Presentation on theme: "Claims EDI Basic Overview 2013"— Presentation transcript:
1 Claims EDI Basic Overview 2013 Florida Division of Workers’ CompensationClaims EDI Basic OverviewWELCOME
2 Presenter: Tonya Granger Administrator, Claims & POC EDI Team Bureau of Data Quality and CollectionFL Division of Workers’ Compensation
3 This training includes: Overview of EDI terminology and Administrative Rule 69L-56, F.A.C.How to investigate errors and utilize EDI resources (e.g., Edit Matrix, Element Req. Table.) to understand errors and make necessary corrections.Review of various EDI scenarios.
4 Rule Chapter 69L of the Florida Administrative Code is the EDI Rule for Proof of Coverage and Claims (non-medical)
5 EDI Rule 69L-56 F.A.C. was effective on January 7, 2007. It requires all insurers to implement the IAIABC Claims EDI Release 3 electronic format.
7 On a National level, in 1990 the IAIABC spearheaded a program to utilize the concept of EDI for Workers’ Compensation data.
8 What is the IAIABC?The International Association of Industrial Accident Boards and Commissions.A 99 year old organization of jurisdictional workers’ compensation administrators and others interested in WC.
9 What is EDI?Electronic Data Interchange is the electronic exchange of data between business trading partners (i.e., claim administrators to state agencies), in a standardized format.This does not include reporting byInjured Workers!
10 Bringing Together the Important Participants Developing an Electronic StandardBringing Together the Important ParticipantsJurisdictionsCarriersVendorsTPA’s
11 Developing a National Standard through the IAIABC EDI Development Committees was a process that required “give” and “take” from all participants.
12 The end result is a national standard format for the reporting of workers’ compensation data electronically.
13 FL DWC chose to implement the national standard for Proof of Coverage and Claims reporting to provide claim administrators with a consistent standard for electronic reporting across multiple states.
14 Where can you find the IAIABC R3 Implementation Guide & Codes?
17 The IAIABC Release 3 Claims EDI Implementation Guide contains essential information for implementing EDI, including the transaction record layouts, data dictionary, business and technical rules, national scenarios, etc.
18 The Release 3 Claims Implementation Guide can be purchased for $195 from the IAIABC’s website: or it is free if your company is an IAIABC EDI Member. The latest R Guide is dated January 1, 2013.
19 The national standard format contains different terminology, edits and various rules, such as sequencing rules, that must be followed and may be different from what you are accustomed to in the paper reporting environment.
20 Each Trading Partner should purchase the IAIABC EDI Claims Release 3 Implementation Guide each year. DWC can not furnish copies of any portions of this Guide.Become familiar with the data elements, definitions and other information in the Guide.
21 It is recommended that at least one person within every company have access to the Claims EDI R3 Implementation Guide.The requirements of this guide are incorporated by reference in the FL EDI Rule 69L-56 F.A.C.
24 GlossaryThe purpose of the glossary is to acquaint the reader with easy-to-understand definitions of workers' compensation terms.
25 GlossaryThe glossary defines terms that are common to FROI/SROI, MED, and POC EDI reporting.Not all of the terms are directly related to one of the IAIABC EDI reporting products, but they are commonly used in the business and data reporting environment.
29 ACRONYMSEDI Committee participants frequently use acronyms in their discussions, and newcomers (and veterans, too!) can easily lose their place in what is going on if they don’t understand what the acronyms stand for.
30 ACRONYM Examples: FTP File Transfer Protocol FEIN Federal Employer Identification NumberFROIFirst Report of InjuryGUIGraphical User InterfaceHTTPHyper Text Transfer ProtocolSROISubsequent Report of InjuryURLUniform Resource Locator
33 Release 3 Combined Business & Technical Data Dictionary
34 The IAIABC Release 3 Claims EDI Implementation Guide contains the data dictionary, which defines each element that is required. It is recommended that this section be saved to your desktop for ready reference.34
35 Release 3 Data Dictionary Section 6 in the Implementation Guide
36 Data Element Dictionary Identifies the Data Number (DN)Gives the Definition of the Data ElementGives the Last Revision Date of the Data Element
37 Data Element Dictionary Gives the Format (i.e. 2 A/N = two characters alpha/numeric)Lists the Valid Values for the DNGives DP (Data Population) Rule to Help Identify the Correct Use of the Data Element
40 Rule 69L-56 Rule Section Overview Claim Administrators must be familiar with the requirements of this rule.
41 EDI Rule 69L-56, F.A.C. was effective 1/7/2007 (Revised effective 5/17/2009) It requires all insurers to implement the IAIABC Claims EDI Release 3 electronic format.
42 EDI Rule 69L-56, F.A.C.This EDI Implementation applies to all required form filings for all Dates of Injuries, and not just those injuries that occur after the Insurer’s EDI Implementation date. This includes legacy claims.
43 Rule 69L-56 Rule Section Overview (Claim Administrators must be familiar with the requirements of this rule.)69L Forms and Instructions69L Definitions
44 69L-56.100 Proof of Coverage (POC) Electronic Reporting Requirements 69L Technical Requirements for POC EDI Transmissions69L Policy Cancellation or Non-renewal Requirements69L Time Periods for Filing Electronic Policy Information
45 69L-56. 300. Claims EDI Reporting. Requirements and 69L Claims EDI Reporting Requirements and Implementation Schedules69L Electronic First Report of Injury or Illness69L Electronic Notice of Denial and Rescinded Denial69L Electronic Periodic Claim Cost Reports
46 69L-56. 304 Electronic Notice of Action or. Change, Including 69L Electronic Notice of Action or Change, Including Change in Claims Administration, Required by the Insurer’s Primary Implementation Schedule
47 69L-56. 3045 Electronic Notice of Action. or Change, Suspensions, and 69L Electronic Notice of Action or Change, Suspensions, and Reinstatement of Indemnity Benefits Required by the Insurer’s Secondary Implementation Schedule** The Secondary Implementation Schedule is currently not being used.
48 69L-56.307 Electronic Cancellation of Claim 69L Technical Requirements for Claims EDI Transmissions69L Claims EDI Test to Production Status Requirements
49 Insurer’s Responsibilities Where Third Party Services Are Utilized 69L , F.A.C.
50 Insurer’s Responsibilities Where Third Party Services Are Utilized If an insurer contracts with any third party (TPA or vendor) or uses their software to send EDI transactions to DWC, the insurer is still responsible for the following…
51 the timely filing of transactions required by this rule Insurer’s Responsibilities Where Third Party Services Are Utilized…the timely filing of transactions required by this rulethe processing of acknowledgementsany penalties and fines that may result from a third party’s untimely EDI filings.
52 The former DWC paper forms previously filed with the Division have been replaced by electronic transactions:DWC-1 First Report Of Injury or IllnessDWC-12 Notice of DenialDWC-13 Claim Cost ReportDWC-4 Notice of Action/ChangeDWC-49 Aggregate Claims Administration Change Report
53 Rule 69L-56, F. A. C. identifies EDI filing requirements (i. e Rule 69L-56, F.A.C. identifies EDI filing requirements (i.e., when a claim administrator must file these EDI transactions with DWC).Rule 69L-3, F.A.C. identifies paper form copies still required to be sent to other parties.
54 Read Rule 69L-56, F. A. C. in it’s entirety. http://www. myfloridacfo
55 The Most Important Thing Necessary to Begin Filing Claims EDI is…
56 …Accurately submitting and maintaining your EDI Trading Partner Profile Documents
57 EDI Trading Partner Profile Documents At least two (2) business days before sending the first test transmission, the Clm. Admin. shall send its current profile information to the DWC at using the following forms adopted in Rule 69L , F.A.C.:
58 EDI Trading Partner Profile Documents DFS-F5-DWC-EDI-1: EDI Trading Partner ProfileDFS-F5-DWC-EDI-2: EDI Trading Partner Insurer / Claim Administrator ID ListDFS-F5-DWC-EDI-2A: EDI Trading Partner Claim Admin. Address ListDFS-F5-DWC-EDI-3: EDI Transmission Profile – Sender’s Specifications
59 EDI Trading Partner Profile Documents If a form is incomplete and does not contain responses to all of the required fields in accordance with the instructions on the form, or does not match information in DWC’s database, it will be returned.
60 EDI Trading Partner Profile Documents A claim administrator can not begin testing with the DWC until the corrected form(s) is re-filed accurately.This is the number 1 problem that claim administrator’s encounter when beginning EDI testing.
61 EDI Trading Partner Profile Documents All Changes to profile information shall be reported by sending revised Trading Partner Profile documents to DWC at at least two (2) business days prior to sending transactions containing revised profile-related information.
62 EDI Trading Partner Profile Documents Failure to report changes to profile information may result in the rejection of an entire transmission or rejectionof individual transaction(s).Changes in FEIN, address/postal codes or addition of an Insurer or new claims office requires Trading Partner documents to be updated.
63 EDI Trading Partner Profile Documents An MTC “02” that is sent to report a change in the Insurer or Claim Admin. FEIN, Claim Admin. Postal Code, or Claim Admin. Claim Number due to the creation or elimination of a claims office location or subsidiary entity within the insurer’s organization does not replace the need to file revised TP Profile docs.
64 EDI Trading Partner Profile Documents The MTC “02” would actually reject if it reported a different Claim Administrator FEIN/Postal Code that was not already in DWC’s profile database.Therefore, before MTC “02” is filed to report, e.g., the transfer of a file to a new claims office location, revised TP Profile documents must be filed with the DWC to report the new location.
65 EDI Trading Partner Profile Documents NOTE: All 9 digits of the Trading Partner’s Postal Code should be sent in the Sender ID. This postal code must match either the Physical or Mailing Sender Address Postal Code, and should be a valid Home or Claims Office location for the company.
66 Insurer/Claim Administrator ID List DFS-F5-DWC-EDI-2If the Sender/Trading Partner is an Insurer who is also reporting for a TPA in its group, it is very helpful to DWC if the Insurers listed on the EDI-2 form are grouped. The Insurers that are part of the corporate group should be listed together, then the Insurers for which the TPA will be the Claim Administrator should be listed under the TPA name.
67 EDI Trading Partner Profile Documents IMPORTANT: If a 9-digit Postal Code is listed for a claims office location on the EDI 2-A form, the DWC profile will be established with all 9 digits; therefore all 9 digits must be sent on the transaction in order to match.If only 5 digits are listed on the form, the last 4 digits must be sent on the filing as blanks (spaces). If zeros are sent in the last 4 digits, this will not match and will cause a rejection.
68 EDI Trading Partner Profile Documents If two different claims office locations are in the same zip code area, the 9-digit Postal Code must be sent for each location on both the EDI-2A and the transaction.Postal code mis-matches between what is listed on the form vs. what is sent in the transaction is one of the top reasons a transaction rejects.
69 EDI Trading Partner Profile Documents There must be a one to one match between a physical address and a mailing address for each claims office location. The EDI 2-A must reflect each of these unique combinations.
70 EDI Trading Partner Profile Documents For example: If you have 5 physical locations on Tab 1 of the EDI 2-A, then you must list 5 corresponding mailing locations on Tab 2 (even if they are the same address).All FEINs for which an address applies should be listed on each Tab.
72 For NEW TP’s still testing: It is highly recommended you test using the actual program you will use in production, and to test with actual claim data.Some Insurers that tested with “mock” data experienced unanticipated errors not discovered in test when they started sending real claim data.
73 For NEW TP’s still testing: DWC also recommends having claim reps who will actually handle the live production cases be involved in the testing process.This will ensure that claims staff are familiar with edits received, how to look up records in the data warehouse, and how to resolve the errors.
74 For NEW TP’s still testing: After you are approved for production status, a 30 day grace period will be applied for FROI filings that are accepted after their filing due date (See Rule 69L (d), F.A.C.)
75 69L (1)6.After the completion of the 30 day grace period, all electronic First Reports of Injury or Illness must be assigned an Application Acknowledgement Code of Transaction Accepted (TA) by the Division within the required filing timeframes established in subsections 69L (1) and (2), F.A.C., to be considered timely filed.
76 69L-24.006(1)6. This rule is often misunderstood. In order to be eligible for the 30 day grace period, the transaction errors MUST be resolved within those 30 days, and RECEIVE A TA.It does not apply to filings received but not successfully filed/accepted during those first 30 days .
77 If a rejection is not resolved and accepted within those first 30 days, penalties may apply in accordance with rule L , F.A.C.
78 It is strongly recommended that First Report/Initial Payments transactions are triggered immediately upon mailing the first indemnity check, or upon decision to deny. This will allow for the maximum time possible to resolve any errors.
79 Ensure your IT staff or Vendor is prepared to react to programming problems discovered with your production data, and can implement solutions quickly during those initial 30 days.
81 Reminder: Test files CAN be sent after a trading partner is approved for production; however, it will only load to DWC’s Test system. If a production file is accidentally sent with a “T” for Test, you will not receive credit for filing those claims until re-sent with a “P” for production.
88 FL’s Claims EDI Webpage If you haven’t already, you should become familiar with FL’s requirement tables (including updated supplement) to determine: When each transaction must be sent (Event Table) Data Elements required for each transaction / MTC (Element Requirement Table)
89 FL’s Claims EDI Webpage (Cont’d)…Review FL’s requirement tables (including updated supplement) to determine: Edits that will reject the record (Edit Matrix)The Population Restrictions Tab of the Edit Matrix will assist you in trouble shooting why you received a particular error.
90 FL Supplement Overview: Tracks all monthly additions or corrections to the requirement tables.Check the EDI website periodically for updates to this Supplement.
91 FL’s Claims EDI Webpage The webpage also contains helpful resource documents including:FL EDI Migration StrategiesMTC Filing InstructionsFL R3 Business ScenariosFL Quick Code Reference GuideMTC to Form CrosswalkCrosswalks of paper DWC Claims Forms to EDI Data Elements
92 Helpful ResourcesOther ResourcesDWC Form Crosswalks
98 Not all MTC filing. requirements set out in Rule. 69L-56, F. A. C Not all MTC filing requirements set out in Rule 69L-56, F.A.C., can be equated to a DWC Form. See rule 69L-56 F.A.C. and “FL Claims EDI Event Table” (also “MTC Filing Instructions”) for a complete accounting of MTC’s required by FL.
102 How Will EDI Errors Be Communicated to Claim Administrators?
103 The Division will acknowledge every EDI R3 transaction received with the standard EDI Acknowledgement format: ‘AKC’.AKC Report
104 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.
105 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.
106 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.
107 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.)
108 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.
109 FL processes transmissions 7 days a week, including holidays.
110 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 Claims EDI Data Warehouse to determine when the FROI and/or SROI batch was received (Click on the “Batch ID” for batch details.
113 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)
114 If DWC re-processes (re-loads) a transaction, the Claim Administrator will receive credit for the date the transaction was originally received by the Division.
115 FL provides EDI Claim Administrators the capability of viewing all FROI’s & SROI’s received, via the on-line Claims EDI Data Warehouse.
116 The 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
117 More detailed information regarding the on-line Claims EDI Data Warehouse is provided in the Claims EDI Data Warehouse Webinar/Training.Claims EDI Warehouse
118 A PowerPoint presentation on use of the Data Warehouse is also posted on the Claims EDI web page. **Updated version will be posted soon.
119 Florida has made many corrections and adjustments to its EDI program to accommodate filing situations we did not initially anticipate.
120 FL may enhance its EDI program weekly or bi-weekly as needed FL may enhance its EDI program weekly or bi-weekly as needed. But if a new filing requirement will result in a rejection, we typically allow a 3 month implementation period before enforcing the new edit.
121 After you have thoroughly investigated the error (using DWC resource documents) and you still do not understand the error...
122 ... please send an email to the Claims EDI Team at email@example.com The EDI Team will answer all questions via an so that both parties have a copy of the response for future reference.CLAIMS EDI
123 By ing your question, the EDI Team has the opportunity to research the specific details of the problem thoroughly. Phone calls do not allow for adequate time for this research. We appreciate your understanding.
124 Reminder: To avoid late filing penalties, the Electronic First Report of Injury or Illness (payment or denial) should be triggered immediately upon the Claim Admin.’s disposition of the claim.
125 This will allow time for correction of potential filing errors and resubmission and subsequent receipt/acceptance by the Division within the filing due dates specified in Rule 69L-56, F.A.C.
127 The following information is reported via Medical EDI and should not be included in OBT (Other Benefit Type Code) 370.Physician (includes physical therapy, functional capacity evaluations, and work hardening)HospitalDentalPharmacyDurable Medical Expenses
128 If you are currently reporting this information under OBT 370, it should be corrected using the following:SROI 02SA (amended)FN (amended)
129 ALL Questions, either Business or Technical, should be sent via email to firstname.lastname@example.org This address is copied to all members of the EDI team. It is the quickest and most efficient way for us to respond to your concerns.