Presentation on theme: "1 Florida Division of Workers Compensation Claims EDI Release 3 History and Overview 2008 (Review prior to attending EDI training or reviewing Business."— Presentation transcript:
1 Florida Division of Workers Compensation Claims EDI Release 3 History and Overview 2008 (Review prior to attending EDI training or reviewing Business Training PowerPoint slides)
2 Rule Chapter 69L-56 of the Florida Administrative Code is the EDI Rule for Proof of Coverage and Claims (non-medical)
3 The EDI Rule 69L-56, F.A.C.
4 EDI Rule 69L-56,F.A.C. was effective January 7, It requires all insurers to implement the IAIABC Claims EDI Release 3 electronic format.
5 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 Insurers EDI Implementation date. This includes legacy claims.
6 69L Forms and Instructions 69L Definitions Rule 69L-56 Rule Section Overview (Claim Administrators must be familiar with the requirements of this rule.)
7 69L 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
8 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and Implementation Schedules 69L Electronic First Report of Injury or Illness 69L Electronic Notice of Denial and Rescinded Denial 69L Electronic Periodic Claim Cost Reports
9 69L Electronic Notice of Action or Change, Including Change in Claims Administration, Required by the Insurers Primary Implementation Schedule 69L Electronic Notice of Action or Change, Suspensions, and Reinstatement of Indemnity Benefits Required by the Insurers Secondary Implementation Schedule
10 69L Electronic Cancellation of Claim 69L Technical Requirements for Claims EDI Transmissions 69L Claims EDI Test to Production Status Requirements
11 69L Electronic Formats for Reporting the Employees 8th Day of Disability and the Claim Administrators Knowledge of 8th Day of Disability (This section will eventually be repealed after all current R1 trading partners implement R3) 69L Insurer Responsibilities Where Third Party Services are Utilized
12 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
13 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.
So Heres A Little Background On EDI …
15 On a National level, in 1990 the IAIABC spearheaded a program to utilize the concept of EDI for Workers Compensation data.
16 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.
17 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. 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 This does not include reporting by Injured Workers! EDI
18 Developing an Electronic Standard Requires Bringing Together the Important Participants Jurisdictions TPAs Vendors Carriers
19 Developing a National Standard through the IAIABC EDI Development Committees was a consensus development process that required give and take from all participants.
20 The end result is a national standard format for the reporting of workers compensation data electronically.
21 IAIABC EDI Project Background 1990: IAIABC membership adopted IAIABC Committees proposal to develop standards for communicating data electronically between providers, payers, and state administrators via EDI. 1990: IAIABC membership adopted IAIABC Committees proposal to develop standards for communicating data electronically between providers, payers, and state administrators via EDI. 1993:Claims Release :Claims Release :Claims Release 2 (Iowa) 2000:Claims Release 2 (Iowa) 2005:Claims Release :Claims Release 3
22 FL DWC chose to implement the national standard for Proof of Coverage and Claims reporting to provide claim administrators with a consistent standard for electronic reporting across multiple states.
23 The national standard format contains different terminology, edits and various rules, such as sequencing rules, that must be followed and may be different from what you are accustomed to in the paper reporting environment.
Where can you find the IAIABC R3 Implementation Guide & Codes?
25 The IAIABC Release 3 Claims EDI Implementation Guide contains essential information for implementing EDI, including the transaction record layouts, data dictionary, business and technical rules, national scenarios, etc.
29 The Release 3 Claims Implementation Guide can be purchased for $95 from the IAIABCs website: or it is free if your company is an IAIABC EDI Member. The latest R3 Guide is dated January 1,
31 There are other code lists you will need. Click here
32 STANDARD USAGE FOR ALL PRODUCTS (found on IAIABC EDI webpage) Country Codes Country Codes State Codes State Codes Industry Codes (NAICS 2002 or 2007) Industry Codes (NAICS 2002 or 2007) Nature of Injury Codes Nature of Injury Codes Cause of Injury Codes Cause of Injury Codes Part of Body Codes Part of Body Codes Permanent Impairment Body Part Codes Permanent Impairment Body Part Codes Error Message Dictionary Error Message Dictionary Glossary Glossary
33 Always sent as 99 for FL
36 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.
37 Glossary The Glossary defines terms that are common to FROI/SROI, MED, and POC EDI reporting. 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. 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.
38 Glossary Example Alphabetical by term
39 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.
FL Claims EDI Webpage Claims EDI
41 FLs Claims EDI Webpage
42 FLs Claims EDI Webpage
43 The Claims EDI Webpage is your complete resource for all of DWCs Claims EDI requirements Scroll Down for much more info
46 These are the Requirement Tables
47 If you havent already, you should become familiar with FLs requirement tables (including updated supplement) to determine: When each transaction must be sent (Event Table) Data Elements required for each transaction / MTC (Element Requirement Table) FLs Claims EDI Webpage
48 (Contd)… Review FLs requirement tables (including updated supplement) to determine: Edits that will reject the record (Edit Matrix) The Population Restrictions Tab of the Edit Matrix will assist you in trouble shooting why you received a certain error. FLs Claims EDI Webpage
49 FL Supplement Overview: Tracks all monthly additions or corrections to the requirement tables. Check periodically for updates to this Supplement.
50 The webpage also contains helpful resource documents including: FL EDI Migration Strategies FL EDI Migration Strategies MTC Filing Instructions MTC Filing Instructions FL R3 Business Scenarios FL R3 Business Scenarios FL Quick Code Reference Guide FL Quick Code Reference Guide Training Questions & Answers Training Questions & Answers MTC to Form Crosswalk MTC to Form Crosswalk Crosswalks of paper DWC Claims Forms to EDI Data Elements Crosswalks of paper DWC Claims Forms to EDI Data Elements FLs Claims EDI Webpage
51 Helpful Resources Training Other Resources Crosswalks
52 Crosswalk of MTCs to DWC Forms
53 See MTC to Form Crosswalk which helps identify what MTCs equate to which DWC forms.
54 MTCs to DWC Forms
55 MTCs to DWC Forms
56 MTCs to DWC Forms
57 MTCs to DWC Forms
58 Not all MTC filing requirements set out in Rule 69L-56, F.A.C., can be equated to a DWC Form. See rule 69L-56 F.A.C. and FL Claims EDI Event Table (also MTC Filing Instructions) for a complete accounting of MTCs required by FL. Not all MTC filing requirements set out in Rule 69L-56, F.A.C., can be equated to a DWC Form. See rule 69L-56 F.A.C. and FL Claims EDI Event Table (also MTC Filing Instructions) for a complete accounting of MTCs required by FL.
Acronyms (see FL Claims EDI webpage for list)
61 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
63 Important and essential information is contained in the R3 Implementation Guide.
64 It is recommended that someone within every company has access to the Claims EDI R3 Implementation Guide. The requirements of this guide are incorporated by reference in the FL EDI Rule 69L-56 F.A.C.
Release 3 Combined Business & Technical Data Dictionary
66 The Release 3 Data Dictionary Section 6 in the Implementation Guide Defines all the data elements used for EDI.
67 The IAIABC Release 3 Claims EDI Implementation Guide contains the data dictionary, which defines each element that is required. It is recommended that this section be saved to your desktop for ready reference.
68 This data dictionary should be used in conjunction with the definitions found in 69L-56, F.A.C.
69 Release 3 Data Dictionary Identifies the Data Number (DN) Identifies the Data Number (DN) Gives the Definition of the Data Element Gives the Definition of the Data Element Gives the Last Revision Date of the Data Element Gives the Last Revision Date of the Data Element
70 Release 3 Data Dictionary Gives the Format (i.e. 2 A/N = two characters alpha/numeric) Gives the Format (i.e. 2 A/N = two characters alpha/numeric) Lists the Valid Values for the DN Lists the Valid Values for the DN Gives DP (Data Population) Rule to Help Identify the Correct Use of the Data Element Gives DP (Data Population) Rule to Help Identify the Correct Use of the Data Element
71 Release 3 Data Dictionary (sample entry)
72 EDI Terminology
73 In R3 EDI, all WC data is sent electronically via a FROI or SROI transaction.
74 What Is A ?
75 First Report of Injury (FROI)
76 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
77 This means the Release 3 FROI transaction requires 2 records to communicate the First Report event, the 148 & R21 records. Release 3 FROI Transaction
78 First Report of Injury FROI =148 + R21
79 The FROI Flat File Section 2 in the Release 3 Implementation Guide
80 FROI Flat File Record Layout is found in Section 2 of the Implementation Guide
81 FROI Flat File (148) Record Layout Data Elements Filler
82 FROI Companion Flat File (R21) Record Layout Data Elements Filler
83 FROI R21 Variable Segments
84 What Is A ?
85 Subsequent Report of Injury (SROI)
86 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
87 This means the Release 3 SROI transaction requires 2 records to communicate the Subsequent Report event, the A49 & R22 records. Release 3 SROI Transaction
88 Subsequent Report of Injury SROI = A49+R22
89 The SROI Flat File Section 2 in the Implementation Guide
90 SROI Flat File Record Layout is found in Section 2 of the Implementation Guide
91 Now Lets Review Important Codes Common To EDI Transactions
92 Important Codes R3 Quick Code Reference Guide (see FL Claims EDI webpage) R3 Quick Code Reference Guide (see FL Claims EDI webpage) Maintenance Type Codes Maintenance Type Codes Benefit Type Codes Benefit Type Codes Other Benefit Type Codes Other Benefit Type Codes
93 R3 Quick Code Reference One Stop Shopping for most codes Found on FL Claims EDI webpage
94 What Is An ? MTC
96 A code that defines the specific purpose of each transaction being transmitted.
97 DWC Forms required to be filed with the Division are replaced by EDI filings identified by MTC codes.
98 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, 4, 12).
99 When an MTC code is required in the Benefits segment on the SROI, it must be the same MTC code sent at the Claim level on the SROI.
100 First Report of Injury MTCs
101 FL FROI MTCs Include : 00 – Original 04 – Total Denial AU – Acquired First Report AQ – Acquired Claim 01 – Cancel (Claim Filed in Error)
102 FL FROI MTCs: Changes 02 – Change
103 Subsequent Report MTCs
104 FL SROI MTCs: Initial Payment Equivalents: IP - Initial Payment EP – Employer Paid Salary in Lieu of Comp PY – Payment AP - Acquired First Payment
105 FL SROI MTCs: Initial Payment Equivalents (contd): CD – Compensable Death-No Known Dependents/Payees VE - Volunteer
106 FL SROI Report MTCs: Denials: 04 – Full Denial PD – Partial Denial (Indemnity Only & other required partial denials).
107 Additions/Changes CB – Change in Benefit Type AB – Add Concurrent Benefit FL SROI MTCs: CA – Change in Benefit Amount
108 Reinstatements ER – Employer Reinstatement RB – Reinstatement of Benefits FL SROI MTCs:
109 Full Suspensions (of all Indemnity) S1 – RTW or Released to RTW S2 - Medical Non-Compliance S3 – Administrative Non-Compliance FL SROI MTCs:
110 Full Suspensions (of all Indemnity) S4 – Claimant Death S5 - Incarceration S6 – Claimants Whereabouts Unknown FL SROI MTCs:
111 Full Suspensions (of all Indemnity) S7 – Benefits Exhausted S8 – Jurisdiction Change FL SROI MTCs: You should recognize these from the DWC-4 Form
112 Partial Suspension (of a concurrent benefit) P7 – Benefits Exhausted FLs 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. FL SROI MTCs:
113 Periodic Reports 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 MTCs:
122 OBTs are codes that represent the type of non-indemnity benefits being paid
– Total Funeral Expenses 310 – Total Penalties 311 – Total Employee Penalties 320 – Total Interest 321 – Total Employee Interest Other Benefit Type Codes (required by FL) 370 – Total Other Medical
– 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 Other Benefit Type Codes (required by FL)
125 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
126 FL no longer requires the reporting of Physician (Medical), Hospital, or Pharmacy/Durable Medical Paid To Date on the EDI Claim Cost Periodic report. Other Benefit Type Codes (not required by FL)
127 How Are MTCs and Insurers Being Phased In for Implementing EDI R3?
128 The Division has established by rule two implementation schedules for phasing in all of the MTCs required for R3 reporting: The Primary Implementation Schedule includes MTCs for reporting the electronic equivalent of the DWC-1, 12, 13 & 49 & some DWC-4 data. The Primary Implementation Schedule includes MTCs for reporting the electronic equivalent of the DWC-1, 12, 13 & 49 & some DWC-4 data. The Secondary Implementation Schedule includes MTCs that equate to most DWC-4s. The Secondary Implementation Schedule includes MTCs that equate to most DWC-4s. EDI Claims R3 Implementation
129 EDI Claims R3 Implementation Again, implementation of EDI R3 applies to all MTCs required by rule for all Dates of Injuries, not just for dates of injuries occurring after the Insurers R3 production implementation date. Legacy claims are included in the mandate.
130 EDI Claims R3 Implementation Paper forms previously filed with DWC do NOT need to be re-submitted electronically.
131 The Division has divided insurers/self-insurers into three test to production periods (tiers), based on Insurer Code #. Insurer Code #s and current Insurer Code #s and current R1 Trading Partners implemented first. Insurer Code #s implemented next. Insurer Code #s implemented next. Insurer Code #s and are implementing last. Insurer Code #s and are implementing last. EDI Claims R3 Implementation
132 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. EDI Claims R3 Implementation
133 Third Party Administrators (TPAs) are not required to implement all of their insurer clients at the same time, but…. EDI Claims R3 Implementation
134 …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. EDI Claims R3 Implementation
135 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. EDI Claims R3 Implementation
136 The first group (Insurer Code #s ) began testing November 1, 2007, and were approved to begin a scheduled phase in to production beginning Claims EDI Primary Implementation Schedule Phase In: First Group Began Testing: First Group Phased In to Production beginning:
137 The second group (Insurer Code #s ) began testing February 1, 2008, and were approved for production no later than the last day of the 3 rd month after the testing period began. Claims EDI Primary Implementation Schedule Phase In: Second Group Began Testing: Second Group In Production By:
138 The third group (Insurer Code #s and ) began testing May 1, 2008, and were approved for production no later than the last day of the 3 rd month after the testing period began. Claims EDI Primary Implementation Schedule Phase In: Third Group Began Testing: Third Group Must Be In Production:
139 The Division has accepted and approved an insurers valid request for an extension to a later tier, and has added a 4 th and final Tier that requires successful testing and production approval no later than
140 Please refer to EDI Business Training PowerPoint slides located on the Claims EDI webpage for detailed instructional training on EDI Release 3 implementation. Please refer to EDI Business Training PowerPoint slides located on the Claims EDI webpage for detailed instructional training on EDI Release 3 implementation.