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1 Florida Division of Workers Compensation Claims EDI Requirements Table Training 2011.

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Presentation on theme: "1 Florida Division of Workers Compensation Claims EDI Requirements Table Training 2011."— Presentation transcript:

1 1 Florida Division of Workers Compensation Claims EDI Requirements Table Training 2011

2 2 Presenter: Tonya Granger Administrator, Claims & POC EDI Team Bureau of Data Quality and Collection FL Division of Workers Compensation

3 FL Trading Partner Tables Requirements and Resource documents

4 4 FL EDI Reporting requirements are defined in the Trading Partner Tables: 1.Required Report(s) 2.Data needed on the Report(s) 3.Applied Editing

5 5 The tables are part of the rule and Trading Partners are responsible for the requirements in those tables. Event Table: When each transaction is due.

6 6 Element Requirement Table: Data Elements required for each transaction (MTC), and under what conditions the data elements are required.

7 7 Edit Matrix: Edits that are applied to the incoming transactions and will reject the record or require follow up with an EDI Liasion. This table includes population restrictions edits, sequencing, duplicate processing and money calculations.

8 8 These very important requirements documents can be found on the Claims EDI webpage, and are your resource for determining when a transaction should be filed and why it may have errored. Important!

9 9 These are the Requirement Tables

10 10 Bookmark the FL Claims EDI Webpage and Check It For New or Updated Information

11 11 What is an Event?

12 12 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 FLs requirements, including: First Report of Injury events First Report of Injury events Subsequent Report events Subsequent Report events Periodic events Periodic events

13 13 2. Initial Payment or Equivalent or Equivalentwith 11. Changes (Non-Indemnity) 9. Lump Sum Payment(s) 9. Lump Sum Payment(s) 1. Establish Claim 4. Suspension of all Benefits 3. Changes to Benefits/Amnts Benefits Claim Event Flow Claim Event Flow in FL Claim Business Events 10.Periodic Reports 12.Cancel 8. Claim Closure

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

15 15

16 16 Due to the national standard format and sequencing requirements, FL requires the reporting of more business events (MTCs) than were required via paper forms.

17 17 Floridas Event Table describes what and when each MTC is due based on claim events. Event Table FL Event Table Example

18 18 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.

19 19 Event Table FL Periodic Reports FN Final – Submitted when Claim Administrator determines no further benefits will be paid. FN Final – Submitted when Claim Administrator determines no further benefits will be paid. SA Sub-Annual – Submitted every 6 months after the DOI, as defined on FLs Event Table. SA Sub-Annual – Submitted every 6 months after the DOI, as defined on FLs Event Table.

20 20 In addition to the Event Table, FL describes its business events in the MTC Filing Instructions. This document is a quick reference tool displaying what MTCs to use in reporting required business events to FL. Event Table MTC Filing Instructions

21 21 Helpful Resources

22 22 FL MTC Filing Instructions FL MTC Filing Instructions

23 23 FL Trading Partner Tables Data needed on the Report(s)

24 24 Element Requirements The FL Element Requirement Table describes the data elements required for each electronic event (MTC) documented on the Event Table.

25 25 Element Requirements Data Element requirements are defined for each transaction (FROI or SROI) at the Maintenance Type Code (MTC) level.

26 26 Element Requirements Requirement Codes express FLs requirement severity by data element and report type (FROI or SROI). The following slides define FLs requirement codes.

27 27 Element Requirements The Element Requirement Table contains 6 worksheets: FROI Element Requirements FROI Element Requirements FROI Conditions (for MCs) FROI Conditions (for MCs) SROI Element Requirements SROI Element Requirements SROI Conditions (for MCs) SROI Conditions (for MCs) Benefit Segment Requirements Benefit Segment Requirements Benefit Conditions (for MCs) Benefit Conditions (for MCs)

28 28

29 29 Element Requirements Fatal. The data element is essential to process the transmission/transaction. F =

30 30 Element Requirements Exclude. The data element is not applicable to the standard requirements for the MTC and may or may not be sent. X = Edits will NOT be applied, nor will the data be loaded for FL.

31 31 Element Requirements Mandatory. The data element must be present and must pass all edits (documented in the Edit Matrix) or the transaction will be rejected. M =

32 32 Element Requirements Mandatory/Conditional. The data element becomes mandatory under conditions documented on the applicable Conditional Requirements worksheets. MC = If the defined condition exists, the data element becomes mandatory and mandatory rules apply.

33 33 Element Requirements Data Elements defined as M or MC (and the condition applies) are required fields. If they are not present on the transaction, the transaction will receive a Mandatory Field Not Present error (Error # 001).

34 34 Element Requirements If Applicable/Available. Data should be sent if available or applicable to the claim. IA = If present, data will be edited for valid value and/or format. If the data passes the edits, the data will be loaded. If the data does not pass the edit, the data will not be loaded, and no error will be returned by FL.

35 35 Element Requirements Not Applicable. The data element is not applicable to FLs requirements for the MTC, and may or may not be sent. FL will not be editing or loading these data elements for this MTC. NA =

36 36 Element Requirements For DNs that are on both the FROI and SROI, FL has identified which transaction (FROI Or SROI, or Both) from which it will edit/load data, and from which the data will be ignored (N/A).

37 37 Element Requirements Interpreting Requirement Tables FLs Claim Number is not required on a FROI 00, 04, AQ or AU, but is Mandatory on a FROI 01 or 02.

38 38 Element Requirements FL Conditional Requirements Table Conditional Requirement Code Data Element Number and Name Business Conditions

39 39 Element Requirements Additional requirement codes were developed for the MTC 02 (Change) transaction.

40 40 Element Requirements A Benefits segment is expected when indemnity benefits have been paid on the claim, for each applicable Benefit Type Code value indicated in the Edit Matrix. Only one Benefits segment can be sent for each Benefit Type Code.

41 41 Element Requirements Event Benefits Requirements are described on the Event Benefits Segment Requirement Table. Event Benefits Requirements are described on the Event Benefits Segment Requirement Table.

42 42 Element Requirements Restricted. The data element value will not be accepted by FL. R = For example, FL does not accept Benefit Type Code 090 (PI) (Permanent Partial Disfigurement) for DOIs 12/31/93

43 43 Element Requirements Restricted Benefit Types for FL Restricted Benefit Types for FL

44 44 Element Requirements DNs in the Benefits segment are required based on the MTC as well as the Benefit Type Code being paid. DNs in the Benefits segment are required based on the MTC as well as the Benefit Type Code being paid. Net Weekly Amount

45 45 Element Requirements Data defined as N/A on the Element Requirement Table, or was not required by the Condition will not be edited, processed or loaded to DWCs system if sent for that MTC. This is commonly misunderstood.

46 46 Element Requirements Example: Gross/Net Amounts are not required for MTC SA or FN. If these data elements are sent incorrectly, they will NOT be errored. However, if Gross/Net Amounts are sent wrong on the next Event where they ARE required (CA, CB, etc.) they WILL be errored.

47 47 Element Requirements Although the same data element may be on both the FROI and SROI, the Element Requirement Table will depict on which transaction the data is required. The other transaction will list the requirement as N/A, which means it will not be edited, processed or loaded to DWCs system if sent for that MTC.

48 48 Element Requirements Example: Claim Type is not looked at on the FROI 00, but is required on the corresponding SROI IP. If it is only sent on the FROI and not the SROI, they will both reject.

49 49 FL Trading Partner Tables AppliedEditing

50 50 Edit Matrix The Edit Matrix details the edits applied by FL.

51 51 If a Transaction successfully passes all edits, what Application Acknowledgement Code is sent?

52 52 TA Transaction Accepted

53 53 If a Transaction fails an edit, what Application Acknowledgement Code is sent?

54 54 TR Transaction Rejected

55 55 Edit Matrix 1. DN-Error Message Table 2. Value Table 3. Match Data Table Sequencing Table 4. Sequencing Table The FL Edit Matrix consists of 8 worksheets: 5. Duplicate Processing ( Proprietary)

56 56 7. FL Min_Max Table ( Proprietary) 8. FL Calculation Table (Proprietary) Three proprietary worksheets (5., 7., and 8.) were added by FL to express additional editing. Edit Matrix 6. Population Restrictions

57 57 The 1 st Tab FL DN-Error Message Table (L Table)

58 58 FL DN-Error Message Table Contains standard logical edits developed for Release 3. Assists the claim administrator in determining what caused a specific error. (FL refers to this as the L Table.) Edit Matrix

59 59

60 60 FL Value Table

61 61 FL Value Table FL Value Table Conveys the code values that are expected to be reported to FL and code values that may be suppressed. Edit Matrix

62 62

63 63 The FL Quick Code Reference Guide assists in interpreting FLs Value Table in the Edit Matrix. FL Value Table Edit Matrix FL Quick Code Reference (FL DWC Website)

64 64 The Value Table is separated into two sections: Section 1: If a Data Element is collected by FL but a certain code value is grayed out (i.e., Not Statutorily Valid in FL), the filing will be rejected if that value is sent. FL Value Table Edit Matrix

65 65 FL Value Table – Section 1 Reflects the FROI and SROI Maintenance Type Codes (MTCs) FL will accept. Edit Matrix

66 66 FL Value Table – Section 1 FL does not accept FROI MTC CO or UI, or SROI MTC CO or RE. Edit Matrix

67 67 Section 1 (contd): If a Data Element is not collected by FL (reflected as N in Capture? column) and code values are grayed out, a filing will NOT be rejected if sent with those values. FL Value Table Edit Matrix

68 68 FL Value Table – Section 1 Ex: FL does not require or process Initial Treatment Codes. Edit Matrix

69 69 Section 2: If a Data Element is statutorily valid in FL (e.g., physician payments), but not required to be reported, the corresponding code value(s) is grayed out on the table, and the filing will NOT be rejected if sent with that value. FL Value Table Edit Matrix

70 70 FL Value Table – Section 2 Section 2: FL will NOT process the grayed out values; however, they ARE statutorily valid (e.g. atty fees). Edit Matrix

71 71 FL Value Table – Section 2 Ex: 330 (Total Employers Legal Expenses) Ex: 340 (Total Claimants Legal Expenses) Clm Admins may suppress these values. Edit Matrix

72 FL Match Data Table

73 73

74 74 FL Match Data Table Describes the data elements that will be used by FL to determine if the transaction will create a new claim, or be associated with an existing claim in DWCs database. Edit Matrix

75 75 FL Match Data Table If you receive Error # 117, Match Data Value Not Consistent With Value Previously Reported, check this table to see which data elements are being used as match data. Edit Matrix

76 76 FL Match Data Table Match criteria will also be applied between FROI and SROI combo filings. If any of the match data is different between the FROI and SROI, they will not be paired together for processing. Edit Matrix

77 77 FL Match Data Table At present, the letter case type must match between the FROI and SROI, e.g., cant send all caps (JOHN SMITH) on FROI and mixed case on SROI (John Smith). Edit Matrix

78 78 FL Match Data Table FL no longer requires a match on Middle Name/Initial. If Middle Name is on DWC record, but not sent on EDI filing, we no longer reject for no match on this field. Edit Matrix

79 79 FL Match Data Table DWC has added a column to the Match Data table to identify how we are matching a FROI with a corresponding SROIs. Edit Matrix

80 80 Standard Match Data Rules are described in Section 4 of the IAIABC R3 Implementation Guide. Match Data Rules

81 FL Sequencing Table

82 82 Edit Matrix FL Sequencing Table The FL Sequencing Table elaborates on standard error messages related to transaction sequencing (error # ).

83 83

84 84 Standard minimum Transaction Sequencing limitations are described in Section 4 of the IAIABC R3 Implementation Guide. Transaction Sequencing

85 85 Transaction Sequencing Understanding Transaction Sequencing in Section 4 of the IAIABC R3 Imp. Guide is necessary for understanding the FL Sequencing Table.

86 86 Edit Matrix FL Sequencing Table The FL Sequencing Table illustrates the sequence in which business events (MTC) typically occur during the life of a claim and what MTC must have preceded the subsequent MTC.

87 87 2. Initial Payment or Equivalent or Equivalentwith 11. Changes (Non-Indemnity) 9. Lump Sum Payment(s) 9. Lump Sum Payment(s) 1. Establish Claim 4. Suspension of all Benefits 3. Changes to Benefits/Amnts Benefits Claim Event Flow Claim Event Flow in FL Transaction Sequencing 10.Periodic Reports 12.Cancel 8. Claim Closure

88 88 Edit Matrix FL Sequencing Table Now lets try to interpret Edit Matrix Sequencing edits Now lets try to interpret Edit Matrix Sequencing edits.

89 89 Edit Matrix FL Sequencing Table FL accepts FROI 00 (with SROI) or FROI 04 to establish a claim. No FROI sequencing edits are applied

90 90 Shows the sequencing edits that will be applied for an IP Edit Matrix FL Sequencing Table or initial payment equivalent MTC.

91 91 Element Error Text (DN0291) is the FL error message text sent on the AKC which clarifies the Error Message Code Invalid Event Sequence. Edit Matrix FL Sequencing Table

92 92 If you do not understand what is meant by the 50 byte error text, you should look it up for more explanation. Edit Matrix FL Sequencing Table

93 FL Duplicate Processing

94 94

95 95 Edit Matrix FL Duplicate Processing

96 96 Edit Matrix FL Duplicate Processing In addition to duplicate errors (#057), there are sequencing (#063) and matching errors (#117) in this table.

97 97 Edit Matrix FL Duplicate Processing Although we do not accept an 00/IP after a previous 00/IP, we WILL accept a 00/IP after a paper DWC-1; however, we will process this as an 00/IP SROI ONLY and not as a First Report on your Report Card/Statistics.

98 FL Population Restrictions

99 99 Edit Matrix FL Population Restrictions All FL data element edits are documented in this worksheet.

100 100

101 101 Each Population Restriction contains: Edit Matrix The DN # and Name; The DN # and Name; Population Restrictions

102 102 Edit Matrix The Error # and Error IAIABC Message description; Population Restrictions

103 103 Edit Matrix The specific text describing the edit; and The specific text describing the edit; and Population Restrictions If you do not understand the 50 byte error message you received, this is the column that explains how the edit was applied.

104 104 Edit Matrix The FL-specific text clarifying the IAIABC Error Message Text. The FL-specific text clarifying the IAIABC Error Message Text. Population Restrictions

105 FL Min_Max Table (Proprietary)

106 106

107 107 FL Min_Max Table (Proprietary) Edit Matrix

108 FL Calculation Table (Proprietary)

109 109

110 110 FL Calculation Table (Proprietary) Edit Matrix

111 111 FL Calculation Table (Proprietary) Edit Matrix This table will be used to validate the Gross Weekly Amount (based on the Wage sent) and the Benefit Type Amount Paid expected from the Claim Administrator ( based on the weeks/days sent.)

112 112 FL Calculation Table (Proprietary) Edit Matrix FL bases all financial calculations on the Average Wage sent. This includes calculations of Calculated Weekly Comp Amount, Gross Weekly Amount, Net Weekly Amount and Benefit Type Amount Paid.

113 113 FL Calculation Table (Proprietary) Edit Matrix For Example: If the Comp Rate sent is correct for the claim, but the Average Wage is incorrect for the claim, the transaction will reject (TR), due to the fact that the Comp Rate will not equal 66 2/3% of the Average Wage sent.

114 114 FL Calculation Table (Proprietary) Edit Matrix Although you may have paid benefits at a Gross/Net Weekly rate that is more or less than 66 2/3s of the AWW, the Weekly Compensation Amount, a/k/a Comp Rate must always equal 66 2/3s of the Wage (within 5 cents). This ensures the validation of Average Wage since this DN is used to check indemnity payments.

115 115 FL Calculation Table (Proprietary) Edit Matrix We see a lot of errors generated for: Net < FL Calc Gross Amt minus Adj/Credit Amts. This typically results when the Net (weekly payment rate for the BTC ) is not accurate for the Average Wage sent (not because of a subtraction error w/offsets.)

116 116 How do you know which Table/Tab to look at to research an error?... Error 001 – Element Requirement Table (including Conditions Tab) Error 057 – Edit Matrix: Pop Rest and Duplicate Tab Error 063 – Edit Matrix: Pop Rest, Sequencing and Duplicate Tab Error Edit Matrix: Pop Rest and Match Data Tab All Other Error #s: Pop Restrictions Tab

117 117 ALL Questions, either Business or Technical, should be sent via to This address is copied to all members of the EDI team. It is the quickest and most efficient way for us to respond to your concerns.

118 118 Questions?

119 119


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