3 FL EDI Reporting requirements are defined in the Trading Partner Tables: RequiredReport(s)Data needed on the Report(s)AppliedEditing
4 The FL EDI Trading Partner Tables are used to convey FL’s EDI reporting requirements. Although they may appear “technical” and are used by IT staff and EDI Vendors to determine FL’s requirements, they were written by and for “business” staff.
5 These very important requirements documents can be found on the Claims EDI webpage, and are your resource for determining when a transaction should be filed and why it may have errored.
9 An Event is a business circumstance that occurs in the life of a WC Claim which requires the reporting of EDI information to DWC. These circumstances reflect FL’s requirements, including:First Report of Injury eventsSubsequent Report eventsPeriodic events
10 Claim Business Events Claim Event Flow in FL 1. Establish Claim with 2. Initial Paymentor Equivalent9. Lump Sum Payment(s)7. Suspend10. Periodic Reports3. Changes to Benefits/Amnts5. Reinstate11. Changes(Non-Indemnity)Benefits6. Change4. Suspension of all Benefits12. Cancel8. Claim Closure
11 This training has been redesigned to follow this claim event flow, regardless of whether an MTC is in the Primary or Secondary Implementation.
12 FL identifies all of the transactions (MTC’s) that are required for reporting specific business events on itsEvent Table.
26 Event Table FL Periodic Reports SA Sub-Annual – Submitted every 6 months after the DOI, as defined on FL’s Event Table.FN Final – Submitted when Claim Administrator determines no further benefits will be paid.
27 Interpreting the FL Event Table We will now look at the online copy of FL’s Event Table….
28 Event TableIn addition to the Event Table, FL describes its business events in the ‘MTC Filing Instructions’. This document (created by Karen Kubie ) is a quick reference tool displaying what MTC’s to use in reporting required business events to FL.MTCFilingInstructions
37 Element Requirements F = Fatal. The data element is essential to process the transmission/transaction.
38 Edits will NOT be applied, nor will the data be loaded for FL. Element RequirementsX =Exclude. The data element is not applicable to the standard requirements for the MTC and may or may not be sent.Edits will NOT be applied, nor will the data be loaded for FL.
39 Element Requirements M = Mandatory. The data element must be present and must pass all edits (documented in the Edit Matrix) or the transaction will be rejected.
40 Element Requirements MC = Mandatory/Conditional. The data element becomes mandatory under conditions documented on the applicable “Conditional Requirements” worksheets.If the defined condition exists, the data element becomes mandatory and mandatory rules apply.
41 Element RequirementsData Elements defined as M or MC (and the condition applies) are required fields. If they are not present on the transaction, the transaction will receive a Mandatory Field Not Present error (Error # 001).
42 Element Requirements IA = If Applicable/Available. Data should be sent if available or applicable to the claim.If present, data will be edited for valid value and/or format. If the data passes the edits, the data will be loaded. If the data does not pass the edit, the data will not be loaded, and no error will be returned by FL.
43 Element Requirements NA = Not Applicable. The data element is not applicable to FL’s requirements for the MTC, and may or may not be sent. FL will not be editing or loading these data elements for this MTC.
44 Element RequirementsFor DN’s that are on both the FROI and SROI, FL has identified which transaction (FROI Or SROI, or Both) from which it will edit/load data, and from which the data will be ignored (N/A).
45 Element RequirementsInterpreting Requirement TablesFL’s Claim Number is not required on a FROI 00, 04, AQ or AU, but is Mandatory on a FROI 01 or 02.
46 Conditional Requirement Code Data Element Number and Name Element RequirementsFL Conditional Requirements TableConditional Requirement CodeData Element Number and NameBusiness Conditions
47 Element RequirementsAdditional requirement codes were developed for the MTC 02 (Change) transaction. These will be discussed later in the training.
48 Element RequirementsA Benefits segment is expected when indemnity benefits have been paid on the claim, for each applicable Benefit Type Code value indicated in the Edit Matrix.Only one Benefits segment can be sent for each Benefit Type Code.
49 Element Requirements“Event” Benefits Requirements are described on the Event Benefits Segment Requirement Table.
50 Element Requirements R = Restricted. The data element value will not be accepted by FL.For example, FL does not accept Benefit Type Code 090 (PI) (Permanent Partial Disfigurement) for DOI’s < 08/01/79 or > 12/31/93
51 Element RequirementsRestricted Benefit Types for FL
52 Element RequirementsDN’s in the Benefits segment are required based on the MTC as well as the Benefit Type Code being paid.Net Weekly Amount
53 Element RequirementsData defined as N/A on the Element Requirement Table, or was not required by the “Condition” will not be edited, processed or loaded to DWC’s system if sent for that MTC.This is commonly misunderstood.
54 Element RequirementsExample: Gross/Net Amounts are not required for MTC SA or FN. If these data elements are sent incorrectly, they will not be errored.However, if Gross/Net Amounts are sent wrong on the next Event where they ARE required (CA, CB, etc.) they WILL be errored.
55 Element RequirementsAlthough the same data element may be on both the FROI and SROI, the Element Requirement Table will depict on which transaction the data is required. The other transaction will list the requirement as N/A, which means it will not be edited, processed or loaded to DWC’s system if sent for that MTC.
56 Element RequirementsExample: Claim Type is not looked at on the FROI 00, but is required on the corresponding SROI IP. If it is only sent on the FROI and not the SROI, they will both reject.
57 Element RequirementsWe will now look at the online copy of FL’s Element Requirement Table….
69 Edit Matrix FL DN-Error Message Table Contains “standard” logical edits developed for Release 3.Assists the claim administrator in determining what caused a specific error.(FL refers to this as the “L” Table.)
70 Edit Matrix FL DN-Error Message Table Release 3 Data Element Numbers and Names are listed down the left columns.
71 Edit Matrix FL DN-Error Message Table Error Message Numbers and associated descriptions are listed across the top of the table.
72 Edit MatrixFL DN-Error Message TableDN Numbers and Error Message Numbers are returned on the Acknowledgement to communicate errors.
73 Edit Matrix FL DN-Error Message Table The spreadsheet is populated with edit defaults by IAIABC.F = Fatal Technical data elements are essential for a transaction to be processed.
74 Edit Matrix FL DN-Error Message Table L = Edit applies to the data elements based on the requirements indicated on the Element Requirement Table. FL added some “L’s” to table (where allowed).
75 Edit Matrix FL DN-Error Message Table FL has added two proprietary codes:FL = Edit results in a nonfatal error which will be documented on the FL Claims EDI Data Warehouse.IA = Edit will be run. If edit fails, no error will be returned and data will not be loaded.
81 Edit MatrixFL Value TableThe FL “Quick” Code Reference Guide assists in interpreting FL’s Value Table in the Edit Matrix.FL QuickCodeReference(FL DWC Website)
82 Edit Matrix FL Value Table The Value Table is separated into two sections:Section 1:If a Data Element is collected by FL but a certain code value is grayed out (i.e., Not Statutorily Valid in FL), the filing will be rejected if that value is sent.
83 Edit Matrix FL Value Table – Section 1 Reflects the FROI and SROI Maintenance Type Codes (MTC’s) FL will accept.
84 Edit Matrix FL Value Table – Section 1 FL does not accept FROI MTC CO or UI, or SROI MTC CO or RE.
85 Edit Matrix FL Value Table Section 1 (cont’d): If a Data Element is not collected by FL (reflected as “N” in “Capture?” column) and code values are grayed out, a filing will not be rejected if sent with those values.
86 Edit Matrix FL Value Table – Section 1 Ex: FL does not require or process Initial Treatment Codes.
87 Edit Matrix FL Value Table Section 2: If a Data Element is statutorily valid in FL (e.g., physician payments), but not required to be reported, the corresponding code value(s) is grayed out on the table, and the filing will not be rejected if sent with that value.
88 Edit Matrix FL Value Table – Section 2 Section 2: FL will NOT process the grayed out values; however, they ARE statutorily valid (e.g. atty fees).
89 Edit Matrix FL Value Table – Section 2 Ex: 330 (Total Employer’s Legal Expenses)Ex: 340 (Total Claimant’s Legal Expenses)Clm Admins may suppress these values.
93 Edit Matrix FL Match Data Table Describes the data elements that will be used by FL to determine if the transaction will create a new claim, or be associated with an existing claim in DWC’s database.
94 Edit Matrix FL Match Data Table If you receive Error # 117, “Match Data Value Not Consistent With Value Previously Reported,” check this table to see which data elements are being used as match data.
95 Edit Matrix FL Match Data Table Match criteria will be also applied between FROI and SROI combo filings. If any of the match data is different between the FROI and SROI, they will not be paired together for processing.
96 Edit Matrix FL Match Data Table DWC has added a column to the Match Data table to identify how we are matching to combine FROI with corresponding SROI’s.
97 Match Data RulesStandard Match Data Rules are described in Section 4 of the IAIABC R3 Implementation Guide.
101 Transaction Sequencing Standard minimum Transaction Sequencing limitations are described in Section 4 of the IAIABC R3 Implementation Guide.
102 Transaction Sequencing Understanding Transaction Sequencing in Section 4 of the IAIABC R3 Imp. Guide is necessary for understanding theFL Sequencing Table.
103 Edit Matrix FL Sequencing Table The FL Sequencing Table illustrates the sequence in which business events (MTC) typically occur during the life of a claim and what MTC must have preceded the subsequent MTC.
104 Transaction Sequencing Claim Event Flow in FL1. Establish Claimwith2. Initial Paymentor Equivalent9. Lump Sum Payment(s)7. Suspend10. Periodic Reports3. Changes to Benefits/Amnts5. Reinstate11. Changes(Non-Indemnity)Benefits6. Change4. Suspension of all Benefits12. Cancel8. Claim Closure
105 Edit Matrix FL Sequencing Table Now lets try to interpret the Edit Matrix “Minimum” Sequencing edits.
106 Edit Matrix FL Sequencing Table FL accepts FROI 00 (with SROI) or FROI 04 to establish a claim.No FROI sequencing edits are applied
107 Edit Matrix FL Sequencing Table Shows the minimum sequencing edits that will be applied for an IPor initial payment equivalent MTC.
108 Edit Matrix FL Sequencing Table Element Error Text (DN0291) is the FL error message text sent on the AKC which clarifies the Error Message Code “Invalid Event Sequence”.
109 Edit Matrix FL Sequencing Table If you do not understand what is meant by the 50 byte error text, you should look it up for more explanation.
113 Edit Matrix FL Duplicate Processing In addition to duplicate errors (#057), there are sequencing (#063) and matching errors (#117) in this table.
114 Edit MatrixFL Duplicate ProcessingAlthough we do not accept a 00/IP after a previous 00/IP, we WILL accept a 00/IP after a paper DWC-1; however, we will process this as an “00/IP SROI ONLY” and not as a First Report on your Report Card/Statistics.
118 Edit Matrix Population Restrictions Each Population Restriction contains:The DN # and Name;
119 Edit Matrix Population Restrictions The Error # and Error IAIABC Message description;
120 Edit Matrix Population Restrictions The specific text describing the edit; andIf you do not understand the 50 byte error message you received, this is the column that explains how the edit was applied.
121 Edit Matrix Population Restrictions The FL-specific text clarifying the IAIABC Error Message Text.
128 FL Calculation Table (Proprietary) Edit MatrixFL Calculation Table (Proprietary)This table will be used to validate the “Gross Weekly Amount” (based on the Wage sent) and the “Benefit Type Amount Paid” expected from the Claim Administrator (based on the weeks/days sent.)
129 FL Calculation Table (Proprietary) Edit MatrixFL Calculation Table (Proprietary)DWC bases all financial calculations on the Average Wage that is sent. This includes calculations of Calculated Weekly Comp Amount, Gross Weekly Amount, Net Weekly Amount and Benefit Type Amount Paid.
130 FL Calculation Table (Proprietary) Edit MatrixFL Calculation Table (Proprietary)For Example: If the Comp Rate sent is correct for the claim, but the Average Wage is incorrect for the claim, the transaction will reject (TR), due to the fact that the Comp Rate will not equal 66 2/3% of the Average Wage sent.
131 How do you know which Table/Tab to look at to research an error?... Error 001 – Element Requirement Table (including Conditions Tab) Error 057 – Edit Matrix: Pop Rest and Duplicate Tab Error 063 – Edit Matrix: Pop Rest, Sequencing and Duplicate Tab Error Edit Matrix: Pop Rest and Match Data Tab All Other Error #’s: Pop Restrictions Tab
132 We will now look at the online copy of FL’s Edit Matrix….
134 How Will EDI Errors Be Communicated to Claim Administrators?
135 The Division will acknowledge every EDI R3 transaction received with the standard EDI Acknowledgement format: ‘AKC’.AKC Report
136 The ‘AKC’ acknowledgement will identify how many transactions passed edits (TA -Transaction Accepted); how many failed edits (TR -Transaction Rejected); and the specific error(s) that caused the transaction to reject.
137 FL does not use the TE – “Transaction Accepted with Errors” Acknowledgement Code; however, certain errors will display in the warehouse as “TA-FL” and must be addressed by the claim administrator.
138 Acknowledgement results from the previous day’s transmission(s) will be posted by 9:00 a.m. the following morning in the EDI Data Warehouse (will be discussed more during the training.)
139 Transmissions received on or before 9:00 p. m. , E. S. T Transmissions received on or before 9:00 p.m., E.S.T., will be processed by DWC the same day the transmission was sent.Transmissions will be acknowledged the next calendar day (usually by 9:00 a.m. E.S.T.)
140 Transmissions received after 9:00 p. m Transmissions received after 9:00 p.m. EST will be processed by DWC the following calendar day,and will be acknowledged the day after the transmission is processed.
141 If you need to confirm if or when a particular filing or group of filings were received by the Division, you can “Search for Batches” in the Data Warehouse to determine when the FROI and/or SROI batch was received (Click on the “Batch ID” for batch details.
144 FL processes transmissions 7 days a week, including holidays.
145 If a transaction is improperly rejected by the Division, the entire batch will be re-processed and re-acknowledged using the ‘ARC’ Acknowledgement format (see the technical training PowerPoint for more details on the Acknowledgement Process)
146 If a transaction is improperly rejected by FL, the Claim Administrator will receive credit for the date the transaction was originally received by the Division.
147 FL provides EDI Claim Administrators the capability of viewing all FROI’s & SROI’s received, via the on-line Claims EDI Data Warehouse.
148 The on-line Claims EDI Data Warehouse will assist claim administrators in resolving EDI errors faster, and may also assist in resolving issues with the Centralized Performance System (CPS).Claims EDI Warehouse
149 More detailed information regarding the on-line Claims EDI Data Warehouse is provided later in the EDI training class.Claims EDI Warehouse
151 JCN stands for “Jurisdiction Claim Number” and is assigned by DWC to a specific accident for a specific claim administrator.
152 JCN’s must be sent on all Subsequent reports, even on legacy cases that started prior to EDI So where do you get these numbers?
153 Claim Administrators are able to obtain a listing of JCN’s for all their Open claims, or those closed on or after , via the warehouse.
154 An updated listing is created weekly. The JCN List contains the Date Prepared for the last DWC 1, 4, 12 and/or 13 on file with DWC.An updated listing is created weekly.Only the last 3 lists generated are kept on the EDI Warehouse.Note: The list can be downloaded to a text delimited file and modified as needed.
155 Jurisdiction Claim Number (JCN) Lists are discussed in more detail later in the training.
159 FL SCENARIO ASSUMPTIONS General scenario assumptions are included in the scenarios to assist in understanding the sample data that is presented.
160 FL SCENARIO ASSUMPTIONS The FL Scenarios were enhanced from the IAIABC scenarios in the R3 Implementation Guide.All the 2001 dates were moved forward to 2007 (the next year where all dates fell on the same day of the week).
161 FL SCENARIO ASSUMPTIONS Calculated Weekly Compensation Amount is the Comp. Rate, and is 66 2/3% of the Average Wage.The statutory comp rate max is not accurate per FL law.
162 FL SCENARIO ASSUMPTIONS Scenarios are presented in uppercase text. However, data may be sent to FL in mixed case format (except between FROI/SROI combos for match data.)Payment of indemnity benefits is based upon a 5 day work weekThe Industry Code must be a 2002 or 2007 NAICS code.
163 FL SCENARIO ASSUMPTIONS FL Scenarios contain required sample data elements pertinent to the scenario. These data are identified as “M” (Mandatory) or “MC” (Mandatory/Conditional) on the FL Element Requirement Table.
164 FL SCENARIO ASSUMPTIONS Additional data elements may be present in the scenario if they are identified as “IA” (If Applicable/Available) on the Element Requirement Table (e.g., Middle Initial and Suffix).
165 FL SCENARIO ASSUMPTIONS Although Claim Administrators may send additional data elements marked “NA” (Not Applicable), such data will not be edited or loaded by FL, and therefore not presented in the scenarios.
166 Note: Do not use the FL Business Scenarios to determine if a data element is required for a particular MTC.The Element Requirement Table is the official source of FL’s data element requirements per MTC and the conditions under which the data must be present.
173 FL SCENARIOSA FROI must be paired with the applicable SROI that is reporting the initial payment or equivalent, unless the FROI is reporting a Full Denial (MTC 04), Cancel (MTC 01), Change (MTC 02) or Acquired Claim (MTC AQ).
174 Complete Scenario for FROI/SROI Combo MTC “00” with “IP” Disability Immediate & ContinuousRule 69L (1)(a)1., F.A.C.
175 Indemnity Benefits other than TP or IB or settlement will be paid, an NEW CLAIM: Lost Time CaseWhere Disability is Immediate and ContinuousIf the Initial Payment of Indemnity Benefits will be made by the Claim Administrator, andIndemnity Benefits other than TP or IB or settlement will be paid, anElectronic First Report of Injury or Illness is due.
176 Due: 21 Days after Claim Administrator’s Knowledge of the Injury NEW CLAIM: Lost Time CaseWhere Disability is Immediate and ContinuousSend: FROI 00 with SROI IPDue: 21 Days after Claim Administrator’s Knowledge of the InjuryNote: Also provide FORM DWC-1 or IA-1 to the employee & employer.
177 To avoid late filing penalties for an Electronic First Report of Injury or Illness, the EDI DWC-1 should be triggered immediately upon the CA’s disposition of the claim (payment or denial), to allow time for correction of potential errors and resubmission and subsequent receipt/acceptance by the Division within the filing due dates specified in Rule 69L-56, F.A.C.
178 FROI “00” Scenario Narrative Employee fell from ladder at employer’s warehouse on 6/15/07.Employee broke his leg.Foreman witnessed the accident.Employee treated and released from the Emergency Room.
179 FROI “00” Scenario Narrative Employee earned $15.00 an hour working 40 hours a week.Employer reported injury to insurer on 6/17/07.
180 FROI MTC “00” SCENARIOClaim Administrator reported the loss to DWC on 6/29/07.
181 FROI MTC “00” SCENARIO Insurer is identified. Claim Administrator details are provided (remainder are on R21).
182 FROI MTC “00” SCENARIO Employer/Insured information is reported. The Employer’s name is on the R21The rest of the Employer’s address is on the R21NAICS Code
183 FROI MTC “00” SCENARIOIf applicable, Policy Number should be reported, but Effective Date & Expiration Date are not required.
184 FROI MTC “00” SCENARIO Details of the accident are included. Employee broke leg falling from a ladder.
185 FROI MTC “00” SCENARIOEmployer reported injury to claim administrator on 6/17/07.
186 FROI MTC “00” SCENARIO Details about injured employee are sent. The rest of the Employee’s name and address is on the R21
187 FROI MTC “00” SCENARIODate the initial disability began & other FROI fields must be reported on the SROI.Manual “Risk” Class Code is only on the FROI.
188 FROI MTC “00” SCENARIOEmployee earned $15.00 an hour and worked 5 days a week.Employee has not returned to work.
189 FROI MTC “00” SCENARIOFROI Companion Record - R21
190 FROI MTC “00” SCENARIOClaim Administrator Claim Number is repeated in the R21. It links the R21 companion to the related 148.
191 FROI MTC “00” SCENARIO Claim Administrator FEIN is sent. Claim Administrator Name is sent,and rest of the Claim Admin Address.456 Main St
192 FROI MTC “00” SCENARIO ID qualifier = S. Positions 232 to 246 contain a Social Security Number.
193 FROI MTC “00” SCENARIORemainder of Employee name, address fields and phone are here in the R21 record.
194 FROI MTC “00” SCENARIO Type of Loss Code is reported on the SROI. Employee has not returned to work.
195 FROI MTC “00” SCENARIOInsured FEIN and Insured Name are reported.
196 FROI MTC “00” SCENARIOInsurer Name and Insurer Type Code are reported.
197 FROI MTC “00” SCENARIODetails of accident site:
202 FROI MTC “00” SCENARIOAccident description exceeds 50 characters; two segments are needed to send entire narrative description.
203 Variable Segment Population Rules for FROI ACCIDENT/INJURY DESCRIPTION NARRATIVES SEGMENT:No more than 10 (50 byte narrative text) segments per claim, and the number of segments sent must equal the “Number” of Accident/Injury Description Narratives segment counter.
204 POP QUIZIf the Accident Description Narrative segments are 50 characters each, and this Accident Description is 161 characters…
205 …how many segments must be sent to report the entire Accident Description Narrative?
206 ANSWER = d (4 segments) * DN Data Element Name Data Beg End 0038 Accident/Injury Description NarrativeAS HELEN WAS LEAVING HER WORK SITE (BLDG 500) SHE16011650WAS WAITING FOR HER HUSBAND TO PICK HER UP ON THE16511700STEPS OF THE BLDG. AS SHE LEANED AGAINST THE RAIL17011750ING & FELL.17511800**If the last segment is less than 50 characters, it should be padded with spaces to complete the 50 character segment.
207 FROI MTC “00” SCENARIOForeman Jones was the only witness.
208 Variable Segment Population Rules for FROI WITNESSES SEGMENT:No more than 5 witnesses per claim, and the number of segments sent must equal the “Number” of Witnesses segment counter.