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Florida Division Of Workers Compensation Employee Assistance and Ombudsman Office FWCI Annual Conference August 24, 2005 Roy O. Wood Bureau Chief.

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Presentation on theme: "Florida Division Of Workers Compensation Employee Assistance and Ombudsman Office FWCI Annual Conference August 24, 2005 Roy O. Wood Bureau Chief."— Presentation transcript:

1 Florida Division Of Workers Compensation Employee Assistance and Ombudsman Office FWCI Annual Conference August 24, 2005 Roy O. Wood Bureau Chief

2 Employee Assistance and Ombudsman Office Effectuate the self-executing features of the workers compensation system without undue expense, costly litigation or delay in the provision of benefits.

3 Core Functions of EAO Outreach and Education Call Center/Request for Assistance Early Intervention Program OmbudsmanInvestigations

4 Outreach Heighten awareness Add value through contact Benefits to all stakeholders

5 Education Employers Employers Injured Workers Injured Workers Carriers Carriers

6 Call Center/Request for Assistance Centralized Access Point Centralized Access Point Dedicated telephone and web-based center Dedicated telephone and web-based center Staffed by professionals who will be Staffed by professionals who will be able to answer questions for all able to answer questions for all stakeholders stakeholders

7 Division of Workers Compensation research suggests that in the past 15 years over 60% of benefit costs were incurred by 10% of claims

8 Early Intervention Program Identification of potentially high exposure claims through the use of technology Identification of potentially high exposure claims through the use of technology Proactively contact injured worker to maximize return to work Proactively contact injured worker to maximize return to work

9 Ombudsman Advocate to foster Advocate to foster communication between communication between employer, adjuster and employer, adjuster and injured workers injured workers Will explain benefits to injured workers Will explain benefits to injured workers Will reduce load on adjuster Will reduce load on adjuster

10 Investigations In the case of an impasse, or unclear facts, a case may be referred to an investigator In the case of an impasse, or unclear facts, a case may be referred to an investigator Objective pursuit of the facts Objective pursuit of the facts Exercise authority provided under (9) F.S. Exercise authority provided under (9) F.S. Facilitate dispute resolution Facilitate dispute resolution

11 EAO EAO vision facilitating the self- execution of the WC law EAO vision facilitating the self- execution of the WC law Legislatively mandated to assist the injured worker Legislatively mandated to assist the injured worker EAO must wear several hats EAO must wear several hats

12 EAO EAO strives to be a professional front-line participant in the WC system adding value through its involvement EAO strives to be a professional front-line participant in the WC system adding value through its involvement

13 Thank you!

14 Workers Compensation Claims 69L-3, F.A.C. Fred Becknell Insurance Administrator Bureau of Monitoring & Audit

15 Workers Compensation Claims 69L-3, F.A.C. 226 days have passed since the Rule became effective on January 10 th. 136 days have passed since the Forms became mandatory on April 10 th.

16 A few observations in regard to the timely filing and accuracy of Workers Compensation claim forms. DWC-1 / First Report of Injury or Illness DWC-4 / Notice of Action/Change DWC-12 / Notice of Denial DWC-13 / Claim Cost Report

17 Required Fields / All Forms 69L-3.003(3) Employees name (First, middle, last) Employees name (First, middle, last) Employees social security number * Employees social security number * Month, day and year of the accident Month, day and year of the accident (mm-dd-yy or mm-dd-ccyy) (mm-dd-yy or mm-dd-ccyy) Sent to Division Date Sent to Division Date * Or Division Assigned Number (DAN) * Or Division Assigned Number (DAN)

18 Reporting of the Social Security Number 69L-3.003(3)(a) Report the actual Social Security Number as assigned by the Social Security Administration. If unknown or the employee does not have one, the claims-handling entity shall contact the Division by means of the Divisions website: Follow the directions (under Records Management - Division Assigned Numbers).

19 Required Fields on all Forms 69L-3.003(3) Insurer Code # & Insurer Name Service Co/TPA Code # * Claims-handling Entity File # Claims-handling Entitys Name, Address & Telephone * If applicable * If applicable

20 Insurer ID# ? What is my Insurer ID#?

21 Divisions web-site: Select the Databases option.

22 Select Insurer/Claim Administrator Database.

23 Type in the company name and hit the Submit Query key. Insurance

24 The Company Name, Insurer ID # & Corresponding Information is Displayed.

25 Filing of WC Forms 69L-3.003(5) All submissions of forms filed with the Division shall conform with the promulgated form in design, layout, field size and content (data elements).

26 DFS-F2-DWC-1 / 69L First Report of Injury or Illness Major changes for discussion 1. Reporting of the Claims-handling Entity Information 2. Reporting of Indemnity Only Denied Cases 3. Reporting of Delayed Disability Cases 4. Reporting of Lost Time Cases 5. Reporting of Penalties & Interest Paid to the Employee

27 Claims-Handling Entity Information 69L (1)(d)

28 Indemnity Only Denied Cases 69L (1)(d)5.b and (2)(g) Report cases where only the indemnity benefits are denied (medical benefits being provided). Box 1(b) Indemnity Only Denied Case is to be marked. Forms DWC-1 and DWC-12 are to be filed with the Division at the same time.

29 Reporting of Delayed Disability Cases 69L (2)(b) When disability is not immediate and continuous but result in 8 or more days of disability - send a completed DWC-1 within 6 days after knowledge of the 8 th day of disability.

30 Delayed Disability Case 69L (1)(d) 5. c. i.

31 Reporting vs. Paying Delayed Disability Cases Important Reminder: Do not confuse the filing of the DWC-1 with the timely payment of indemnity benefits pursuant to s (2)(a), F.S. Payment is due on the 6 th day after the 8 th day of disability. Filing is due within 6 days after the knowledge of the 8 th day of disability.

32 Reporting of Lost Time Cases 69L (2)(a) When disability is immediate and continuous for 8 or more days, send a completed DWC-1 within 14 days after knowledge of the injury or illness.

33 Reporting of Lost Time Cases 69L (2)(a) 1. Initial lost time cases 2. Full salary cases (employer paid for 8 or more days) 3. Death cases with/without dependents 4. Volunteers

34 Lost Time Case – Required Fields 69L (1)(d) 5.d.

35 Reporting of Lost Time Cases 69L (2)(c) – TP Benefits 69L (2)(d) – IBs 69L (2)(e) - Settlements If the initial payment of indemnity benefits is for TP, IB or results from an agreement or order for indemnity benefits send the completed DWC-1 within 14 days after the date payment mailed.

36 Reporting of Penalties & Interest 69L (1)(f)

37 DWC-4 Notice of Action/Change 69L File with the Division within 14 days of the knowledge of the action or change which is being reporting for lost time cases. Copies of the Form are to be mailed to the employee and employer at the same time.

38 Incomplete DWC-4s 69L The filing of the form with only the Remarks Section completed will not constitute filing of the required information - applicable field(s) are left blank.

39 Suspensions of Benefits 69L (2) State the Effective Date (the last date through which benefits were paid) of the suspension and the applicable suspension Reason Code.

40 69L (3) Reinstatements Upon the reinstatement of indemnity benefits after a suspension, report the effective date of the Indemnity Reinstated After Suspension & the Disability Type of benefits being reinstated.

41 69L (4) Return To Work Report when the employee has been medically released to RTW, been medically released to RTW, the assignment of physical restrictions, the assignment of physical restrictions, the removal of all physical restrictions, the removal of all physical restrictions, the actual RTW. the actual RTW.

42 69L (5) Settlements Report the Date Payment Mailed resulting from a final order of indemnity benefits pursuant to s (11), F.S. * This date can not be reported as earlier than the date the settlement was actually approved.

43 DWC-12 Notice of Denial 69L-3.012(1) Copies of the DWC-12 are to be mailed to the employee, employer and any additional party requesting payment or authorization, within 14 days of the date the decision to deny or rescind the denial.

44 Denial of Compensability 69L-3.012(2) When denying the compensability of or coverage for a case, send the DWC-12 to the Division within 14 days after notification of the injury, illness or death with a completed DWC-1.

45 Denial of Indemnity Only 69L-3.012(3) When denying only the indemnity benefits of a claim send the DWC-12 to the Division within 14 days after notification of the injury, illness or death with a completed DWC-1.

46 Denial of Subsequent Indemnity 69L-3.012(4) When denying any subsequent indemnity benefit on a lost time case send Form DWC-12 within 14 days of the knowledge of the requested benefit being denied.

47 Petition for Benefits 69L-3.012(5) If a Petition for Benefits (PFB) is the first notification of an injury and you are denying the case in its entirety (or only the indemnity portion), send Forms DWC-12 and DWC-1 to the Division within 14 days of the receipt of the PFB.

48 Rescinded Denial 69L-3.012(6) When rescinding the denial of previously denied indemnity benefits send Form DWC-12 with the Denial Rescinded Section completed within 14 days of the date that the denial was rescinded.

49 DWC-13 Claims Cost Report 69L Initial Report – file within 30 days after the 6 th month anniversary of the date of accident – no early filings accepted – unless filing as the final report. Initial Report – file within 30 days after the 6 th month anniversary of the date of accident – no early filings accepted – unless filing as the final report. Annual Reports – file within 30 days after the annual anniversary of the date of accident – no early filings accepted – unless filing as the final report. Annual Reports – file within 30 days after the annual anniversary of the date of accident – no early filings accepted – unless filing as the final report.

50 Workers Compensation Claim Forms 69L-3.025(3) All forms filed on or after April 10 th, 2005 must be the 08/2004 version (regardless of the date of injury).

51 Coming Spring 06 Update of 69L-3 / DWC-1 Optional reporting of the SIC Code until October 2006 in lieu of the NAICS Code. Required reporting of the employers knowledge of the injury or illness. Required reporting of the NAICS (SIC) Code and the NCCI Code on the DWC-1.

52 Coming Spring 06 Update of 69L-3 / DWC-13 The reporting of previous paid indemnity and medical for acquired claims can be reported in an Acquired or Unallocated format. All reporting will include the claim cost amounts for each applicable indemnity and medical in addition to the acquired amounts.

53 DWC-e-Alert Program Great way to keep current with updates from the Division. Sign up for the DWC e-Alert program for the quickest notification of rule making & other DWC activities. Located on the Divisions Website.

54 Fred Becknell - Insurance Administrator

55 Division of Workers Compensation Office of Data Quality & Collection Don Davis Senior Manager Analyst Supervisor Data Quality & Collection (850) How to Avoid Form Rejection and Penalty Exposure

56 Data Quality – Procedures for Filing Documents W.C. Claims Rule 69L (1) effective January 10, 2005 The Division shall return to the claims-handling entity any document on which the appropriate information required in subsection (3) of this section and paragraph 69L (1)(d) F.A.C. does not appear, and will notify the claims-handling entity of its error or omission.The Division shall return to the claims-handling entity any document on which the appropriate information required in subsection (3) of this section and paragraph 69L (1)(d) F.A.C. does not appear, and will notify the claims-handling entity of its error or omission. The document will be considered completed and in compliance when the corrected document is resent to the Division.The document will be considered completed and in compliance when the corrected document is resent to the Division.

57 Document Returned by Division Due to Non-compliance with Rule 69L Reviewer: ______________ Date: ____________ Effective April 11, 2005, the Division began enforcing the submission of required data fields for DWC forms pursuant to the WC Claims Rule, 69L-3.003(1), F.A.C.Effective April 11, 2005, the Division began enforcing the submission of required data fields for DWC forms pursuant to the WC Claims Rule, 69L-3.003(1), F.A.C. Indemnity Claim Forms (DWC-1, DWC-4, DWC-12, DWC-13) Example for Paper Filed Forms

58 Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1) #1 #1 – Sent to Division Date is Missing

59 #2 – Claims Handling Information is Incomplete #2 Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1)

60 #3 – Injury/Illness that Occurred is Missing #3 Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1)

61 #4 #4 – Insurer Name and/or Insurer Code Number are Missing #4 Top Reasons for Rejecting the Paper Filed First Report of Injury/Illness (DWC-1)

62 Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13) #1 #1 – Weeks/days missing for indemnity when $ amount is given

63 #2 – Insurer Name and/or Insurer Code Number are Missing #2#2 Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13)

64 #3 #3 – Settlement Dates are Missing #3 Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13)

65 #4 #4 – AWW / Comp Rate Missing Top Reasons for Rejecting the Paper Filed Claim Cost Report (DWC-13)

66 Question – What percentage of all returned DWC-1s and DWC-13s are rejected for these preceding top 4 data fields? A. 25 – 49% B. 50 – 75% C. 76 – 100% Answer : B – 75%

67 Legislative Mandate to Review All Medical Bills (DWC-9, 10, 11, 90) Section (2)(b), F.S. The division is now required to review 100 percent of all submitted medical bills to evaluate insurer performance. The division is now required to review 100 percent of all submitted medical bills to evaluate insurer performance. Last fiscal year, over four million medical bills were electronically reviewed in order to assess timely insurer performance standards pursuant to s (6)(b), F.S. Last fiscal year, over four million medical bills were electronically reviewed in order to assess timely insurer performance standards pursuant to s (6)(b), F.S.

68 Florida Workers Compensation Medical Services, Billing, Filing and Reporting Rule (69L F.A.C.) Effective Date: July 4, 2004 Projected Amended Effective Date: Mid-September 2005 Requirements for Medical Bill Completion and Filing (DWC-9, 10, 11, 90)

69 Important Highlights for Insurer Responsibilities Medical claim bills are required to be filed with the Division for ALL MEDICAL ONLY AND LOST TIME CASES. Medical claim bills are required to be filed with the Division for ALL MEDICAL ONLY AND LOST TIME CASES. Insurer must pay, adjust and pay, disallow or deny bill within 45 calendar days from date received [s (2)(b)] Insurer must pay, adjust and pay, disallow or deny bill within 45 calendar days from date received [s (2)(b)]

70 Important Highlights for Insurer Responsibilities Insurer must correct and re-file all rejected medical bills within the 45-day filing timeline. Insurer must correct and re-file all rejected medical bills within the 45-day filing timeline. Once the medical bill records are uploaded to our system, an electronic confirmation report is immediately issued to the EDI submitter that details the acceptance or rejection of each record submitted. Once the medical bill records are uploaded to our system, an electronic confirmation report is immediately issued to the EDI submitter that details the acceptance or rejection of each record submitted.

71 Rejected Medical Bills (DWC-9, 10, 11 & 90) can lead to penalties if not properly corrected and timely resubmitted to the division. CAUTION!

72 Top 4 Data Elements Causing Rejection of DWC-9 #1 #1 – Federal Employer Identification Number (FEIN) provided by the EDI Submitter does not match Division Records EDI Medical Record Layout #2 – EOBR Codes used incorrectly #2

73 #4 – No Matching Code Value from AMA CPT or ICD Manuals #4 #3 #3 – Blank or Zero Values submitted in the EDI Record Layout #3 EDI Medical Record Layout Top 4 Data Elements Causing Rejection of DWC-9

74 The Industry Has Significantly Improved!

75 Rejected Medical Bills For calendar year 2003, over 43,000 medical bills were rejected by the division for quality issues, and never corrected and resubmitted. For calendar year 2003, over 43,000 medical bills were rejected by the division for quality issues, and never corrected and resubmitted. For calendar year 2004, over 31,000 medical bills were rejected by the division for quality issues, and never corrected and resubmitted. For calendar year 2004, over 31,000 medical bills were rejected by the division for quality issues, and never corrected and resubmitted.

76 For the first six months of calendar year 2005, only 2,294 medical bills were rejected by the division for quality issues, and not corrected and resubmitted to the division. For the first six months of calendar year 2005, only 2,294 medical bills were rejected by the division for quality issues, and not corrected and resubmitted to the division. Rejected Medical Bills

77 Division Steps to Help Insurers File Accurately and Timely Contacted all 101 EDI medical submitters individually to validate and/or correct their insurer and FEIN numbers. Contacted all 101 EDI medical submitters individually to validate and/or correct their insurer and FEIN numbers. Created an educational/training guide (with the assistance of AHCA) on the proper usage of EOBR codes, and sent it to all Medical EDI submitters. The guide is also posted on DWCs website, under the EDI link. Created an educational/training guide (with the assistance of AHCA) on the proper usage of EOBR codes, and sent it to all Medical EDI submitters. The guide is also posted on DWCs website, under the EDI link.

78 HELP from the Medical EDI System Same day notification to Insurers of the Claim Processing Report listing accepted/rejected medical bills. Rejected data fields are noted in red for quick and easy identification – real time access Same day notification to Insurers of the Claim Processing Report listing accepted/rejected medical bills. Rejected data fields are noted in red for quick and easy identification – real time access Potential duplicate medical bills are identified in the new system (MDS), and flagged for correction on the Claims Processing Report – real time access Potential duplicate medical bills are identified in the new system (MDS), and flagged for correction on the Claims Processing Report – real time access

79 Developed a cumulative Outstanding Rejected Medical Claims report which is ed to submitters twice a month. This feedback helps our customers manage rejected medical claims. Developed a cumulative Outstanding Rejected Medical Claims report which is ed to submitters twice a month. This feedback helps our customers manage rejected medical claims. Created an Internet Website for direct online entry, validation, submission, correction, and resubmission of medical data. This website went live in January 2005 – real time access. Created an Internet Website for direct online entry, validation, submission, correction, and resubmission of medical data. This website went live in January 2005 – real time access. HELP from the Medical EDI System

80 An Acknowledgement report listing detailed errors is returned to Claim Administrators for every Claims EDI submission. An Acknowledgement report listing detailed errors is returned to Claim Administrators for every Claims EDI submission. HELP from the Claims EDI System Claim Administrators notified if no DWC-1 on file, for an electronically filed DWC-13. Claim Administrators notified if no DWC-1 on file, for an electronically filed DWC-13.

81 Report cards are issued monthly to Claim Administrators, which include the top 5 recurring errors. Report cards are issued monthly to Claim Administrators, which include the top 5 recurring errors. HELP from the Claims EDI System A cumulative monthly report of Rejected But Not Resubmitted DWC- 1s and DWC-13s is also provided. A cumulative monthly report of Rejected But Not Resubmitted DWC- 1s and DWC-13s is also provided.

82 Suspense of Paper Filed Claim Forms when Required Data is Missing Original Sent to Division Date: 06/15/05 Original Sent to Division Date: 06/15/05 Form received at Division (DWC): 06/20/05 Form received at Division (DWC): 06/20/05 DWC rejection stamp date: 06/21/05 DWC rejection stamp date: 06/21/05 (date form is returned to sender) (date form is returned to sender) Date completed form must be resent to DWC: 07/05/05 Date completed form must be resent to DWC: 07/05/05 (06/21/ days) (06/21/ days) New Sent to Division date: 06/30/05 New Sent to Division date: 06/30/05 Data completed Form received at DWC: 07/06/05 Data completed Form received at DWC: 07/06/05 Original Sent to Division date honored by DWC: 06/15/05 Original Sent to Division date honored by DWC: 06/15/05

83 Distribute the information for top reasons for rejection to the appropriate personnel responsible for completing the forms. Conduct training if necessary. Distribute the information for top reasons for rejection to the appropriate personnel responsible for completing the forms. Conduct training if necessary. Recommendation to Reduce Paper Filed Claim Forms

84 Recommendations to Reduce Medical Bill Violations Submit data to the division daily if possible, or at a minimum of once per week. Submit data to the division daily if possible, or at a minimum of once per week. Require your medical bill review vendor to copy you on the bi-monthly Outstanding Rejected Medical Claims report. Use the Centralized Performance System (CPS) to monitor your medical bill rejections. Require your medical bill review vendor to copy you on the bi-monthly Outstanding Rejected Medical Claims report. Use the Centralized Performance System (CPS) to monitor your medical bill rejections.

85 Encourage your medical bill vendor to build in-house edits that match the divisions edits and requirements, and have the vendor edit your medical filings prior to submission to the division. Encourage your medical bill vendor to build in-house edits that match the divisions edits and requirements, and have the vendor edit your medical filings prior to submission to the division. Contact the Office of Data Quality and Collection for a customized report that identifies the top reasons your medical bills are rejecting. Contact the Office of Data Quality and Collection for a customized report that identifies the top reasons your medical bills are rejecting. Recommendations to Reduce Medical Bill Violations

86 Thank you!

87 Division of Workers Compensation Update on Proof Of Coverage and Claims EDI Linda Yon, EDI Coordinator Phone:

88 Rule Chapter 69L-56 Florida Administrative Code is the EDI Rule for Proof of Coverage and Claims (non-medical) A copy is available on DWCs website at

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90 Overview of changes to 69L-56 effective Revised all EDI Trading Partner Forms For Proof of Coverage - adopted the IAIABC Release 2 Proof of Coverage Implementation Guide, and a revised FL POC EDI Implementation Manual

91 Transferred Proof of Coverage cancellation/non-renewal requirements and filing requirements from 69L and 69L to 69L-56. Transferred Proof of Coverage cancellation/non-renewal requirements and filing requirements from 69L and 69L to 69L-56. Overview of changes to 69L-56 effective

92 As of June 1, 2005, EDI transactions must be sent as follows: POC EDI: via Secure Socket Layer/File Transfer Protocol (SSL/FTP) POC EDI: via Secure Socket Layer/File Transfer Protocol (SSL/FTP) Claims EDI: via SSL/FTP or the Advantis Value Added Network (VAN). Claims EDI: via SSL/FTP or the Advantis Value Added Network (VAN). Overview of changes to 69L-56 effective

93 An insurer may contract with a third party vendor, or use a third party vendors software for electronically sending transactions to the Division, but the insurer will still remain responsible for the timely filing of EDI transactions. An insurer may contract with a third party vendor, or use a third party vendors software for electronically sending transactions to the Division, but the insurer will still remain responsible for the timely filing of EDI transactions.

94 Overview of changes to 69L-56 The Electronic Supplement to the First Report Of Injury (8 th Day of Disability) requirement was effective It will remain in place, through the date the insurer begins submitting via EDI in the new IAIABC Release 3 format.

95 Overview of changes to 69L-56 After the insurer is submitting data in the R3 format, the Supplement to the First Report format will no longer be required.

96 Future EDI Claims Filing Requirement for ALL Insurers

97 The requirement to implement Claims EDI will begin with the electronic form equivalent of: First Report of Injury or Illness (DWC-1) First Report of Injury or Illness (DWC-1) Claim Cost Report (DWC-13) Claim Cost Report (DWC-13) Claims EDI Filing Requirement

98 Proposed EDI Claims Implementation Requirement: The Division will divide insurers/self-insurers into three implementation groups, based on insurer code number. Lowest one third in the series, and current Release 1 Trading Partners will implement first. Lowest one third in the series, and current Release 1 Trading Partners will implement first. Middle one third in the series will implement next. Middle one third in the series will implement next. Highest one third in the series will implement last. Highest one third in the series will implement last.

99 The first group is to begin testing 9 months after the effective date of the rule, and must be in production no later than 1 quarter after the testing period begins. Sample Claims EDI Implementation Schedule Example: If Effective Date of Rule: First Group Must Begin Testing: First Group Must Be In Production:

100 The second group is to begin testing no later than 12 months after the effective date of the rule, and must be in production no later than one quarter after the testing period begins. Proposed Claims EDI Implementation Schedule

101 The third group is to begin testing no later than 15 months after the effective date of the rule, and must be in production no later than one quarter after the testing period begins. Proposed Claims EDI Implementation Schedule

102 When the R3 rules become effective and it is the Insurers scheduled time to begin submitting DWC-1s and 13s via EDI: An Insurer must submit EDI transactions to the Division using the national IAIABC Claims EDI Release 3 format.

103 The Release 3 Claims Implementation Guide can be downloaded from the IAIABCs website. This guide contains the transaction record layouts, data dictionary, scenarios, trading partner requirements, etc. This guide contains the transaction record layouts, data dictionary, scenarios, trading partner requirements, etc.

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105 Then click on implementation guides

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107 Floridas POC EDI Implementation Manual is available under the EDI link on the Divisions website. It provides all the FL specific requirements, including required fields, edits and error messages. EDI

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111 The FL Claims EDI Implementation Manual will be revised to match the requirements of Release 3 prior to the filing of the Rule 69L-56 amendments requiring the electronic reporting of EDI First/Sub Reports.

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114 Download (at no charge) the EDI Claims R3 Implementation Guide from Download (at no charge) the EDI Claims R3 Implementation Guide from Become familiar with the flat file formats, data elements, etc. Become familiar with the flat file formats, data elements, etc. How To Prepare For EDI Claims Release 3

115 Determine what fields you may have to change or add in your system to meet the EDI R3 requirements. Determine what fields you may have to change or add in your system to meet the EDI R3 requirements. (Ex: EE name must be sent as separate fields- First, Middle, Last, Suffix) (Ex: EE name must be sent as separate fields- First, Middle, Last, Suffix)

116 Determine if you will do the programming in house or use a claims system or vendor that is prepared to handle the R3 format and specifications. Determine if you will do the programming in house or use a claims system or vendor that is prepared to handle the R3 format and specifications. Consider attending Release 3 training provided by the IAIABC EDI Leadership Team. Linda Yon will be one of the instructors. Consider attending Release 3 training provided by the IAIABC EDI Leadership Team. Linda Yon will be one of the instructors. How To Prepare For EDI Claims Release 3

117 Analyze the quality of your data. If you receive a large volume of phone calls/letters from the Division regarding deficiencies of the data on your paper forms (ex: DWC-13), carefully analyze any trends in the deficiencies and correct them prior to EDI. Analyze the quality of your data. If you receive a large volume of phone calls/letters from the Division regarding deficiencies of the data on your paper forms (ex: DWC-13), carefully analyze any trends in the deficiencies and correct them prior to EDI. How To Prepare For EDI Claims Release 3

118 Examples of Data Deficiencies on DWC-13s: DWC-13 filed, but no DWC-1 previously filed. DWC-13 filed, but no DWC-1 previously filed. IB Benefits paid, but no prior DWC-4 filed reporting MMI Date or PI rating. IB Benefits paid, but no prior DWC-4 filed reporting MMI Date or PI rating.

119 Examples of Data Deficiencies on DWC-13s: Indemnity or Medical benefits previously reported on DWC-13 are not reported on current DWC-13. Indemnity or Medical benefits previously reported on DWC-13 are not reported on current DWC-13. Indemnity or Medical benefits reported on current DWC-13 are less than previously reported on prior DWC-13. Indemnity or Medical benefits reported on current DWC-13 are less than previously reported on prior DWC-13.

120 EDI is intended to be a computer-to- computer exchange of information and less likely to have errors; HOWEVER, it is essential that claim administrators edit the data as it is input in to their database, and before it is sent to the Division.

121 All EDI programs at the Division have standard edits that are applied to ensure data quality, and those edits are provided to all claim administrators in the Florida EDI Implementation Manuals.

122 The Division will acknowledge every EDI transaction, on the standard EDI Acknowledgement (AKC) format. This report tells the Claim Administrator how many records passed edits (TA), how many failed edits (TR), and the errors that caused the record to reject. ACK Report

123 The EDI Team is proud to announce its new online web based Claims EDI Data Warehouse (for existing EDI Trading Partners)

124 This web database will allow claim administrators in any field office to have access to review the Claims EDI transactions they have submitted, and any fields that were in error. EDI

125 Claim Administrators will be able to view the actual data submitted on any EDI transaction, which may appear different than what is seen on the claim administrators internal system.

126 This database will assist the claim administrators in resolving EDI errors faster, and may also assist in resolving CPS data issues. Claims EDI Warehouse

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131 You can search for an individual claim or query by date ranges Claims EDI Data Warehouse

132 BESTTPA SMITH, JOHN

133 Claim Administrators will also have instant access to Florida specific (proprietary) performance reports produced by the EDI Team, and must access this database to receive those reports. Proprietary Acknowledgement Reports Proprietary Acknowledgement Reports Monthly Rejected/Not Resubmitted Report Monthly Rejected/Not Resubmitted Report Monthly Report Card Monthly Report Card Note: These Florida Performance Reports will no longer be sent via FTP. Claim Administrators must now access them via this database.

134 BESTTPA

135 IAIABC Claims EDI Comprehensive Release 3 Training In Florida

136 This 3 day training will be given by the national Co-Chairs of the IAIABC EDI Committees and will provide a detailed overview of the Claims EDI R3 Implementation Guide

137 IAIABC Claims EDI Comprehensive Release 3 Training In Florida November 29 th - December 1 st Sarasota – Hyatt Space limited to first 150 to submit registration with payment

138 IAIABC Claims EDI Comprehensive Release 3 Training In Florida This training will provide critical instruction for both a business person and a technical/systems person from within a company. To register see the information on the IAIABC website under the EDI link.

139 EDI Contacts at DWC Linda Yon EDI Coordinator Karen Kubie Claims EDI Tonya Granger POC EDI

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142 What is the Centralized Performance System? A web based, real time interface between insurers/self insurers and the Division of Workers Compensation Allows the Division and insurers/self insurers to monitor payment and filing performance Two modules – Medical and Indemnity

143 CPS Medical Module Review of medical billing payment and filing performance by insurer in accordance with standards set forth in Florida Statutes, Chapter 440.

144 CPS Medical Module Activated in November 2004 Activated in November 2004 Insurers were integrated into CPS as all medical data was reported electronically. Insurers were integrated into CPS as all medical data was reported electronically. Two key components are: Two key components are: -Payment performance evaluation -Filing performance evaluation

145 Payment performance component Medical bills must be paid, disallowed, or denied within 45 days of the insurers receipt of the bill. Medical bills must be paid, disallowed, or denied within 45 days of the insurers receipt of the bill. Performance is measured by a statutory performance standard of 95% timely payment of bills. Performance is measured by a statutory performance standard of 95% timely payment of bills. CPS Medical Module

146 Failure to maintain a performance standard of 95% timely payment results in the following: $25.00 per bill for each bill below the 95% timely performance standard, but meeting a 90% timely performance standard. $50.00 per bill for each bill below the 90% timely performance standard. CPS Medical Module

147 Violations are calculated monthly Performance standard is applied to all bills of each individual form type DWC9, DWC10, DWC11, and DWC90 CPS Medical Module

148 Filing performance component Medical bills must be filed with the Division within 45 days of the final disposition of the bill. Medical bills must be filed with the Division within 45 days of the final disposition of the bill. Failure to meet the 45 days filing performance results in violations. Failure to meet the 45 days filing performance results in violations. CPS Medical Module

149 Rejected not Resubmitted Medical Bills Bills that have been submitted to the Division but were rejected for failure to pass system edits. When the bill is resubmitted properly, it is processed through CPS. Failure to resubmit the bill within 90 days of the rejection date results in a filing violation.

150 CPS Indemnity Module Review of the DWC-1 (Notice of Injury) initial payment of compensation and filing performance as set forth in Chapter 440, Florida Statutes.

151 CPS Indemnity Module Activated in June 2005 Activated in June 2005 Analyzes all DWC-1 forms submitted to the Analyzes all DWC-1 forms submitted to the Division in a calendar month Division in a calendar month Evaluates information for two components: Evaluates information for two components: - Timely payment of initial compensation - Timely payment of initial compensation - Timely filing of the DWC-1 with the Division - Timely filing of the DWC-1 with the Division

152 CPS Indemnity Module The Division monitors the timeliness of the initial compensation payment to insure injured workers are promptly compensated as required by law. Failure to provide benefits timely results in the following…

153 Violations for the Late Payment of Compensation in accordance with Section , Florida Statutes: 20% Penalty on the Unpaid Installment20% Penalty on the Unpaid Installment 12% Interest on the Unpaid Installment12% Interest on the Unpaid Installment CPS Indemnity Module

154 The DWC-1 must be filed within the time frames prescribed in Rule 69L-3, F.A.C. in order for the Division to monitor timely payment. Failure to timely submit forms will result in a violation as follows: The DWC-1 must be filed within the time frames prescribed in Rule 69L-3, F.A.C. in order for the Division to monitor timely payment. Failure to timely submit forms will result in a violation as follows: $ days late $ days late $ days late $ day late $500 for over 28 days late CPS Indemnity Module

155 CPS Basics

156 CPS System The Medical and Indemnity modules have the following common characteristics: System setup and site navigation. System setup and site navigation. Method to review information and process data. Method to review information and process data. Account administration functions. Account administration functions.

157 A few common definitions: Batch: A monthly assessment of all information submitted in one calendar month. Summary page: CPS overview of all information on an insurers batches. Workbench: The page where batches are processed by insurers/self insurers. This is where all work is done. Stage: The timeframe for the insurer/self insurer to work on the batch and respond to the Division.

158 CPS Stages Preliminary Notice of Violation - The initial 30 day period for the insurer to review the Divisions identification of untimely payments and filings, to dispute/concur with the information, provide additional information or correct data, pay and resolve the batch. Notice of Violation – Administrative order by the Division to the insurer of the outstanding unresolved violations. Formal Hearing – Should the insurer dispute the violations, they can preserve their rights and request an administrative hearing.

159 A few more definitions: Insurer Statuses: Dispute: The Insurer has reviewed the CPS information upon which a violation is asserted and does not agree that a violation has occurred. Concur: The Insurer has reviewed the CPS information and agrees that the violation is valid. Data Correction Sent – The insurer has sent corrected information for the CPS to review.

160

161 CPS Tutorial Power point presentation Power point presentation Can be downloaded and utilized for training purposes Can be downloaded and utilized for training purposes It is only the Indemnity Module. However, it is useful in learning either system It is only the Indemnity Module. However, it is useful in learning either system

162 CPS Logon Page

163 The CPS Home Page… status bar

164 Online Help Files Can be accessed from any screen in CPS Can be accessed from any screen in CPS Separate help files for each module Separate help files for each module

165 Menu bar…

166 Feedback….

167 The Centralized Performance System Administrative Functions

168 The Insurer Administrator: Is the primary contact for the insurer in CPS Is the primary contact for the insurer in CPS Creates new sub-accounts (users) Creates new sub-accounts (users) Edits the permissions of sub-accounts Edits the permissions of sub-accounts CPS Insurer Administrator

169

170 To create a sub-account…

171 Account Creation…

172 Account Access Rights View Items and Add Notes: This is the basic level of permission to allow the viewing of CPS data and to add notes to CPS batches. View Items and Add Notes: This is the basic level of permission to allow the viewing of CPS data and to add notes to CPS batches. View Items and Update Status: This secondary level of permission may view items, add notes, assign statuses of concur/dispute to preliminary violations. View Items and Update Status: This secondary level of permission may view items, add notes, assign statuses of concur/dispute to preliminary violations. Submit Batches: This is the broadest permission level. Users can view items, add notes, assign statuses, and submit batches to the Division. By default this permission is given to each companys Insurer Administrator. Submit Batches: This is the broadest permission level. Users can view items, add notes, assign statuses, and submit batches to the Division. By default this permission is given to each companys Insurer Administrator.

173 Claims Handling Entity assignment…

174 Claims Handling Entity Access Rights Claims Handling Entities (CHE) have a separate login in the Indemnity module. Claims Handling Entities (CHE) have a separate login in the Indemnity module. CHEs can view all DWC-1s submitted to the Division with their CHE code. CHEs can view all DWC-1s submitted to the Division with their CHE code. The insurer administrator can grant higher level access to allow the CHE to respond to the violations. The insurer administrator can grant higher level access to allow the CHE to respond to the violations. The CHE can do all necessary work except submit batches on the insurers behalf. The CHE can do all necessary work except submit batches on the insurers behalf.

175 Overview

176 Welcome screen…

177 Summary …

178 Workbench…

179 Detail page options…

180 Summary information from the DWC-1 Key Dates Penalties assessed Contacts

181 Responding to a violation…

182 WorWor Work Area to concur/ dispute penalties and Add notes/upload documents

183

184 The View All Screen … from the top header

185 View All screen… bottom of the page

186 MS Excel Output…

187 CSV Output…

188 Batch Submission When an insurer has responded to all violations assessed in the batch they may submit it to the Division. The Division will review the response, make any necessary data revisions/corrections, and accept or deny the insurers disputes. The Division will return the batch to the insurer for review. This process continues until the insurer/Division agree on the violations and payment is made or the insurer proceeds to the Notice of Violation stage.

189 A close up of the buttons…

190 The Confirmation page…

191 Batch Payment Options: There are two payment options available at any time. A Full Payment is simply the total batch payment amount. A Partial Payment is the sum of all concurred filing penalties in a batch.

192 Making Payment to the Division

193 Payment Entered for full or partial payment

194 The Reports Tab…

195 Select a date range…

196 How is your company performing vs. industry?

197 Medical Module – Additional Functions

198 Rejected but not resubmitted medical bills

199

200 Medical Reports

201

202

203 Common Errors - Indemnity Incorrect coding of case type: Incorrect coding of case type: ML or LT Failure to input all key dates Failure to input all key dates Failure to input penalties & interest already paid in first installment Failure to input penalties & interest already paid in first installment

204 Common Errors - Medical Incorrect insurer/claims handling entity coding Incorrect insurer/claims handling entity coding Incorrect payment dates Incorrect payment dates Rejected bills are not promptly corrected and resubmitted Rejected bills are not promptly corrected and resubmitted

205 The Key to success is Data Quality!

206 Questions? Should you have further questions contact Robin Ippolito or your assigned specialist at Should you have further questions contact Robin Ippolito or your assigned specialist at

207 Florida Division of Workers Compensation Centralized Performance System Robin Ippolito Bureau of Monitoring & Audit

208 Division of Workers Compensation 2005

209 Bureau of Monitoring and Audit Todays Discussion: Practices that Drive Audit Costs Looking Back Over The Past Years Audit Performance Evolution of the Audit Process

210 Bureau of Monitoring and Audit Poor Practices that Drive Audit Costs: 1. DWC-1 Untimely Filings 2.Untimely Payment of Medical Bill 3.Permanent Total Benefit Calculations

211 Poor Practices Driving Audit Costs Timely Filing of DWC-1s: File on indemnity settlements of any type If Impairment Income Benefits is the first indemnity benefit paid, you must file the DWC-1 upon payment of these benefits

212 Poor Practices Driving Audit Costs Timely Payment of Indemnity & Medical Benefits: Timely Payment of Indemnity & Medical Benefits: Prior to January 1, % Performance Standard Post January 1, % Performance Standard

213 Poor Practices Driving Audit Costs Permanent & Total Benefit Calculations: Inaccurate calculation of PT benefits & PT Supplemental benefits Timely payment of PT benefits and PT Supplemental benefits Social Security Disability offset calculations Grice limitations

214 FY Audit Results A Summary of Audit Performances in the Following Areas: Timely Payment of Indemnity Timely Payment of Medical Timely Reporting of the DWC-1 Timely Reporting of the DWC-13 Timely Sending of Employee Brochures

215 Timely Payment of Compensation

216 Timely Payment of Medical

217 Timely Reporting of DWC-1

218 Timely Reporting of DWC-13

219 Timely Mailing of Employee Brochures

220 Medical Bills Evaluated by CPS Since November 2004

221 Latest CPS Performance Medical Data for July 2005

222 Evolution of the Audit Process Our Audit Process has been Impacted by: –Claims Rule (69L-3) –Medical Billing Rule (69L-7.602) –Upcoming EDI – Indemnity Mandate (69L-56) –The Centralized Performance System

223 Evolution of the Audit Process Changing How We Review the First Report of Injury (DWC-1) –Timely Reporting of the DWC-1 and Initial Indemnity Payment Assessed by CPS –Audit Will Focus on Data Quality Reported to DWC (Claim File is the Source Document)

224 Evolution of the Audit Process Changing How We Review Medical Bills –Timely Payment and Timely Reporting of DWC-9, DWC-10, DWC-11 and DWC-90 is Now Assessed by CPS –Audit Will Focus on Data Quality Reported to DWC (Claim File is the Source Document)

225 New & Essential Audit Components Insurers / Claims-handling Entities Must Have Documented Processes and Procedures (in writing). Expect a Complete Review of : 1. Step-by-Step Check Issuance 2. Step-by-Step Date Stamping 3. Step-by-Step Mailroom Operations

226 Bureau of Monitoring and Audit IMPORTANT NOTE: Electronic Systems Must be Transparent For Audit Purposes 1. Medical Data 2. EDI Data 3. Payment Information 4. All Adjuster Notes / Comments

227 Evolution of the Audit Process Implementation of CPS Provides More Time: –Indemnity Calculations –Permanent Total Calculations –Indemnity Timeliness –Forensic Review of Claim File

228 Bureau of Monitoring and Audit IMPORTANT NOTE: Insurers / Claims-handling Entities Must Improve the Documentation in a Claim File (If it isnt in the claim file, you didnt do it)

229 Bureau of Monitoring & Audit Thank You! Greg Jenkins, Chief Bureau of Monitoring and Audit Phone:


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