Presentation on theme: "Electronic Periodic Claim Cost Reports"— Presentation transcript:
1 Electronic Periodic Claim Cost Reports SROI SA, FNElectronic Periodic Claim Cost ReportsElectronic DWC-13 Equivalent Required to be filed with DWC per Rule L , F.A.C.
2 SROI SA, FN – Electronic Periodic Claim Cost Reports Periodic Reports are Subsequent Reports (SROI) that equate to FL’s Claim Cost Report (DWC-13).Represented by SROI SA, FN.
3 SROI SA, FN – Electronic Periodic Claim Cost Reports Periodic filings, SROI SA, FN report the total cumulative amounts paid in indemnity (Benefits segment) and certain medical costs (Other Benefits segment.)
4 Pop Quiz: “Event” Benefit Segments, or Are the “Benefits Segments” on an SA or FN:“Event” Benefit Segments, or“Sweep” Benefit Segments?
6 SROI SA, FNRecap: A “Sweep” Benefits Segment does NOT require the following ‘event-driven’ data elements:• MTC• Gross Weekly Amount• Gross Weekly Amount Effective Date• Net Weekly Amount• Net Weekly Amount Effective Date• Benefit Payment Issue Date
7 SROI SA, FNRecap: A “Sweep” Benefits Segment only requires reporting of the following “historical’ data elements:• Benefit Type Code,• Benefit Period Start Date (except legacy claims),• Benefit Period Through Date (except legacy claims),• Benefit Type Claim Weeks,• Benefit Type Claim Days, and• Benefit Type Amount Paid
8 “Benefit Period Start Date” Recap: For Periodic MTC’s SA, FN, “Benefit Period Start Date” is:Earliest date for a BTC;Even if multiple benefit periods have been paid for the BTC.
9 “Benefit Period Through Date” Recap: For Periodic MTC’s SA, FN, ‘Benefit Period Through Date’ is:Latest date for a BTC;Even if multiple benefit periods have been paid for the BTC.
10 SROI SA, FN – Electronic Periodic Claim Cost Reports In general:SROI SA (Sub-Annual) is required to be filed for Open cases every 6 months from the DOI until the claim is closed.SROI FN (Final Report) is required for Closed cases where no further indemnity or medical benefits are anticipated to be paid.
12 SROI SASpecifically, in accordance with Rule 69L (4)(a), F.A.C.:SROI SA (Sub-Annual) is due:DOI + 6 Months (+30 Days), orDOI + 12 months (+30 Days) if LT occurs > 6 Months from DOI
13 SROI SASA, Sub-Annual is also required to be filed with DWC if the claim is re-opened to pay ongoing indemnity or reportable medical benefits (per Rule 69L (4)(b)3., F.A.C.)Due at 6 month intervals from DOI (+ 30 Days) until Final is filed.
14 Sequencing Rule (in Edit Matrix) for SROI SA (Sub-Annual) The first MTC SA (Sub-Annual) must not be sent prior to the end of six (6) months from theDate of Injury, or thetransaction will reject.
15 Duplicate Processing Note (in Edit Matrix) for“SA after SA”If a subsequent SROI MTC SA is sent more than 7 days before the date it is due, it will be considered an amendment to the previously accepted MTC SA (vs. a duplicate or the next required MTC SA filing.)
16 “Duplicate Processing” Note (SA after SA)Example: DOI =1st SA: File no earlier than and no later than(Not always exactly 180 days-use calendar mo’s)2nd SA: File no earlier than 7 days prior to and no later than days after ( ) to fulfill the 2nd SA filing reqm’t.
17 “Duplicate Processing” Note (SA after SA)Another Example: DOI =1st SA: File no earlier than and no later than (If 6 mo. interval yields invalid date, use 1st day of next mo.)2nd SA: File no earlier than 7 days prior to and no later than 30 days after ( ) to fulfill the 2nd SA filing reqm’t.
19 Monthly Missing SA Report Due to a decline in the proper filing of Claim Cost reports, DWC instituted a “Monthly Missing SA Report” last year (11/1/09)Posted in Data Warehouse under ‘Proprietary Claims EDI Reports’.
20 Monthly Missing SA Report However, due to an internal data clean up project , the ‘Missing SA’ report had been temporarily suspended.It was resumed in April 2010.The due date for reconciling the initial April report will be August 2, 2010.
21 Monthly Missing SA Report Please reconcile each month’s Missing SA report.An advisory will be sent when each Missing SA Report is posted in the warehouse.This revised version of the report includes the EE’s Name and Date of Birth (SSN was removed.)
22 Monthly Missing SA Report DWC sends notification regarding the posting of the Missing SA Report to each person having a data warehouse account.However, if you do not want to receive s for this purpose …
23 Monthly Missing SA Report … your account administrator can ‘uncheck’ the “Receives Monthly Missing MTC SA Report Notices” in your warehouse account/profile.
24 Monthly Missing SA Report The Monthly Missing SA Report identifies:Claims that are due an SA transaction, andClaims for which no SA or FN has been filed with DWC.
25 Monthly Missing SA Report The Missing SA Report includes:OPEN, LOST TIME Claims (not cancelled or total denials where no indemnity has been paid) for whichA DWC-1 or DWC-13 (paper or EDI) is ‘on file’ and ...,
26 Monthly Missing SA Report Claims where:DOI > 1/1/2005; orEDI R1/R3 accepted (any DOI); orPT/PT Supp $ paid (any DOI); orRecent DWC Form (1, 4, 12, or 13) rec’d on/after 1/1/2008 (regardless of DOI).
27 Monthly Missing SA Report DWC advises Claim Admin.’s to ensure they file an SA (and receive a TA) every 6 months from DOI until the claim is closed and an FN is sent and accepted.Missing SA’s or FN’s should be triggered and filed with DWC.
28 Monthly Missing SA Report The Missing SA Report also incorporates the below timeframes:If IB is initial payment: SA due next 6 month increment after Payment Issue Date.If Settlement is Initial Payment: SA due next 6 month increment after Award/order Date.
29 Monthly Missing SA Report The Bureau of Monitoring and Audit will also have access to query the Monthly Missing SA Reports.PT Section of M&A is also soliciting overdue SA’s (respond to these upon receipt of request.)
31 SROI FNAs mentioned earlier, a SROI FN (FINAL) EDI DWC-13 equivalent, is required to be filed with DWC if the claim is Closed.
32 SROI FNIn accordance with Rule L (4)(b), F.A.C., SROI FN (Final) is due:On or before 30 days after the due date of the next SA, orAfter final payment of indemnity and medical benefits, orUpon closure of claim by Claim Administrator.
33 SROI FNSROI FN (Final) may be sent prior to the due date of the next “SA” if :The case is closed and no further indemnity or medical benefits will be paid.
34 SROI SA, FN Electronic Claim Cost In addition to indemnity benefits, the following Other Benefit Type Codes/Amounts are required on Electronic Claim Cost Reports MTC SA and FN:OBT 300 (Funeral),OBT 310/311 (Penalties),OBT 320/321 (Interest),OBT 370 (Other/Misc. medical)...
36 SROI SA, FN Electronic Claim Cost Miscellaneous Medical includes costs not otherwise classified or required to be reported to DWC pursuant to Rule 69L-7.602, F.A.C., including,Custom handicapped equipped housing, incl. ramps, wide doorways, etc.,Custom vans,Therapeutic hot tubs,Home attendant care,On-site field case management services……
37 …Telephonic nurse case management services (except where Claim Admin …Telephonic nurse case management services (except where Claim Admin. uses the services of a case manager for a face-to-face meeting with the physician to conduct a telephone call with the treating physician or participate in a team conference, in which case the claim administrator should report under medical EDI codes through 99373),Hospice, etc.
38 SROI SA, FN Electronic Claim Cost Expense items should not be reported under Other Medical/OBT 370, e.g.:,Cost for bill review services, orDetermining correct medical reimbursement relating to PPO discounts,Drug screen expenses, etc.Note: Payments to the EE for EE-paid Rx are reported as an ‘employee reimbursement’ via the medical EDI format (vs. Other medical).
39 SROI SA, FN Electronic Claim Cost FL no longer requires the inclusion of the following costs on the SROI SA or FN, since the following are reported via the medical EDI format:OBT Code 350 (Physician),OBT Code 360 (Hospital),OBT Code 450 (Pharmacy)OBT Code 455 (Durable medical),OBT Code 460 (Physical therapy) andOBT Code 465 (Chiropractic).
40 SROI SA, FN Electronic Claim Cost SROI SA/FN is not required for the following types of claims (and therefore not on Missing SA Report): , unless one or more BTC’s or required OBT’s have been paid:FROI 04 (Total Denial)00/PD (Indemnity Only Denied)00/CD (Compensable Death, No Depndts)00/VE (Compensable Volunteer)S8 (Claim transferred to another juris)PY with RBAC S or N (Settlement with $0)FROI 01 (Claim cancelled)
41 Caveats and Tips for Successfully Filing SROI SA, FN
42 Caveats and Tips for Filing SA, FN The majority of SA filings are rejecting for the error:NBR OF BENEFITS SHOULD NOT BE > WHAT IS ON FILEAs mentioned earlier, this appears to be caused by incorrectly leaving off BTC(s) on either the initial transaction that ‘set the benefit picture’, or due to including the “R” code that excuses missing benefits.
43 HELPFUL HINTIf a suspension is not yet ‘on file’ and you need to report a BTC paid in the past that was improperly left off the previous accepted filing, our program will allow you to ‘introduce’ the new Benefit type via MTC CB.(Even though you are not actually changing the current BTC to the new BTC.)
44 HELPFUL HINTHowever, if you need to report a BTC that was paid in the past but left off the previously accepted transaction but a suspension has already been filed, it is difficult to fix the ‘benefit picture’ with another transaction / MTC.
45 HELPFUL HINTIn this case, you would not send a SROI RB if indemnity benefits have truly not been reinstated. If you filed an RB, you would be precluded from sending another Sx with the same (true) Susp. Effective Date.Therefore, you would need to send a request to the Claims EDI Team for special handling.
46 As a result of seeing this situation occur for legacy as well as new claims, FL has proposed a new Lump Sum Payment/Settlement Code (ND – Non Disputed) to enable the reporting of a one time payment of back benefits without having to “change” or “reinstate” benefits (pending IRR discussion/vote.)
47 NO SROI S1-8, 04, CD, VE, PY OR PD ON FILE Caveats and Tips for Filing SA, FNThe majority of FN filings are rejecting for the error:NO SROI S1-8, 04, CD, VE, PY OR PD ON FILE
48 Caveats and Tips for Filing SA, FN For non-legacy claims, one of the following must be ‘on file’ before the FN will be accepted:Suspension (S1-S8); orTotal Denial (FROI or SROI 04), or,Partial/Indemnity Only Denial (PD Code A or E), orFinal Settlement (PY w/LSPS Code SF, SP)
49 Caveats and Tips for Filing SA, FN (cont’d) …If none of these transactions were previously filed, an FN will also be accepted if:Paper DWC-1 was filed or,Claim was acquired via AQ and the acquiring Claim Admin. never paid indemnity (i.e., no subsequent AP, PY.)
50 Other common errors for SA, FN filings are: Caveats and Tips for Filing SA, FNOther common errors for SA, FN filings are:PI % CANT BE 1ST RPTED ON THIS MTCPI % CANT BE CHANGED VIA THIS MTCMMI CANT BE 1ST RPTED ON THIS MTCAVG WAGE MUST BE CHANGED VIA MTC 02 CB CA AP OR RB
51 Caveats and Tips for Filing SA, FN PI, MMI, and AWW information is required to be reported via EDI DWC-4 equivalents, e.g., 02, CA, CB, RB, PY (where it was not applicable at time the EDI First Report was filed.)
52 SA and FN filings are also often rejected for: Caveats and Tips for Filing SA, FNSA and FN filings are also often rejected for:BEN TYPE CODE PREVIOUSLY REPORTED NOT SENT ON SROIHere, you may need to legitimately report the “R” code if a BTC was totally converted to another BTC…
53 Caveats and Tips for Filing SA, FN ... and is no longer applicable to the claim, orOBT 430 (Acquired Unallocated Indemnity) needs to be included to show prior BTC’s ‘rolled up’, orA Benefit Type Code(s) really was inadvertently left off the transaction.
54 IF DOI >= 1/1/94, BTC 030 (IB) DAYS CANT BE > 0 Caveats and Tips for Filing SA, FNAnother error frequently occurring for FN filings is:IF DOI >= 1/1/94, BTC 030 (IB) DAYS CANT BE > 0DWC expects IB (030) to have been paid in whole weeks (unless claim was settled or EE died before IB days could be reclassified into another BTC.)
56 SROI MTC “SA” Scenario With Recovery Code “880” The Claim Administrator previously sent MTC “00/IP” to report its initial payment of TT benefits eff. 6/16/07.MTC “S1” was subsequently sent to report the suspension of TT benefits eff. 8/24/07.
57 SROI MTC “SA” Scenario With Recovery Code “880” On 8/29/07, two days after the Claim Administrator had sent the SROI S1, the employer informed the Claim Administrator the employee actually returned to work on 8/11/07, two weeks earlier.
58 SROI MTC “SA” Scenario With Recovery Code “880” As a result, the previous SROI S1 reflected the payment of TT benefits for 2 weeks more than were due.Because the Claim Administrator confirmed the check had not yet been tendered, a stop payment was placed on the check.
59 SROI MTC “SA” Scenario With Recovery Code “880” On 12/21/07, the Claim Admin. sends its initial Sub-Annual (SROI SA) to DWC to report the total cumulative amount paid for TT and some medical costs.The “SA” reflects the reduction in TT previously reported on the S1, as a result of the recovery/cancellation of the last TT check.
60 SROI MTC “SA” Scenario With Recovery Code “880” Note: Prior to filing the initial SROI SA, the Claim Administrator must file a SROI 02 to report the change in the “Initial Return to Work Date” and “Suspension Effective Date”, as FL does not look at this information on Electronic Claim Cost Reports.
61 SROI MTC “SA” Scenario With Recovery Code “880” The Claim Administrator must ensure that a Recovery Segment is sent on the “SA” to explain the difference in the lower amount of TT benefits reported on the “ SA” compared to the higher amount previously reported on the “S1”.
62 SROI MTC “SA” Scenario With Recovery Code “880” The claim administrator sends its Initial MTC SA on 12/21/07.
63 SROI MTC “SA” Scenario With Recovery Code “880” 1 BT, 2 OBT’s, and 1 Recovery are reported.
64 SROI MTC “SA” Scenario With Recovery Code “880” The Benefit Segment for 050 reflects the total amount paid for TT (does not include the amount recovered.)
65 SROI MTC “SA” Scenario With Recovery Code “880” Let’s compare the previous S1 to the SAS1SA
66 SROI MTC “SA” Scenario With Recovery Code “880” In addition to the 2 OBT’s, Recovery Code 880 and corresponding Amount are sent to reflect indemnity benefits (TT) were voided/cancelled.
67 In addition to BTC’s and certain OBT’s, SROI SA and FN should also report the following information if applicable to the claim:Ongoing adjustments;Ongoing credits;Ongoing redistributions; andRecoveries.