Presentation on theme: "Electronic First Reports of Injury or Illness (EDI DWC-1 Equivalent)"— Presentation transcript:
1 Electronic First Reports of Injury or Illness (EDI DWC-1 Equivalent)
2 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 IPRequired to be filed with DWC per Rule 69L , F.A.C.
3 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.
4 Electronic First Report of Injury or Illness 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:
5 Other SROI’s Sent with FROI 00: Electronic First Report of Injury or IllnessOther SROI’s Sent with FROI 00:CD – Compensable Death with no Known Dependents/PayeesEP – Employer PaidPD – Partial DenialPY – Lump Sum Payment/SettlementVE – Volunteer (covered under FL law)FROI Only04 – Full (Total Denial)
6 Electronic First Report of Injury or Illness Please note that we will be deferring discussion on AU/AP EDI DWC-1 equivalents and other Acquired Claims issues until tomorrow.
14 Lump sum payments / settlements will be discussed in more detail during tomorrow’s training.
15 Another POP Quiz:When is the 00/IP considered timely filed with the Division?
16 Electronic First Report of Injury or Illness 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.
17 Electronic First Report of Injury or Illness 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.)
18 HELPFUL HINTTo 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.)
19 HELPFUL HINTThis 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.
20 Electronic First Report of Injury or Illness 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.)
21 Electronic First Report of Injury or Illness 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.
22 Electronic First Report of Injury or Illness 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.
23 Electronic First Report of Injury or Illness 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…
24 Electronic First Report of Injury or Illness … 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.
25 Now let’s take a detailed look at the Benefits Segment on the SROI
26 The Benefits segment on the SROI consists of the following data elements (DN’s):
27 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.
28 SROI BENEFITS SegmentThe 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.
29 SROI BENEFITS SegmentIf you have paid indemnity, a Benefits Segment for EVERY indemnity Benefit Type paid should be included on EVERY SROI transaction.
30 SROI BENEFITS SegmentException: 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.)
31 SROI BENEFITS SegmentCorrespondingly, 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.
32 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.
33 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.
34 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.
35 Variable Segment Population Rules for the SROI Benefits Segment
36 SROI BENEFITS SegmentOnly 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.
37 SROI BENEFITS SegmentThe Benefits segment is populated with the current values at the time of transmission, based upon the Benefit Type Codes paid on the claim (snapshot).
38 SROI BENEFITS SegmentException: 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.
39 SROI BENEFITS SegmentWhen 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.
40 SROI BENEFITS SegmentExample: 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.
41 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.
42 SROI BENEFITS Segment0 (zero) Benefits Segments are also allowed if Reduced Benefit Amount Code is reported as:S (Settlement on Another DOI) orN (No Money Settlement).
43 SROI BENEFITS SegmentReduced 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.
44 SROI BENEFITS SegmentWhere 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.
45 SROI BENEFITS Segment0 (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.)
48 “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.
49 “EVENT” BENEFITS SEGMENT RULES 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)
50 “EVENT” BENEFITS SEGMENT RULES Note (exception to the exception):Benefit Period Start Date is required for BTC 020 & BTC 240, andBenefit 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.
51 “EVENT” BENEFITS SEGMENT RULES MTCWhen 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).
53 SROI Benefits segmentIf MTC is sent in the Benefits segment, it will be edited as an “Event” Benefits segment.
54 “EVENT” BENEFITS SEGMENT EXAMPLE MTC is reported in the Benefits segmentwhen a benefit type is being initiated or terminated (AB, AP, CB, CA, S1-8, P7, EP, ER, IP, or RB).
55 “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).
56 “EVENT” BENEFITS SEGMENT RULES BENEFIT PERIOD START DATE – DN0088For 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.
57 “EVENT” BENEFITS SEGMENT RULES BENEFIT PERIOD START DATE – DN0088For 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.
58 “EVENT” BENEFITS SEGMENT RULES 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.
59 HELPFUL HINTRecap: 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.)
60 HELPFUL HINTAn 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 …
61 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.
62 HELPFUL HINTRecap: 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…
63 … 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…
64 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.
66 “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.
67 “SWEEP” BENEFITS SEGMENT RULES 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),04PDPY reporting BTC 5XXPeriodics: SA & FN
68 “SWEEP” BENEFITS SEGMENT RULES 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.
69 “SWEEP” BENEFITS SEGMENT RULES 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)…
70 “SWEEP” BENEFITS SEGMENT RULES 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).
71 “SWEEP” BENEFITS SEGMENT RULES A “Sweep” Benefits Segment must include the following data elements:Benefit Type CodeBenefit Period Start DateBenefit Period Through DateBenefit Type Claim WeeksBenefit Type Claim DaysBenefit Type Amount Paid
72 “SWEEP” BENEFITS SEGMENT RULES A “Sweep” Benefits Segment will NOT include the following:MTC (if sent would imply Event Segment)Gross Weekly AmountGross Weekly Amount Effective DateNet Weekly AmountNet Weekly Amount Effective DateBenefit Payment Issue Date
73 “SWEEP” BENEFITS SEGMENT RULES BENEFIT PERIOD START DATEFor 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.
74 “SWEEP” BENEFITS SEGMENT RULES 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.MTCIf MTC sent it will be edited as an Event segment.
78 BOTH FROI & SROI MUST PASS EDITS TO ACCEPT FILING Caveats and Tips for Successfully Filing 00/IPIf you receive the error,BOTH FROI & SROI MUST PASS EDITS TO ACCEPT FILINGthis 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.
79 We are also still seeing the following errors with great frequency: Caveats and Tips for Successfully Filing 00/IPWe are also still seeing the following errors with great frequency:NO MATCHING FIRST REPORTNO MATCHING SUBSEQUENT REPORT
80 Caveats and Tips for Successfully Filing 00/IP 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.
81 Caveats and Tips for Successfully Filing 00/IP It is critical these errors are resolved asap to avoid any resulting penalty for late filing with the Division.
83 Caveats and Tips for Successfully Filing 00/IP 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…
84 Caveats and Tips for Successfully Filing 00/IP … 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, …
85 Caveats and Tips for Successfully Filing 00/IP … 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.
86 Caveats and Tips for Successfully Filing 00/IP 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.)
87 Caveats and Tips for Successfully Filing 00/IP 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.)
88 Caveats and Tips for Successfully Filing 00/IP 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.
89 Caveats and Tips for Successfully Filing 00/IP 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.)
90 Caveats and Tips for Successfully Filing 00/IP 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.)
91 Caveats and Tips for Successfully Filing 00/IP 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.
92 Caveats and Tips for Successfully Filing 00/IP If filing late, or re-sending an 00/IP that previously rejected, AND another indemnity check has been issued since the first installment…
93 Caveats and Tips for Successfully Filing 00/IP … 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.
94 Caveats and Tips for Successfully Filing 00/IP 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.
95 Caveats and Tips for Successfully Filing 00/IP 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 …
96 Caveats and Tips for Successfully Filing 00/IP … 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.
97 Caveats and Tips for Successfully Filing 00/IP Accuracy of Claim Type is extremely important. Claim Type must be correct in relation to the Initial Date Disability Began and RTW information…
98 Caveats and Tips for Successfully Filing 00/IP 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.
99 Caveats and Tips for Successfully Filing 00/IP 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);
100 Caveats and Tips for Successfully Filing 00/IP 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.)
102 What does the data element , ‘Initial Date of Lost Time’ represent?
103 ‘Employee’s 8th Day of Disability’ ANSWER:‘Employee’s 8th Day of Disability’
104 Caveats and Tips for Successfully Filing 00/IP ‘Initial Date of Lost Time’ is not the same as ‘Initial Date Disability Began’.These are two different data elements.
105 Caveats and Tips for Successfully Filing 00/IP 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.
106 Caveats and Tips for Successfully Filing 00/IP 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.
107 Caveats and Tips for Successfully Filing 00/IP 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.
108 Caveats and Tips for Successfully Filing 00/IP 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.)
109 Caveats and Tips for Successfully Filing 00/IP 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.
110 Caveats and Tips for Successfully Filing 00/IP We will discuss Reduced Benefit Amount Codes in more detail relative to other SROI MTC’s later in the training.
111 Caveats and Tips for Successfully Filing 00/IP 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.
112 Caveats and Tips for Successfully Filing 00/IP If you are receiving errors for:NET < FL CALC GROSS AMT MINUS ADJ/CREDIT AMTSThis means the Net Weekly Amount you are sending is not in line with the amount calculated by DWC’s program (within 5¢).
113 Caveats and Tips for Successfully Filing 00/IP 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).
114 Caveats and Tips for Successfully Filing 00/IP 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.
115 Caveats and Tips for Successfully Filing 00/IP 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.)
116 Caveats and Tips for Successfully Filing 00/IP
117 Caveats and Tips for Successfully Filing 00/IP If you are receiving errors for:NET $.05 OVER FL CALC GROSS MINUS ADJ/CREDIT AMTSThis means that the Net Weekly Amount you are sending is more than 5¢ over the amount calculated by our program.
118 Caveats and Tips for Successfully Filing 00/IP 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.
119 Caveats and Tips for Successfully Filing 00/IP 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.
120 Caveats and Tips for Successfully Filing 00/IP 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.
121 POP QUIZ: True or False: DWC defaults to a value of ‘5’ if ‘Number of Days Worked Per Week’ is not sent.
122 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.
123 WKLY COMP AMT NOT CORRECT FOR AWW Caveats and Tips for Successfully Filing 00/IPIf you are receiving errors for:WKLY COMP AMT NOT CORRECT FOR AWWThe 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).
124 Caveats and Tips for Successfully Filing 00/IP 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.
125 Caveats and Tips for Successfully Filing 00/IP 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.
126 Caveats and Tips for Successfully Filing 00/IP 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.)
127 Caveats and Tips for Successfully Filing 00/IP 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...
128 Caveats and Tips for Successfully Filing 00/IP …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.
129 Caveats and Tips for Successfully Filing 00/IP 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….
130 …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.
131 Caveats and Tips for Successfully Filing 00/IP 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.
132 Caveats and Tips for Successfully Filing 00/IP 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.
133 Acknowledgement ‘Free Form Text’ Messages for Claim Administrators
134 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
135 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.
136 Let’s complete a SROI for Scenario 1-A-8 (New) in your Handouts…
137 Electronic First Report of Injury or Illness Initial Payment – 00/IPBTC 070 with Multiple Initial RTW Dates on same IP(Scenario 1-A-8)
138 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.
139 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.
140 The SROI IP will contain partial data excerpted from the SROI, and includes: 1 Benefits Segment and1 Payments Segment.
141 Claim Administrator Postal Code 379921223 0001Transaction Set IDA9Subsequent Report0002Maint. Type CodeIPInitial Payment0003MTC DateJan.23, 20100004Jurisdiction CodeFL0006Insurer FEIN0014Claim Administrator Postal Code0056Initial Date Disability BeganJan. 1, 20100072Current Return to Work DateN/A
142 Jan. 1, 2010 Indemnity/ Lost Time 0063Wage Period Code01Weekly0064Number of Days Worked Per Week50031Date of InjuryJan. 1, 20100015Claim Admin. Claim NumberWC0005Jurisdiction Claim NumberN/A0074Claim Type CodeIIndemnity/ Lost Time
143 R22 Data Elements0001Transaction Set IDR220298Date Claim Administrator Had Knowledge of Lost Time (Clm Admin’s Knowledge of 8th Day of Dis for FL)N/A0015Claim Administrator Claim NumberWC0187Claim Administrator FEIN
144 Social Security Number 0188Claim Administrator NameOLD RELIABLE INSURANCE COMPANY0140Claim Administrator Claim Rep NameAngie,,AdjusterAngie Adjuster0137Claim Admin. Claim Rep Phone Number(850)0270Employee ID Type QualifierSSocial Security Number0042Employee SSN
145 0043Employee Last NameSMITH0044Employee First NameJOHN0045Employee Middle Name/InitialJ0255Employee Last Name SuffixJR0052Employee Date of BirthMay 1, 19530202Reduced Benefit Amount CodeN/A
146 Non-Consecutive Period Code N/A 0228Return To Work With Same Employer IndYYes0212Non-Consecutive Period CodeN/A0145Current Date Last Day WorkedN/A0144Current Date Disability BeganN/A0065Initial Date Last Day WorkedJan. 1, 20100189Return To Work Type CodeAActual
147 0224Physical Restrictions Ind.YYes0134Calculated Weekly Compensation Amount$400.000256Wage Effective DateJan. 1, 20100290Type of Loss Code01Trauma0058Employment Status Code1Full Time
148 0068Initial Return to Work DateJan. 10, 20100066Full Wages Paid For Date Of Injury IndicatorNNo0273Employer Paid Salary in Lieu of Comp. IndicatorNNo0286Average Wage$600.000297Initial Date of Lost Time (8th Day)N/A0200Claim Admin. Alternate Postal Code (Mailing)
149 1 Occurrence 1 Occurrence Variable Segment Counters0288Number of Benefits011 Occurrence0283Number of Payments011 Occurrence0282Number of Other Benefits022 Occurrences0289Number of Benefit ACR000284Number of Recoveries00
150 0285Number of Reduced Earnings000275Number of Concurrent Employers000277Number of Full Denial Reason Code000276Number of Denial Reason Narratives000287Number of Suspension Narratives00
151 Gross Weekly Amount Effective Date N/A for TP Variable SegmentsBenefits1 Occ0085Benefit Type Code070Temporary Partial0002Maint. Type CodeIPInitial Payment0174Gross Weekly AmtN/A for TP0175Gross Weekly Amount Effective DateN/A for TP0087Net Weekly AmountN/A for TP0211Net Weekly Amount Effective DateN/A for TP
152 0088Benefit Period Start DateJan. 1, 20100089Benefit Period Through DateJan. 21, 20100090Benefit Type Claim Weeks00030091Benefit Type Claim Days0086Benefit Type Amount Paid$0192Benefit Payment Issue DateJan. 23, 2010
153 Temporary Partial $1152.00 Jan. 1, 2010 Jan. 21, 2010 Jan. 23, 2010 Payments1 Occ0222Payment Reason Code070Temporary Partial0217PayeeJOHN J SMITH JR0218Payment Amount$0219Payment Covers Period Start DateJan. 1, 20100220Payment Covers Period Through DateJan. 21, 20100195Payment Issue DateJan. 23, 2010P&I reported under OBT 311 and 321
155 More on Other First Report / EDI DWC-1 Equivalent MTC’s
156 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.)
157 EDI DWC-1 EquivalentsThe following SROI’s (sent with FROI 00), will still require a Benefits segment:EP – Employer PaidPY – Lump Sum Payment/Settlement
158 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, andPD (Partial/Indemnity Only Denial).
159 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?
161 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.”
162 EMPLOYER PAID BENEFITS This does NOT include the waiting week if the employee was not disabled for 22 or more days”.
163 EMPLOYER PAID BENEFITS 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.
164 EMPLOYER PAID BENEFITS 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.
165 A 00/EP filing must contain only 2xx benefits segment(s). EMPLOYER PAID BENEFITSA 00/EP filing must contain only 2xx benefits segment(s).240 Employer Paid Unspecified Indemnity benefits250 Employer Paid TT benefits270 Employer Paid TP benefits
166 EMPLOYER PAID BENEFITS Also valid, but not as typical:210 Employer Paid Death benefits230 Employer Paid Impairment Income benefits242 Employer Paid Voc Rehab (TT – R&E)251 Employer Paid TT Catastrophic (80%)
167 EMPLOYER PAID BENEFITS 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).
168 EMPLOYER PAID BENEFITS 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.
169 Data Population Rules for Employer Paid Benefits
170 Caveats and Tips for Successfully Filing 00/EP
171 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).
172 Caveats and Tips for Successfully filing 00/EP 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?
173 Caveats and Tips for Successfully filing 00/EP ANSWER:00/IP
174 Caveats and Tips for Successfully filing 00/EP 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.)
175 Caveats and Tips for Successfully filing 00/EP 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…
176 Caveats and Tips for Successfully filing 00/EP … 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.)
177 Caveats and Tips for Successfully filing 00/EP 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.) …
178 Caveats and Tips for Successfully filing 00/EP … 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.)
179 Caveats and Tips for Successfully filing 00/EP 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; …
180 Caveats and Tips for Successfully filing 00/EP … 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).
181 Caveats and Tips for Successfully filing 00/EP Also, Reduced Benefit Amount Code “R” must be present on the 02 to explain the ‘disappearance’ of the previously reported BTC 2xx.
182 Caveats and Tips for Successfully filing 00/EP 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.
183 Caveats and Tips for Successfully filing 00/EP 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):
184 DN’s Changed by 02 if Next Accepted Filing: Salary Cont’d in Lieu of Comp Ind.BTC 240 (Salary) Through DateOriginal BTCClaim Admin. Knowledge of InjuryPayment Issue DatePen & Int Amount Paid in 1st Payment (OBT’s 311 and 321)
185 Caveats and Tips for Successfully filing 00/EP 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.
186 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”.
187 Caveats and Tips for Successfully filing 00/EP 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.
188 Caveats and Tips for Successfully filing 00/EP 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, …
189 … 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.
190 Caveats and Tips for Successfully filing 00/EP 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.
191 Caveats and Tips for Successfully filing 00/EP 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.
192 Caveats and Tips for Successfully filing 00/EP 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.
193 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?
195 IP after EPIf 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.
196 If your initial payment, after the Employer paid benefits, is for a Final Settlement, send SROI PY (instead of IP.)
197 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.)
198 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.)
199 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.
200 EP after IPIf 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.)
201 EP after SxEP 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.)
202 … 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.)
203 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.)
205 POP QUIZ:What MTC is used to report a Totally Denied Electronic First Report of Injury or Illness?
206 ANSWER: FROI MTC 04 Full (Total) Denial EDI DWC-1 Equivalent required to be filed with DWC per Rule 69L (2).
207 FROI MTC 04 Full (Total) Denial FROI 04 represents a total denial of all indemnity and medical benefits, including denials based on compensability.
208 FROI MTC 04 Full (Total) Denial This is the only EDI DWC-1 equivalent that does not require a corresponding SROI MTC to be paired with a FROI MTC.
209 FROI MTC 04 Full (Total) Denial 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.
210 FROI MTC 04 Full (Total) Denial The corresponding Electronic Notice of Denial, EDI DWC-12 equivalent, is also due, and reported on the same FROI 04.
211 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.
212 FROI MTC 04 - Full (Total) Denial “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.
213 FROI MTC 04 - Full (Total) Denial Also, Full Denial Reason Code “5B” (Right to Reserve) can not be the only Full Denial Reason Code sent.
214 FROI MTC 04 - Full (Total) Denial “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.)
215 FROI MTC 04 - Full (Total) Denial “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.
216 FROI MTC 04 - Full (Total) Denial 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…
217 FROI MTC 04 - Full (Total) Denial 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.)
218 FROI MTC 04 - Full (Total) Denial 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.
219 FROI MTC 04 - Full (Total) Denial 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 ...
220 FROI MTC 04 - Full (Total) Denial …there would not be any associated ‘8th day of disability’ information to report, which is required if Claim Type = “L”.
221 FROI MTC 04 - Full (Total) Denial 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.
222 Filing Caveats and Tips for Successfully Filing FROI 04
223 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..
224 Caveats and Tips for Successfully Filing 04: 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.)
225 Caveats and Tips for Successfully Filing 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.
226 Caveats and Tips for Successfully Filing 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).
227 Caveats and Tips for Successfully Filing 04: 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.)
228 Caveats and Tips for Successfully Filing 04: 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.
230 POP QUIZ:What MTC is used to report an Indemnity Only Denied Electronic First Report of Injury or Illness?
231 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.
232 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentA 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.
233 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentThe 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), andDenial Reason Narrative to provide details about why indemnity benefits will not be paid.
234 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentPARTIAL DENIAL CODE identifies which portion of the claim is being denied (not the reason it is denied).
235 Partial Denial Codes for FL A Denying Indemnity in whole, but not Medical (Indemnity Only Denied Case)B Denying Indemnity in part, but not MedicalE Denying Indemnity in whole and Medical in part (Indemnity Only Denial)G Denying both Indemnity and Medical in part
236 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentThe 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).
237 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentFor 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” …
238 Partial (Indemnity Only) Denial 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.)
239 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentDenial 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.
240 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentAgain, 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).
241 Partial (Indemnity Only) Denial EDI DWC-1 EquivalentMTC “PD” (Partial Denial) is not used in conjunction withFull Denial data elements:Full Denial Reason CodeFull Denial Effective DateDENIED
242 Partial (Indemnity Only) Denial 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.
243 Caveats and Tips for Successfully Filing FROI 00 + SROI PD
244 Only Codes A and E represent ALL indemnity is being denied. Caveats and Tips for Successfully Filing 00/PDIf 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.
245 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).
246 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.
247 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.
248 Caveats and Tips for Successfully filing 00/PD 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.
249 Caveats and Tips for Successfully filing 00/PD 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.
250 Caveats and Tips for Successfully filing 00/PD 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.)
251 Caveats and Tips for Successfully filing 00/PD 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.)
252 Caveats and Tips for Successfully filing 00/PD 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…
253 Caveats and Tips for Successfully filing 00/PD …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.
254 Caveats and Tips for Successfully filing 00/PD Recap: A Partial Denial Code can be changed on an 02 or PD, but neither transaction will represent the initiation of indemnity benefits.
255 Caveats and Tips for Successfully filing 00/PD 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
256 Caveats and Tips for Successfully filing 00/PD 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.