment Status Code 1 Full Time

0068 Initial Return to Work Date 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 $600.00 0297 Initial Date of Lost Time (8th Day) N/A 0200 Claim Admin. Alternate Postal Code (Mailing)

1 Occurrence 1 Occurrence
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

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

Gross Weekly Amount Effective Date N/A for TP
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

0088 Benefit Period Start Date Jan. 1, 2010 0089 Benefit Period Through Date Jan. 21, 2010 0090 Benefit Type Claim Weeks 0003 0091 Benefit Type Claim Days 0086 Benefit Type Amount Paid $ 0192 Benefit Payment Issue Date Jan. 23, 2010

Temporary Partial $1152.00 Jan. 1, 2010 Jan. 21, 2010 Jan. 23, 2010
Payments 1 Occ 0222 Payment Reason Code 070 Temporary Partial 0217 Payee JOHN J SMITH JR 0218 Payment Amount $ 0219 Payment Covers Period Start Date Jan. 1, 2010 0220 Payment Covers Period Through Date Jan. 21, 2010 0195 Payment Issue Date Jan. 23, 2010 P&I reported under OBT 311 and 321

Questions?

More on Other First Report / EDI DWC-1 Equivalent MTC’s

Other First Report/EDI DWC-1 Equivalents
Recap: EDI DWC-1 Equivalent MTC’s 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.)

EDI DWC-1 Equivalents The following SROI’s (sent with FROI 00), will still require a Benefits segment: EP – Employer Paid PY – Lump Sum Payment/Settlement

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

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?

Answer: MTC 00/EP EMPLOYER PAID BENEFITS

EMPLOYER PAID BENEFITS
69L (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.”

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

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.

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.

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

Also valid, but not as typical: 210 Employer Paid Death benefits 230 Employer Paid Impairment Income benefits 242 Employer Paid Voc Rehab (TT – R&E) 251 Employer Paid TT Catastrophic (80%)

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).

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 req’d for these BTC’s.) If the specific benefit type is unknown, BTC 240 should be used.

Data Population Rules for Employer Paid Benefits

Caveats and Tips for Successfully Filing 00/EP

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).

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?

ANSWER: 00/IP

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.)

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…

… 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.)

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.) …

… 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.)

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; …

… however, the SROI 02 must be the next accepted filing. Also, “MTC 02” must be included in the Benefits segment. Otherwise, DWC’s program will not edit/load the Benefits segment(s).

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

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.

If the 02 is the next accepted filing, the following fields will be updated in DWC’s database automatically (so the Claims EDI Team will not have to manually revise DWC’s claim record prior to CPS re-evaluation):

DN’s Changed by 02 if Next Accepted Filing:
Salary Cont’d 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 (OBT’s 311 and 321)

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.

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”.

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.

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, …

… 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 DWC’s system to reflect the initial payment of indemnity as salary in lieu of comp.

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 DWC’s database.

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 DWC’s database upon verification of the corrected data on the 02.

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.

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?

Answer: SROI MTC IP

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.

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

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.)

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.)

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

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 (5), F.A.C. (No DWC-4 or letter required.)

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 (5), F.A.C. (No DWC-4 or letter required.)

… SROI ER would only be applicable in this situation if the employer had previously paid (EP – IP – Sx – ER.) See Rule 69L (6), F.A.C. (No DWC-4 or letter required.)

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.)

Questions?

POP QUIZ: What MTC is used to report a Totally Denied Electronic First Report of Injury or Illness?

ANSWER: FROI MTC 04 Full (Total) Denial
EDI DWC-1 Equivalent required to be filed with DWC per Rule 69L (2).

FROI MTC 04 Full (Total) Denial
FROI 04 represents a total denial of all indemnity and medical benefits, including denials based on compensability.

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

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.

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

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.

“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 >= one year after the DOI.

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

“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.)

“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.

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…

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.)

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.

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 ...

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

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.

Filing Caveats and Tips for Successfully Filing FROI 04

Caveats and Tips for Successfully Filing 04:
We don’t see that many rejections associated with FROI 04’s since there aren’t 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 04’s..

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.)

‘Duplicate Denial” errors are also occurring when more than one FROI 04 is sent in the same batch. Note: Unnecessary SROI 04’s 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.

FROI 04’s 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).

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

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.

Questions?

POP QUIZ: What MTC is used to report an Indemnity Only Denied Electronic First Report of Injury or Illness?

ANSWER: FROI 00 + SROI PD (Partial Denial)
EDI DWC-1 Equivalent required to be filed with DWC per Rule L (2)(c), F.A.C.

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.

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.

EDI DWC-1 Equivalent PARTIAL DENIAL CODE identifies which portion of the claim is being denied (not the reason it is denied).

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

EDI DWC-1 Equivalent The Partial Denial Code should identify which portion of the claim is currently being denied (vs. evaluating if any indemnity and medical benefits have been paid in the past).

EDI DWC-1 Equivalent For example: If indemnity benefits were previously paid and the Claim Admin. decided to deny all future indemnity but not deny all medical, they would send a Partial Denial Code “A” or “E” …

EDI DWC-1 Equivalent … to indicate that ALL indemnity is currently being denied (and not Partial Denial Code “B” or “G” on the basis that some indemnity had been paid in the past.)

EDI DWC-1 Equivalent Denial Reason Narrative is required to convey the specific benefits and reasons for the denial, and should not repeat the information already represented by the code itself.

EDI DWC-1 Equivalent Again, the narrative should NOT be defaulted to the text description of the code. This will result in additional correspondence from EAO and you will be required to send another transaction (MTC 02).

EDI DWC-1 Equivalent MTC “PD” (Partial Denial) is not used in conjunction with Full Denial data elements: Full Denial Reason Code Full Denial Effective Date DENIED

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

Caveats and Tips for Successfully Filing FROI 00 + SROI PD

Only Codes A and E represent ALL indemnity is being denied.
Caveats and Tips for Successfully Filing 00/PD If a First Report of Injury or Illness is not already on file with DWC (paper or EDI), a Partial (Indemnity Only) Denial 00/PD can only be sent with Partial Denial Code A or E. Only Codes A and E represent ALL indemnity is being denied.

Caveats and Tips for Successfully Filing 00/PD
Partial Denial Codes C or D are never applicable in FL because they represent a denial of medical in whole or part, but not indemnity. Partial Denial Codes used for FL filings must address some aspect of indemnity denial (all or part).

Caveats and Tips for Successfully Filing 00/PD
Partial Denial Code F should also never be sent because it represents a denial of all medical where indemnity will continue to be paid. This is N/A in FL since indemnity can’t be paid without on-going medical substantiation.

Caveats and Tips for Successfully filing 00/PD
If you originally filed a 00/PD with PD Code A or E & you subsequently decide to pay some or all indemnity, you must file a SROI IP with a Denial Rescission Date.

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

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

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

If a Partial Denial Code needs to be changed because the previous PD Code was sent incorrectly, this can be done with MTC 02 (e.g., changing A to E or B to G.)

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

…You will need to also send another transaction (e.g., IP, PY) to communicate the initiation of indemnity benefits since neither an 02 or PD can initiate benefits. If the claim is still being partially denied, another PD (after IP, PY, etc.) will have to be sent.

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

There is no specific DN for ‘partial denial date”, so FL uses the MTC Date associated with the SROI PD filing for comparison to other data. e.g., DEN RESC DTE MUST BE >= DEN EFF DTE OR PD MTC DTE

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

Questions?

POP QUIZ: If an EDI DWC-1 equivalent has been filed and you subsequently deny indemnity, what MTC is used to report the Electronic Notice of Denial?

ANSWER: To report the subsequent denial of indemnity:
SROI (if also denying medical) or SROI PD

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

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

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