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1 Add Concurrent Benefit Type Electronic Notice of Action/Change Required to be filed with DWC per Rule 69L-56.3045(4), F.A.C. SROI AB.

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Presentation on theme: "1 Add Concurrent Benefit Type Electronic Notice of Action/Change Required to be filed with DWC per Rule 69L-56.3045(4), F.A.C. SROI AB."— Presentation transcript:

1 1 Add Concurrent Benefit Type Electronic Notice of Action/Change Required to be filed with DWC per Rule 69L (4), F.A.C. SROI AB

2 2 SROI AB - Add Concurrent Benefit Type A SROI AB, EDI DWC-4 equivalent, is required to be filed when: A SROI AB, EDI DWC-4 equivalent, is required to be filed when: Adding or Adding or Reinstating a concurrent BTC.Reinstating a concurrent BTC.

3 3 Concurrent BTCs occur when: Concurrent BTCs occur when: Indemnity benefits are currently being paid,Indemnity benefits are currently being paid, A second Benefit Type Code begins,A second Benefit Type Code begins, The first Benefit Type Code is still being paid.The first Benefit Type Code is still being paid. SROI AB - Add Concurrent Benefit Type

4 4 Example: If PT Supplemental Benefits (021) begin after previous payment of ongoing Permanent Total Benefits (020), If PT Supplemental Benefits (021) begin after previous payment of ongoing Permanent Total Benefits (020), SROI AB should be sent and SROI AB should be sent and Receive TA 14 days after Claim Admin.s knowledge of entitlement.) SROI AB - Add Concurrent Benefit Type

5 5 Pop Quiz: What is another example of Concurrent Benefit Types?

6 6 ANSWER: When Salary in Lieu of Compensation was paid and the EE also had concurrent employment.

7 7 Example: Accident EMPR pays salary in lieu of compensation and later learns of concurrent employment that raises AWW. Accident EMPR pays salary in lieu of compensation and later learns of concurrent employment that raises AWW. EE must now be compensated at 66 2/3% of combined wages (where both 0xx and 240 would be reported for same period.) EE must now be compensated at 66 2/3% of combined wages (where both 0xx and 240 would be reported for same period.)

8 8 SROI AB - Add Concurrent Benefit Type In this case, DWCs program allows Start Date of the current BTC being added to equal the Start Date of a previous BTC where: In this case, DWCs program allows Start Date of the current BTC being added to equal the Start Date of a previous BTC where: The previous BTC is 2xx and The previous BTC is 2xx and Concurrent Employer data is provided. Concurrent Employer data is provided.

9 9 SROI AB - Add Concurrent Benefit Type SROI AB follows the Event Benefits segment rules. SROI AB follows the Event Benefits segment rules. MTC AB is only populated in the Benefits segment of the Benefit Type Code that is being added. MTC AB is only populated in the Benefits segment of the Benefit Type Code that is being added.

10 10 Caveats and Tips for Successfully Filing SROI MTC AB

11 11 Caveats and Tips for Filing SROI AB The error we see most frequently for SROI AB filings is: The error we see most frequently for SROI AB filings is: BTC MUST = 020 OR 021 IF MTC = AB OR P7 This error indicates that either…

12 12 Caveats and Tips for Filing SROI AB SROI AB is not the correct MTC, orSROI AB is not the correct MTC, or An incorrect BTC was reported or left off the AB, or An incorrect BTC was reported or left off the AB, or Concurrent Employment was not reported.Concurrent Employment was not reported.

13 13 Caveats and Tips for Filing SROI AB The next most frequently occurring error on SROI AB filings is: NO SROI ER OR RB PREVIOUSLY ON FILE The next most frequently occurring error on SROI AB filings is: NO SROI ER OR RB PREVIOUSLY ON FILE This error is generated when DWC reflects indemnity was suspended or denied but not yet resumed prior to receipt of the AB.

14 14 Pop Quiz: What MTC would be sent each January to report the new PT Supp Rate?

15 15 Answer: SROI CA To report the new Net Weekly Amt for BTC 021 (PTS).

16 16 Suspensions (Full) SROI S1-S8 Electronic Notice of Action/Change Required to be filed with DWC per Rule 69L , F.A.C.

17 17 SROI S1 – S8: Suspensions (Full) SROI S1-S8 (Sx), EDI DWC-4 equivalent, is required If ALL payments of indemnity benefits have stopped (not just one class of benefits). SROI S1-S8 (Sx), EDI DWC-4 equivalent, is required If ALL payments of indemnity benefits have stopped (not just one class of benefits).

18 18 SROI S1 – S8: Suspensions (Full) The following DNs relate to SROI Sx filings: The following DNs relate to SROI Sx filings: Suspension Effective Date (required), Suspension Effective Date (required), Suspension Narrative (IA), and Suspension Narrative (IA), and Number of Suspension Narratives. Number of Suspension Narratives.

19 19 SUSPENSION EFFECTIVE DATE For MTCs S1-S8 (Suspension): The last date through which all indemnity benefits are due. The last date through which all indemnity benefits are due. Note: This date is not always the last day through which benefits were paid if there was an overpayment.

20 20 SUSPENSION NARRATIVE SEGMENT Per IAIABC Variable Segment Rules: Maximum of 3 Suspension Narrative segments may be sent, and Maximum of 3 Suspension Narrative segments may be sent, and Must equal theNumber of Suspension Narratives sent. Must equal theNumber of Suspension Narratives sent. Note: This is an If Available/Applicable field for FL, but not required.

21 21 Pop Quiz: Are Suspensions an Event Benefit Segment, or Sweep Benefit Segment?

22 22 Answer: Event Benefit Segment

23 23 SROI S1 – S8: Suspensions (Full) Therefore, the MTC (Sx) is required to be included in the Benefits segment, as well as all other required benefit segment data. Therefore, the MTC (Sx) is required to be included in the Benefits segment, as well as all other required benefit segment data.

24 24 Caveats and Tips for Successfully Filing SROI S1 – S8

25 25 Caveats and Tips for Filing Sx Caveats and Tips for Filing Sx If a DWC-4 was previously filed and it reported suspension of one type of indemnity, BUT NOT ALL benefits were truly suspended: If a DWC-4 was previously filed and it reported suspension of one type of indemnity, BUT NOT ALL benefits were truly suspended: You will have to reinstate benefits (file RB) prior to sending the next event. You will have to reinstate benefits (file RB) prior to sending the next event.

26 26 Caveats and Tips for Filing Sx If you filed an incorrect Suspension Code (Sx) MTC: If you filed an incorrect Suspension Code (Sx) MTC: Send correct Sx code; AND Send correct Sx code; AND Suspension Effective Date must be the same as the previous Suspension Eff. Date. Suspension Effective Date must be the same as the previous Suspension Eff. Date.

27 27 Caveats and Tips for Filing Sx One of the most frequently occurring errors for Sx filings is: One of the most frequently occurring errors for Sx filings is: SUSP EFFECT DATE MUST <= LATEST BEN THROUGH DATE

28 28 Caveats and Tips for Filing Sx This particular effective date is not when you took the action to suspend; This particular effective date is not when you took the action to suspend; It is the date through which all benefits were due. It is the date through which all benefits were due.

29 29 Caveats and Tips for Filing Sx Therefore, the effective date of the suspension should not be later than the date through which benefits were due. Therefore, the effective date of the suspension should not be later than the date through which benefits were due. Exception: Suspension Effective Date may be a future date if IBs are paid in a lump sum and are currently being suspended (i.e., Sx MTC in Event segment.)

30 30 Caveats and Tips for Filing Sx Also, do not report SROI S1 (RTW) prematurely before the last indemnity payment has been reported on the transaction. Also, do not report SROI S1 (RTW) prematurely before the last indemnity payment has been reported on the transaction. If the Benefit Period Through Date on the next transaction is later than the Through Date reported on the S1, the transaction will reject. (Thru Date must not be > prev Thru Date.)

31 31 Caveats and Tips for Filing Sx Caveats and Tips for Filing Sx Future Suspension Effective Dates are allowed: Future Suspension Effective Dates are allowed: But must not be more than 2 weeks after DWC Recd transmission. But must not be more than 2 weeks after DWC Recd transmission. Exception: IBs (030 or 530) is currently being suspended (where MTC Sx is in the 030/530 Benefits segment)

32 32 Caveats and Tips for Filing Sx Do not send SROI S1 solely to report RTW information. Do not send SROI S1 solely to report RTW information. Suspension codes should only be sent to report the cessation of ALL indemnity benefits.Suspension codes should only be sent to report the cessation of ALL indemnity benefits.

33 33 Caveats and Tips for Filing Sx For Example: If EE RTW light duty & there is a possibility TP (070) will be paid in the near future, S1 should not be filed. If EE RTW light duty & there is a possibility TP (070) will be paid in the near future, S1 should not be filed. Instead, RTW data should be reported via MTC 02 if the requirement to report RTW (2 weeks after knowledge) falls due prior to changing benefits, or CB. Instead, RTW data should be reported via MTC 02 if the requirement to report RTW (2 weeks after knowledge) falls due prior to changing benefits, or CB.

34 34 Caveats and Tips for Filing Sx Other typical errors we are seeing for Sx filings are: Other typical errors we are seeing for Sx filings are: NET WKLY AMT EFF DT CANT BE CHANGED WITH THIS MTC and GROSS AMT MUST CHANGE VIA MTC CB CA 02 AP OR RB

35 35 Caveats and Tips for Filing Sx A new Net weekly rate (with a new Effective Date) cannot be introduced via SROI Sx. A new Net weekly rate (with a new Effective Date) cannot be introduced via SROI Sx. Changes or corrections to the AWW/CR that affect the Gross/Net weekly Amounts must first be reported via MTC CA. Changes or corrections to the AWW/CR that affect the Gross/Net weekly Amounts must first be reported via MTC CA.

36 36 Caveats and Tips for Filing Sx We are also seeing a lot of errors for: We are also seeing a lot of errors for: DUPLICATE SUSPENSION WITH SAME EFF DATE

37 37 Caveats and Tips for Filing Sx This error usually occurs when benefits are erroneously reinstated, or reinstated to correct a past benefit picture, e.g. RB sent when benefits are not actually being reinstated; then another same Sx is sent to try to re-suspend the claim. This error usually occurs when benefits are erroneously reinstated, or reinstated to correct a past benefit picture, e.g. RB sent when benefits are not actually being reinstated; then another same Sx is sent to try to re-suspend the claim.

38 38 Caveats and Tips for Filing Sx If trying to change Benefit segment data for past benefits, a reinstatement should not be sent. If trying to change Benefit segment data for past benefits, a reinstatement should not be sent. RB should only be sent if benefits are being reinstated. RB should only be sent if benefits are being reinstated.

39 39 Caveats and Tips for Filing Sx In many situations, MTC 02 can be used to change / correct Benefit segment information, unless introducing a new BTC. In many situations, MTC 02 can be used to change / correct Benefit segment information, unless introducing a new BTC.

40 40 Sx Caveats and Tips for Filing Sx Do not file a fake Sx to get around the DUPLICATE SUSPENSION WITH SAME EFF DATE error. Do not file a fake Sx to get around the DUPLICATE SUSPENSION WITH SAME EFF DATE error.

41 41 Caveats and Tips for Filing Sx Instead of filing an RB and then subsequently sending another Sx, if an RB is sent in error, the EDI team asking to remove the RB. Instead of filing an RB and then subsequently sending another Sx, if an RB is sent in error, the EDI team asking to remove the RB.

42 42 Caveats and Tips for Filing Sx Another frequent error, primarily in relation to SROI S7 (Benefits Exhausted) filings is: Another frequent error, primarily in relation to SROI S7 (Benefits Exhausted) filings is: CAN NOT ACCEPT SUSP AFTER SUSP W-OUT ER, RB OR EP

43 43 Caveats and Tips for Filing Sx If you filed a Sx and afterwards sent another Sx with a different Suspension Effective Date, you wont be able to report the second suspension until after you file an RB, ER or EP to resume benefits after the first suspension. If you filed a Sx and afterwards sent another Sx with a different Suspension Effective Date, you wont be able to report the second suspension until after you file an RB, ER or EP to resume benefits after the first suspension.

44 44 Caveats and Tips for Filing Sx If a Suspension (Sx) was filed in error but accepted, and you subsequently receive a rejection when trying to report a CA, CB, etc., If a Suspension (Sx) was filed in error but accepted, and you subsequently receive a rejection when trying to report a CA, CB, etc., Do not file an RB to get around the edit that is expecting an RB after Sx... Do not file an RB to get around the edit that is expecting an RB after Sx...

45 45 Caveats and Tips for Filing Sx … Instead, contact the EDI team for special processing assistance. We may be able to manually remove the suspension status from our file and re-process the CA, CB, etc. We may be able to manually remove the suspension status from our file and re-process the CA, CB, etc.

46 46 Questions?

47 47 Partial Suspension SROI P7 Electronic Notice of Action/Change Required to be filed with DWC per Rule 69L (5)(j), F.A.C.

48 48 SROI P7 - Partial Suspension P7 (Benefits Exhausted) is only used in relation to concurrent BTCs. P7 (Benefits Exhausted) is only used in relation to concurrent BTCs. Occurs when one of the concurrent benefits is suspended, but the other benefit continues. Occurs when one of the concurrent benefits is suspended, but the other benefit continues.

49 49 SROI P7 - Partial Suspension SROI P7 is required if Permanent Total Supplemental (021) benefits are suspended, but Permanent Total (020) benefits are continuing. SROI P7 is required if Permanent Total Supplemental (021) benefits are suspended, but Permanent Total (020) benefits are continuing.

50 50 SROI P7 - Partial Suspension SROI P7 - Partial Suspension P7, Partial Suspension is considered an Event; P7, Partial Suspension is considered an Event; Therefore, MTC P7 is reported in the Benefits segment for the concurrent benefit type that is being stopped. Therefore, MTC P7 is reported in the Benefits segment for the concurrent benefit type that is being stopped.

51 51 SROI P7 - Partial Suspension SROI P7 - Partial Suspension Any remaining Benefit Type Codes are sent as Sweep Benefits segments. Any remaining Benefit Type Codes are sent as Sweep Benefits segments.

52 52 Caveats and Tips for Successfully Filing SROI P7

53 53 Caveats and Tips for Filing SROI P7 We dont see many errors for this SROI (probably because it is not filed that often), but the following occurs the most frequent: We dont see many errors for this SROI (probably because it is not filed that often), but the following occurs the most frequent: BTC MUST = 020 OR 021 IF MTC = AB OR P7 If you receive this error, either … If you receive this error, either …

54 54 Caveats and Tips for Filing SROI P7 … P7 was not appropriate and you need to send another MTC, or … P7 was not appropriate and you need to send another MTC, or An incorrect BTC was sent, or An incorrect BTC was sent, or BTC 020, 021 was left off the P7. BTC 020, 021 was left off the P7. Note: This edit is not run if Number of Concurrent Employers is > 0 or on file, and BTC 2xx is present.

55 55 Caveats and Tips for Filing SROI P7 Below is a sequencing error occurring with P7 filings: Below is a sequencing error occurring with P7 filings: NO SROI ER OR RB PREVIOUSLY ON FILE This error is generated when a suspension notice was previously filed, but… This error is generated when a suspension notice was previously filed, but…

56 56 Caveats and Tips for Filing SROI P7 … benefits have not yet been reported as having been resumed. … benefits have not yet been reported as having been resumed. Therefore, a SROI RB (or ER) will need to be filed before the P7 can be accepted. Therefore, a SROI RB (or ER) will need to be filed before the P7 can be accepted.

57 57 Questions?

58 58 Reinstatement of Benefits By Claim Administrator SROI RB Required to be filed with DWC per Rule 69L-69L (6)(a), F.A.C.

59 59 SROI RB - Reinstatement of Benefits by Claim Administrator SROI RB, EDI DWC-4 equivalent is required if indemnity payments previously paid by the Claim Administrator are being resumed by the Claim Administrator. SROI RB, EDI DWC-4 equivalent is required if indemnity payments previously paid by the Claim Administrator are being resumed by the Claim Administrator.

60 60 SROI RB - Reinstatement of Benefits by Claim Administrator The Benefit Type (BTC) being reinstated may or may not have been previously paid. The Benefit Type (BTC) being reinstated may or may not have been previously paid.

61 SROI RB – Reinstatement of Benefits by Claim Administrator A prior SROI terminating all indemnity benefits must have been filed via either: A prior SROI terminating all indemnity benefits must have been filed via either: SROI S1-S8 (Full Suspension), or … SROI S1-S8 (Full Suspension), or …

62 SROI RB – Reinstatement of Benefits by Claim Administrator SROI MTC 04 (Full Denial), SROI MTC 04 (Full Denial), or or SROI MTC PD with Partial Denial Codes A or E. SROI MTC PD with Partial Denial Codes A or E. SROI 04 & PD (A or E code) act like a suspension where all indemnity benefits are being terminated at the time of denial. SROI 04 & PD (A or E code) act like a suspension where all indemnity benefits are being terminated at the time of denial.

63 63 SROI RB – Reinstatement of Benefits by Claim Administrator For all MTCs that initiate or reinstate a Benefit Type Code (AB, IP, RB, EP, ER, CB): For all MTCs that initiate or reinstate a Benefit Type Code (AB, IP, RB, EP, ER, CB): The Benefit Period Start Date is the first date of the uninterrupted period of benefit payments that corresponds to the Benefit Type Code being paid. The Benefit Period Start Date is the first date of the uninterrupted period of benefit payments that corresponds to the Benefit Type Code being paid.

64 64 Caveats and Tips for Successfully Filing SROI RB

65 65 Caveats and Tips for Filing RB Caveats and Tips for Filing RB The most frequent error occurring for SROI RB filings is: The most frequent error occurring for SROI RB filings is: NO CORRESPONDING SROI S1-8, 04, OR PD ON FILE

66 66 Caveats and Tips for Filing RB Indemnity benefits must have been previously stopped via suspension or denial notice / transaction before a reinstatement can be accepted. Indemnity benefits must have been previously stopped via suspension or denial notice / transaction before a reinstatement can be accepted.

67 67 Caveats and Tips for Filing RB This next error is for legacy cases. If an RB is filed, without a previous suspension, denial or FN on file, this message will be returned. This next error is for legacy cases. If an RB is filed, without a previous suspension, denial or FN on file, this message will be returned. NOT APPLICABLE; DWC DOESN'T SHOW BENEFITS ENDED Note: For legacy cases, an FN served to suspend benefits.

68 68 Caveats and Tips for Filing RB We are also seeing a lot of errors for: We are also seeing a lot of errors for: MTC RB ER SENT AFTER PREV SETTLEMENT ON FILE

69 69 Caveats and Tips for Filing RB If you truly need to resume indemnity benefits, but you previously filed a PY with the wrong Lump Sum Payment / Settlement Code (SF or SP), you will need to file an 02 to correct this code and re-send the RB. If you truly need to resume indemnity benefits, but you previously filed a PY with the wrong Lump Sum Payment / Settlement Code (SF or SP), you will need to file an 02 to correct this code and re-send the RB.

70 70 Caveats and Tips for Filing RB Another frequently occurring error on the RB is: Another frequently occurring error on the RB is: MTC RB SWEEP SEG THRU DATE MUST = PREV THRU DATE

71 71 Caveats and Tips for Filing RB Except for the BTC you are resuming, all other sweep BTC Through Dates on the RB should be the same as previously reported (except for BTC 2xx or if benefits were reclassified.) Except for the BTC you are resuming, all other sweep BTC Through Dates on the RB should be the same as previously reported (except for BTC 2xx or if benefits were reclassified.)

72 72 Questions?

73 73 Reinstatement of Employer Paid Benefits SROI ER Electronic Notice of Action/Change Required to be filed with DWC per Rule 69L (6)(b), F.A.C.

74 74 SROI ER – Reinstatement of Employer Paid Benefits SROI ER, EDI DWC-4 equivalent, is required if the employer is resuming payment of salary in lieu of compensation following the suspension of all prior employer paid indemnity benefits. SROI ER, EDI DWC-4 equivalent, is required if the employer is resuming payment of salary in lieu of compensation following the suspension of all prior employer paid indemnity benefits.

75 75 Caveats and Tips for Successfully Filing SROI ER

76 76 Caveats and Tips for Filing ER We dont see that many errors for ER (not many are sent), but most ERs reject for: We dont see that many errors for ER (not many are sent), but most ERs reject for: NO EP & SROI S1-8, 04, PD OR FN ON FILE

77 77 Caveats and Tips for Filing ER A SROI EP or BTC 2xx (full salary information) must have been accepted, and A SROI EP or BTC 2xx (full salary information) must have been accepted, and Every SROI ER must be preceded by a corresponding S1-8, or SROI 04, or PD (and FN for legacy claims.) Every SROI ER must be preceded by a corresponding S1-8, or SROI 04, or PD (and FN for legacy claims.)

78 78 Questions?

79 79 SROI PY – Lump Sum Payments/Settlements Electronic Notice of Action/Change EDI DWC-4 Equivalent Required to be filed with DWC per Rule 69L , F.A.C.

80 80 SROI PY – Lump Sum Payment/Settlement SROI PY, EDI DWC-4 equivalent, is required to be filed when an indemnity check is issued for a lump sum payment or settlement, either as the initial payment or subsequent to the initial payment. SROI PY, EDI DWC-4 equivalent, is required to be filed when an indemnity check is issued for a lump sum payment or settlement, either as the initial payment or subsequent to the initial payment.

81 81 SROI PY – Lump Sum Payment/Settlement SROI PY requires a Lump Sum Payment/Settlement Code. SROI PY requires a Lump Sum Payment/Settlement Code. Exception: May be sent as spaces when paying IB (030) in a lump sum. Exception: May be sent as spaces when paying IB (030) in a lump sum. This code describes the type of lump sum payment or settlement made. This code describes the type of lump sum payment or settlement made.

82 82 SF AS SPAW AD Lump Sum Payment/Settlement Codes

83 83 A settlement agreed upon by all parties to end past, present, and future liability of all benefits. A settlement agreed upon by all parties to end past, present, and future liability of all benefits. SF Lump Sum Payment/Settlement Codes No future indemnity or medical benefits are due. No future indemnity or medical benefits are due. Settlement Full (washout) BTC 500 or 524 is required. BTC 500 or 524 is required.

84 84 Settlement Partial Settle all medical, but not indemnity (reported as BTC 501)… Settle all medical, but not indemnity (reported as BTC 501)… SP Lump Sum Payment/Settlement Codes A settlement agreed upon by all parties to: A settlement agreed upon by all parties to: Settle all indemnity benefit type codes, but not medical (reported as BTC 500 or 524 for FL) ; or Settle all indemnity benefit type codes, but not medical (reported as BTC 500 or 524 for FL) ; or

85 85 Settlement Partial SP Lump Sum Payment/Settlement Codes A settlement agreed upon by all parties to: A settlement agreed upon by all parties to: Settle a specific indemnity benefit type code(s), other than BTC 500 or 501 (reported as a specific BTC 5xx code). Settle a specific indemnity benefit type code(s), other than BTC 500 or 501 (reported as a specific BTC 5xx code). This new use of SP is not accepted in FL.

86 86 A lump sum payment agreed upon by the parties of one or more benefit types for a disputed period of disability. A lump sum payment agreed upon by the parties of one or more benefit types for a disputed period of disability. AS Lump Sum Payment/Settlement Codes Agreement Stipulated Does not limit future liability. Does not limit future liability.

87 87 An adjudicated lump sum payment of one or more benefit types for a disputed period of disability. An adjudicated lump sum payment of one or more benefit types for a disputed period of disability. AW Lump Sum Payment/Settlement Codes Award Does not limit future liability. Does not limit future liability.

88 88 AD Lump Sum Payment/Settlement Codes A lump sum payment of benefits in advance of when it is due. A lump sum payment of benefits in advance of when it is due. May be recouped as a weekly credit against future benefits not to exceed 20%. May be recouped as a weekly credit against future benefits not to exceed 20%. Advance

89 89 Lump Sum Payment/Settlement Codes If a rate and time period are specified, Benefit Type Code 0xx (vs 5xx) series is used for: If a rate and time period are specified, Benefit Type Code 0xx (vs 5xx) series is used for: ASAW Award AD AdvanceAgreementStipulated

90 90 Lump Sum Payment/Settlement Codes Note: If BTC 0xx was sent for benefits that were paid in a lump sum, DWCs program will apply edits to check accuracy of the 0xx payment $. Note: If BTC 0xx was sent for benefits that were paid in a lump sum, DWCs program will apply edits to check accuracy of the 0xx payment $.

91 91 If a rate and time period are not specified, Benefit Type Code 5xx series is used for: ADAdvance AWAward SF Settlement Full (BTC 500 or 524 only) Settlement Partial SP AS Agreement Stip. Lump Sum Payment/Settlement Codes (BTC 500, 524 or 501 only)

92 92 Population Rules for Lump Sum Payments/Settlements

93 93 SROI PY - Population Rules: For FL, a Payments segment must be included on the SROI PY in addition to the Benefits segment. For FL, a Payments segment must be included on the SROI PY in addition to the Benefits segment. Exception: Reduced Benefit Amount Code = S or N. Exception: Reduced Benefit Amount Code = S or N.

94 94 Payment Reason Code must equal a Benefit Type Code on the transaction. Payment Reason Code must equal a Benefit Type Code on the transaction. SROI PY - Population Rules:

95 95 Payment Issue Date is required unless Reduced Benefit Amount Code = S or N. Payment Issue Date is required unless Reduced Benefit Amount Code = S or N. FL uses Payment Issue Date sent in Payments segment to load to date payment mailed (vs. Benefit Payment Issue Date.) FL uses Payment Issue Date sent in Payments segment to load to date payment mailed (vs. Benefit Payment Issue Date.) SROI PY - Population Rules:

96 96 Example: Payment Reason Code equals Benefit Type Code 500. SROI PY - Population Rules:

97 97 BTC 0xx reporting indemnity paid in a lump sum represents an Event Benefits segment. BTC 0xx reporting indemnity paid in a lump sum represents an Event Benefits segment. BTC 5xx represents a Sweep Benefits segment. BTC 5xx represents a Sweep Benefits segment. SROI PY - Population Rules:

98 98 SROI PY - Population Rules: If more than one check is issued for a lump sum payment/settlement, only the check(s) that relates to indemnity Benefit Type Codes should be populated in the Payments segment with (Payment Issue Date) and repeated in the Benefits segment. If more than one check is issued for a lump sum payment/settlement, only the check(s) that relates to indemnity Benefit Type Codes should be populated in the Payments segment with (Payment Issue Date) and repeated in the Benefits segment.

99 99 SROI PY - Population Rules: For Example: If a settlement resulted in the payment of a check to the EE and Dr. Smith, only the check to the EE would be reported in the Payments segment. For Example: If a settlement resulted in the payment of a check to the EE and Dr. Smith, only the check to the EE would be reported in the Payments segment. The other check to Dr. Smith represents an OBT Code.The other check to Dr. Smith represents an OBT Code.

100 100 SROI PY - Population Rules: If multiple checks for different Payees are cut for the same indemnity type, multiple Payments segments (reflecting different Payees) should be sent with the same Payment Reason Code. If multiple checks for different Payees are cut for the same indemnity type, multiple Payments segments (reflecting different Payees) should be sent with the same Payment Reason Code.

101 101 SROI PY – Population Rules: For Example: If you issue one settlement check to the EE and cut another check to the court for child support, where both checks are coded the same 5xx Payment Reason Code, both amounts should be reported in separate Payments segment, because of different Payees and amounts.

102 102 Standard processing rules for reporting Lump Sum Payments/Settlements are described in Section 4 of the Release 3 Implementation Guide.

103 103 Also, Variable Segment Population Rules for Lump Sum Payments / Settlements are included in this section

104 104 This section also addresses Population Rules for the Payments Section.

105 105 Mini SCENARIO: 00/PY Mini SCENARIO: 00/PY Initial Payment as Full Settlement EDI DWC-1 Equivalent Required to be filed with DWC per Rule 69L (1)(a)1., F.A.C.

106 106 Lump Sum Payments/Settlement Example: Settlement Full Benefit Type Code 500 Equals Payment Reason Code

107 107 Benefit Type Amount Paid Equals Payment Amount Payment was issued February 21, Lump Sum Payments/Settlement

108 108 Lump Sum Payments/Settlement Rules If indemnity benefits will be paid after the PY lump sum payment, the next applicable transaction should be filed (e.g., IP after 00/PY, AP after AU/PY, or RB) to report the type of benefits that will be paid on an ongoing basis by the Claim Administrator. If indemnity benefits will be paid after the PY lump sum payment, the next applicable transaction should be filed (e.g., IP after 00/PY, AP after AU/PY, or RB) to report the type of benefits that will be paid on an ongoing basis by the Claim Administrator.

109 109 This is to ensure there is not a sequencing failure on future transactions (e.g., for not having previously reported a particular BTC.)This is to ensure there is not a sequencing failure on future transactions (e.g., for not having previously reported a particular BTC.) Lump Sum Payments/Settlement

110 110 The IP, AP, RB after PY can introduce an entirely new BTC not previously reported on the PY (no SROI CB necessary.) The IP, AP, RB after PY can introduce an entirely new BTC not previously reported on the PY (no SROI CB necessary.) Lump Sum Payments/Settlement

111 111 If the initial payment is a lump sum amount for IB Only (030), 00/PY should be filed (vs. 00/IP). If the initial payment is a lump sum amount for IB Only (030), 00/PY should be filed (vs. 00/IP). As mentioned earlier, Lump Sum Payment/Settlement Code is not required to be reported here because IBs are not always an Advance payment (might be for IB owed for a past time period.) As mentioned earlier, Lump Sum Payment/Settlement Code is not required to be reported here because IBs are not always an Advance payment (might be for IB owed for a past time period.) Lump Sum Payments/Settlement

112 112 In light of the DCA opinion (Seminole County v. Baumgardner), if IBs were paid in a lump sum at the reduced rate because the EE initially RTW earning full pre- injury wages, … In light of the DCA opinion (Seminole County v. Baumgardner), if IBs were paid in a lump sum at the reduced rate because the EE initially RTW earning full pre- injury wages, … Lump Sum Payments/Settlement

113 113 … the Claim Admin. should monitor the EEs post-MMI earnings to determine if IBs need to be adjusted for a given week during which the EE did not earn 100% of pre-injury wages (whether causally related to the injury or not.) … the Claim Admin. should monitor the EEs post-MMI earnings to determine if IBs need to be adjusted for a given week during which the EE did not earn 100% of pre-injury wages (whether causally related to the injury or not.) M&A may audit for this. Lump Sum Payments/Settlement

114 114 Caveats and Tips for Successfully Filing SROI PY

115 115 Caveats and Tips for Filing PY Most PYs are failing edits for: Most PYs are failing edits for: AWARD/ORDER DATE MISSING This date is required unless: You are reporting an advance < = $2,000 or You are reporting an advance < = $2,000 or IBs were paid in one lump sum. IBs were paid in one lump sum.

116 116 Caveats and Tips for Filing PY Award/Order Date corresponds to the date the JCC or mediator signed the order/agreement. Award/Order Date corresponds to the date the JCC or mediator signed the order/agreement. DWC will also accept the date the parties signed a (settlement) release… DWC will also accept the date the parties signed a (settlement) release…

117 117 Caveats and Tips for Filing PY … As a result, y ou do not have to wait for JCC to sign order approving the attorney fee to file the PY. … As a result, y ou do not have to wait for JCC to sign order approving the attorney fee to file the PY. This should help to avoid late filing penalties for 00/PY where the settlement check was mailed more than 14 days before the JCC order. This should help to avoid late filing penalties for 00/PY where the settlement check was mailed more than 14 days before the JCC order.

118 118 Caveats and Tips for Filing PY Other errors frequently occurring are: Other errors frequently occurring are: PAYMENT REASON CODE MUST = 500 OR 524 and IF LS SETT CDE = SF, BEN SEG W/500 OR 524 REQUIRED

119 119 Caveats and Tips for Filing PY FL only accepts Payment Reason Codes 500 or 524 if reporting a Final Settlement, i.e., Lump Sum Payment Code SF. FL only accepts Payment Reason Codes 500 or 524 if reporting a Final Settlement, i.e., Lump Sum Payment Code SF. Exception: RBAC is S or N.Exception: RBAC is S or N.

120 120 Caveats and Tips for Filing PY Another frequent error is: Another frequent error is: LUMP SUM PAYMENT/SETTLEMENT CODE MISSING Lump Sum Payment/Settlement Code is required unless the lump sum payment is for BTC 030 (IB). Lump Sum Payment/Settlement Code is required unless the lump sum payment is for BTC 030 (IB).

121 121 Caveats and Tips for Filing PY Other commons errors: Other commons errors: PAYMENT REASON CODE MUST = BEN TYPE CODE and IF PYMT SEG, BTC IN BEN SEG MUST = PYMT REAS CODE There must be an identical BTC in the Benefits Segment that matches the Payment Reason Code reported. There must be an identical BTC in the Benefits Segment that matches the Payment Reason Code reported.

122 122 Questions?

123 123 SROI MTC PY (Advance) SCENARIO See Rule 69L (4), F.A.C.

124 124 While receiving TT benefits, the EE requested the Claim Admin. provide a $1,000 advance against future TT benefits. Lump Sum Payments/Settlement Advance of TT benefits Advance of TT benefits

125 125 Benefit Type Code Equals Payment Reason Code Lump Sum Payments/Settlement Advance TT benefits

126 126 Benefit Type Amount Paid Includes Advance Payment Amount. Lump Sum Payments/Settlement

127 127 The Payment Covers Period From/Thru relates to the Advance payment. Lump Sum Payments/Settlement

128 128 Questions?

129 129 SROI SCENARIO MTC PY (subsequent to Initial Payment) See Rule 69L (4), F.A.C.

130 130 Lump Sum Payment/Settlement (not the Initial Payment) If subsequent to the initial payment, an award/order is signed for a lump sum payment/settlement of indemnity benefits (i.e., award, advance, stipulated agreement, or final settlement), an Electronic Notice of Action or Change is represented by sending: SROI PY SROI PY

131 131 SROI MTC PY Scenario Narrative Previously submitted Reports: 1.00 FROI with IP SROI 2.CB changing from TTD to IB Employee hired an attorney because he disagreed with doctors impairment rating of 10%. Employee hired an attorney because he disagreed with doctors impairment rating of 10%.

132 132 SROI MTC PY Scenario Narrative Attorney petitioned for a different treating physician. Attorney petitioned for a different treating physician. The new doctor assigned an 18% impairment rating. The new doctor assigned an 18% impairment rating. Claim administrator requested an IME which rendered a 14% impairment rating. Claim administrator requested an IME which rendered a 14% impairment rating.

133 133 Parties negotiated a full and final settlement of $10,000 to pay a 15% whole body rating. Parties negotiated a full and final settlement of $10,000 to pay a 15% whole body rating. On 12/19/07, claim administrator issued a check payable to the attorney and the employee. On 12/19/07, claim administrator issued a check payable to the attorney and the employee. On 1/2/08, JCC enters order approving attorney fees, and claim administrator sends PY transaction to DWC. On 1/2/08, JCC enters order approving attorney fees, and claim administrator sends PY transaction to DWC. PY Scenario Narrative

134 134 SROI MTC PY Scenario (only pertinent DEs listed) On 1/2/08, the Claim Administrator sends a PY Payment report to DWC.

135 135 SROI MTC PY Scenario (only pertinent DEs listed)

136 136 Parties reached a full settlement. Agreement signed SROI MTC PY Scenario (only pertinent DEs listed)

137 137 Award/Order Date is required unless the Lump Sum Payment/Settlement code = AD (Advance < $2,000), or BTC = 030 (IB). Award/Order Date is required unless the Lump Sum Payment/Settlement code = AD (Advance < $2,000), or BTC = 030 (IB). Lump Sum Payment/Settlement Rules

138 138 SROI MTC PY Scenario (only pertinent DEs listed)

139 139 BTC 500 Benefits Segment SROI MTC PY Scenario

140 140 BTC 030 Benefits Segment SROI MTC PY Scenario 0

141 141 BTC 050 Benefits Segment SROI MTC PY Scenario

142 142 Payments Segment SROI MTC PY Scenario

143 143 Questions?

144 144 Lump Sum Payment followed by a Later Settlement for the same Benefit Type (PY after PY)

145 145 Lump Sum Payments followed by a Settlement of same Benefit Type Code When an Award or Stipulated Agreement was previously reported with Benefit Type Code 5XX When an Award or Stipulated Agreement was previously reported with Benefit Type Code 5XX AND now a Full or Partial Settlement of the same 5XX Benefit Type is being reported...

146 146...the Benefit Type Amount Paid will include the Award or Stipulated Agreement amount as well as the Settlement amount. The Payment Amount will only be the amount of the most recent Settlement Amount.The Payment Amount will only be the amount of the most recent Settlement Amount. Lump Sum Payments followed by a Settlement of same Benefit Type Code

147 147 Lump Sum Payments/Settlements Covering More Than 1 DOI

148 148 Lump Sum Payment/Settlement Limitations Settlements covering more than one Date of Injury: Settlements covering more than one Date of Injury: A Full Settlement may involve more than one date of injury, but the settlement amount will only be reported on one PY transaction. A Full Settlement may involve more than one date of injury, but the settlement amount will only be reported on one PY transaction.

149 149 Lump Sum Payment/Settlement Limitations Settlements covering more than one Date of Injury: Settlements covering more than one Date of Injury: To report the settlement of the other dates of injury, a PY MTC should be sent for each claim with the Reduced Benefit Amount Code S. To report the settlement of the other dates of injury, a PY MTC should be sent for each claim with the Reduced Benefit Amount Code S. Note: FROI 00 will have to accompany the PY if not previously sent. Note: FROI 00 will have to accompany the PY if not previously sent.

150 150 Lump Sum Payment/Settlement Limitations Settlements covering more than one Date of Injury: Settlements covering more than one Date of Injury: Reduced Benefit Amount Code S Reduced Benefit Amount Code S Lump Sum P/S Code SF Lump Sum P/S Code SF and Award/Order Date and Award/Order Date

151 151 Lump Sum Payment/Settlement Limitations The PY with a Reduced Benefit Amount Code S will not contain a Benefits segment unless indemnity benefits were paid on the case prior to the settlement.

152 152 For DOIs where the statute of limitations has expired but the DOI is still referenced in the settlement order, a 00/PY to DWC will not be required for DOIs more than 5 years prior to the Award/Order Date.

153 153 POP QUIZ: How do you report a settlement involving $0 payout (e.g., waiver of third party lien)?

154 154 Answer: SROI PY with Reduced Benefit Amount Code N (No Money Settlement).

155 155 Questions about PY?

156 156 We have already discussed A/C/R segments, so we will now address Recoveries Segments.

157 157 Recoveries Segment Recoveries segments are comprised of: Recoveries segments are comprised of: Recovery Code, and Recovery Code, and Recovery Amount. Recovery Amount.

158 158 RECOVERY CODES Recovery Code identifies the type of recovery being made. Recovery Code identifies the type of recovery being made. A Recovery Code is required if a Recovery Amount is sent. A Recovery Code is required if a Recovery Amount is sent.

159 159 RECOVERY CODES Note: For non-legacy claims, Recovery Code 850 (Second Injury Fund) must be sent instead of Recovery Code 800 (Special Fund Recovery).

160 160 Recovery Amount is the sum of monies received to date by the insurer for the corresponding recovery code. Recovery Amount is the sum of monies received to date by the insurer for the corresponding recovery code. RECOVERY AMOUNT A Recovery Amount is required if a Recovery Code is sent. A Recovery Amount is required if a Recovery Code is sent.

161 161 Recoveries should not be backed out of their respective Benefit Type Amount Paid or Other Benefit Type Amounts. Recoveries should not be backed out of their respective Benefit Type Amount Paid or Other Benefit Type Amounts. Exception: Recovery Codes 830, 880 & 890 – see next slide. Exception: Recovery Codes 830, 880 & 890 – see next slide. RECOVERY AMOUNT

162 162 RECOVERY AMOUNT To ensure the claim reflects costs actually incurred, only the following recoveries should be deducted from the applicable Benefit Type Amount Paid or Other Benefit Type Amount Paid: To ensure the claim reflects costs actually incurred, only the following recoveries should be deducted from the applicable Benefit Type Amount Paid or Other Benefit Type Amount Paid: 830 (Overpayment Recovery) 830 (Overpayment Recovery)…

163 163 RECOVERY AMOUNT … 880 (Voided Indemnity Benefits Check Recovery, or 880 (Voided Indemnity Benefits Check Recovery, or 890 (Voided Other Benefit Check Recovery). 890 (Voided Other Benefit Check Recovery).

164 164 The presence of this recovery data will excuse edits that would otherwise invoke if a Benefit Type Amount Paid is sent as less than previous. The presence of this recovery data will excuse edits that would otherwise invoke if a Benefit Type Amount Paid is sent as less than previous. RECOVERIES Segment Rules

165 165 Unlike A/C/R segments, a Recovery segment should always be included on each SROI transaction once a Recovery has been made on the claim (unless the recovery was reported in error.) Unlike A/C/R segments, a Recovery segment should always be included on each SROI transaction once a Recovery has been made on the claim (unless the recovery was reported in error.) RECOVERIES Segment Rules

166 166 RECOVERIES Segment Rules Number of Recoveries reported in the Variable Segment Counters should match the # of Recovery codes sent.

167 167 RECOVERIES Segment Rules Example: Recovery Code Second Injury Fund Recovery Amount - $

168 168 Questions?


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