FL Claims EDI Release 3 Training

1
Florida Division of Workers Compensation
Claims EDI Release 3 Training
2008
WELCOME
2
Your Trainer

• Linda Yon
• FL DWC EDI Coordinator

3
Additional DWC Staff

• Karen Kubie - DWC Claims EDI Lead Business
  Analyst
• Kim Wiley DWC EDI IT Project Manager
• Janice Youngblood DWC EDI IT
  Consultant/Programmer
• Margaret Forsman - DWC Claims EDI Business
  Analyst

4
Additional DWC Staff

• Tonya Granger - DWC Lead EDI POC Analyst
  Claims Analyst
• Debra Lee DWC EDI Claims Analyst
• Laura Cotner - DWC EDI Claims and POC Analyst

5
Rule Chapter 69L-56 of the
Florida Administrative Code is the EDI
Rule for Proof of Coverage and
Claims (non-medical)
6
EDI Rule 69L-56,F.A.C. was effective
January 7, 2007. It requires all insurers
to implement the IAIABC Claims EDI Release 3
electronic format.
7
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
Insurers EDI Implementation date. This includes
legacy claims.
8
So Heres A Little Background On EDI
9
On a National level, in 1990 the IAIABC
spearheaded a program to utilize the concept of
EDI for Workers Compensation data.
10
What is the IAIABC?

• The International Association of Industrial
  Accident Boards and Commissions.
• A 93-year-old organization of jurisdictional
  workers compensation administrators and others
  interested in WC.

11
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 by
• Injured Workers!

EDI
12
Developing an Electronic Standard
Bringing Together the Important Participants
Jurisdictions
Carriers
Vendors
TPAs
13
Developing a National Standard through the IAIABC
EDI Development Committees was a consensus
development process that required give and
take from all participants.
14
The end result is a national standard format for
the reporting of workers compensation data
electronically.
15
IAIABC EDI Project Background

• 1990 IAIABC membership adopted IAIABC
  Committees proposal to develop standards for
  communicating data electronically between
  providers, payers, and state administrators via
  EDI.
• 1993 Claims Release 1
• 2000 Claims Release 2 (Iowa)
• 2005 Claims Release 3

16
Where can you find the IAIABC R3 Implementation
Guide Codes?
17
The Release 3 Claims Implementation Guide can be
purchased for 95 from the IAIABCs website
www.iaiabc.org, or it is free if your company is
an IAIABC EDI Member. The latest R3
Guide is dated
January 1, 2008
18
The Release 3 Claims Implementation Guide
contains the transaction record layouts, data
dictionary, business and technical rules,
national scenarios, etc.
19
www.iaiabc.org
20
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http//www.iaiabc.org/EDI/implementation.asp
22
STANDARD USAGE FOR ALL PRODUCTS

• Error Message Dictionary
• Glossary

• Country Codes
• State Codes
• Industry Codes (NAICS 2002 or 2007)
• Nature of Injury Codes
• Cause of Injury Codes
• Part of Body Codes
• Permanent Impairment Body Part Codes

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Glossary
25
Glossary
The purpose of the Glossary is to acquaint the
reader with easy-to-understand definitions of
workers' compensation terms that are not defined
in the R3 Dictionary as Data Elements.
26
Glossary
The 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.
27
Glossary
Alphabetical by term
28
However, terms that are specific to approved
Data Elements for Claims, POC and Med reporting
will be found in the Data Dictionary section of
the respective IAIABC Implementation Guide.
29
Acronyms (see your
handout)
30
ACRONYMS

• EDI 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 dont understand what
  the acronyms stand for. 

31
ACRONYMExamples
32
RELEASE 3
RELEASE 3
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Release 3 Combined Business Technical Data
Dictionary
35
The Release 3 Data Dictionary
Section 6 in the Implementation Guide
36
Release 3 Data Dictionary

• Identifies the Data Number (DN)

• Gives the Definition of the Data Element

• Gives the Last Revision Date of the Data
  Element

37
Release 3 Data Dictionary

• Gives the Format (i.e. 2 A/N two
  characters alpha/numeric)

• Lists the Valid Values for the DN

• Gives DP (Data Population) Rule to Help
  Identify the Correct Use of the Data Element

38
Release 3 Data Dictionary
39
FLs Claims EDI Webpage
http//www.myfloridacfo.com/wc/
40
FLs Claims EDI Webpage
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(No Transcript)
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FL Supplement Overview Tracks all monthly
additions or corrections to the requirement
tables.
44
FLs Claims EDI Webpage
If you havent already, begin reviewing FLs
requirement tables (including updated supplement)
immediately to determine
When each transaction
must be sent (Event Table)
Data Elements required for each
transaction / MTC (Element Requirement Table)

45
FLs Claims EDI Webpage
(Contd) Review FLs requirement tables
(including updated supplement) immediately to
determine
Edits that will reject the record
(Edit Matrix)
46
FLs Claims EDI Webpage

• The FL Claims EDI Webpage contains helpful
  resource documents including
• FL EDI Migration Strategies
• MTC Filing Instructions
• FL R3 Business Scenarios
• FL Quick Code Reference Guide
• Training Questions Answers
• MTC to Form Crosswalk
• Crosswalks of paper DWC Claims Forms to EDI Data
  Elements

47
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Questions?
49
In R3 EDI, all WC data is sent electronically
via a FROI or SROI transaction.
50
What Is A
?
FROI
51
First Report of Injury (FROI)
52
Release 3 FROI Transaction
Originally, the EDI First Report of Injury Record
was identified by a Transaction Set ID of '148'
and had a specific Record Layout. In Release 3,
the 148 record must be paired with a companion
record - R21, FROI Companion Record to complete
the First Report of Injury transaction.
53
Release 3 FROI Transaction
This means the Release 3 FROI transaction
requires 2 records to communicate the First
Report event, the 148 R21 records.
54
First Report of Injury FROI 148 R21
55
The FROI Flat File Section 2 in the Release 3
Implementation Guide
56
FROI Flat File Record Layout
57
FROI Flat File (148) Record Layout
Data Elements
Filler
58
FROI Companion Flat File (R21) Record Layout
Data Elements
Filler
59
FROI R21 Variable Segments
60
POP QUIZ
If the Accident Description Narrative segments
are 50 characters each, and this Accident
Description is 161 characters
61

• how many segments must be sent to report the
  entire Accident Description Narrative?
• 1 Segment
• 2 Segments
• 3 Segments
• 4 Segments

62
ANSWER d (4 segments)
63
What Is A
?
SROI
64
Subsequent Report of Injury (SROI)
65
Release 3 SROI Transaction
Originally, the EDI Subsequent Report of Injury
Record was identified by a Transaction Set ID of
A49' and had a specific Record Layout. In
Release 3, the A49 must be paired with a
companion record - R22, SROI Companion Record, to
complete the SROI transaction.
66
Release 3 SROI Transaction
This means the Release 3 SROI transaction
requires 2 records to communicate the
Subsequent Report event, the A49
R22 records.
67
Subsequent Report of Injury SROI A49R22
68
The SROI Flat File Section 2 in the
Implementation Guide
69
SROI Flat File Record Layout
70
Now Lets Discuss Important Codes Common To EDI
Transactions
71
Important Codes

• R3 Quick Code Reference Guide (see handout)
• Maintenance Type Codes
• Benefit Type Codes
• Other Benefit Type Codes

72
R3 Quick Code Reference
Included with your handouts
One Stop
73
What Is An
?
MTC
MTC
74
Maintenance
Type
Code
75
Maintenance Type Code
A code that defines the specific purpose of each
transaction being transmitted.
76
Maintenance Type Code
DWC Forms required to be filed with the Division
are replaced by EDI filings identified by MTC
codes.
77
Maintenance Type Code
Most MTC codes equate to a specific DWC Form that
will no longer be required to be filed with DWC.
However the DWC Form may still be required to be
sent to other parties (e.g., DWC-1, DWC-4).
78
First Report of Injury MTCs
79
FL FROI MTCs Include
00 Original
04 Total Denial
01 Cancel (Claim Filed in Error)
AQ Acquired Claim
AU Acquired First Report
80
FL FROI MTCs Changes
02 Change
81
Subsequent Report MTCs
82
FL SROI MTCs Initial Payment Equivalents
IP - Initial Payment
PY Payment
EP Employer Paid Salary in Lieu of Comp
AP - Acquired First Payment
83
FL SROI MTCs Initial Payment Equivalents
(contd)
CD Compensable Death-No Known
Dependents/Payees
VE - Volunteer
84
FL SROI Report MTCs Denials
04 Full Denial
PD Partial Denial (Indemnity Only other
required partial denials).
85
FL SROI MTCs
Additions/Changes
AB Add Concurrent Benefit
CA Change in Benefit Amount
CB Change in Benefit Type
86
FL SROI MTCs
Reinstatements
RB Reinstatement of Benefits
ER Employer Reinstatement
87
FL SROI MTCs
Full Suspensions (of all Indemnity)
S1 RTW or Released to RTW S2 - Medical
Non-Compliance S3 Administrative Non-Compliance
88
FL SROI MTCs
Full Suspensions (of all Indemnity)
S4 Claimant Death S5 - Incarceration S6
Claimants Whereabouts
Unknown
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FL SROI MTCs
Full Suspensions (of all Indemnity)
S7 Benefits Exhausted S8 Jurisdiction Change
You should recognize these from the DWC-4 Form
90
FL SROI MTCs
Partial Suspension (of a concurrent
benefit)
P7 Benefits Exhausted
FLs only concurrent benefit type is PT and PT
Supplemental Benefits. If one benefit is
suspended but the other benefit continues, a
Partial Suspension is filed.
91
FL SROI MTCs
Periodic Reports
SA Sub Annual
For EDI R3, the Annual Claim Cost Report has been
replaced with a Sub Annual report, due every
6 months from the Date of Injury until the claim
is closed.
92
FL SROI MTCs
Periodic Reports (contd)
FN Final
93
FL SROI MTCs
Changes
02 Changes
EDI
94
What are Benefit Type Codes (BTC) ?
95
IB - 030
TT - 050
TP - 070
BTCs are codes that identify the type of
indemnity benefits being paid.
96
Benefit Type Codes
010 Fatal/Death 020 Permanent Total 021
Permanent Total Supplemental
030 Perm Partial Scheduled (Impairment
Income) 040 Perm Partial Unscheduled
(Supplemental Income) 050 Temporary Total
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Benefit Type Codes
051 Temporary Total Catastrophic 070
Temporary Partial
090 Permanent Partial Disfigurement 410 Voc
Rehab Maintenance 500 Unspecified Lump Sum
Pmt/Settlement 5XX Specific Lump Sum
Pmt/Settlement per Benefit Type Code (e.g., 510,
550, etc.)
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Benefit Type Codes
210 Employer Paid Fatal (Death) 230 Employer
Paid Perm Partial (IBs) 240 - Employer Paid
Unspecified 242 Employer Paid Voc Rehab
Maintenance 250 Employer Paid Temporary
Total 251 Employer Paid Temporary Total
Catastrophic 270 Employer Paid Temporary
Partial
99
What are
Other Benefit Type Codes (OBTs)?
100
370
311
321
OBTs are codes that represent the type of
non-indemnity benefits being paid.
101
Other Benefit Type Codes (required by FL)
300 Total Funeral Expenses 310 Total
Penalties 311 Total Employee Penalties 320
Total Interest 321 Total Employee Interest

370 Total Other Medical
102
Other Benefit Type Codes (required by FL)
380 Total Voc Rehab Evaluation 390 Total Voc
Rehab Education 400 Total Other Voc Rehab
430 Total
Unallocated Prior Indemnity Benefits (acquired
claims) 475 Total Medical Travel Expenses
103
300
400
475
FL has reduced the amount of OBT Codes required
to be reported for R3, because the majority of
medical information is already being reported to
the Division via another electronic format.
104
Other Benefit Type Codes (not required by FL)
FL no longer requires the reporting of Physician
(Medical), Hospital, or Pharmacy/Durable Medical
Paid To Date on the EDI Claim Cost Periodic
report.
105
Questions?
106
What Is The Claims EDI Mandate All About ?
How Does It Affect FL WC
Insurers?
107
Rule 69L-56 Rule Section
Overview
69L-56.001 Forms and Instructions 69L-56.002 Defi
nitions
108
69L-56.100 Proof of Coverage (POC) Electronic
Reporting Requirements 69L-56.110 Technical
Requirements for POC EDI Transmissions 69L-56.20
0 Policy Cancellation or Non-renewal
Requirements 69L-56.210 Time Periods for Filing
Electronic Policy Information
109
69L-56.300 Claims EDI Reporting Requirements and
Implementation Schedules 69L-56.301 Electronic
First Report of Injury or Illness 69L-56.3012
Electronic Notice of Denial and Rescinded
Denial 69L-56.3013 Electronic Periodic Claim
Cost Reports
110
69L-56.304 Electronic Notice of Action or
Change, Including Change in Claims
Administration, Required by the Insurers
Primary Implementation Schedule 69L-56.3045
Electronic Notice of Action or Change,
Suspensions, and Reinstatement of Indemnity
Benefits Required by the Insurers Secondary
Implementation Schedule
111
69L-56.307 Electronic Cancellation of
Claim 69L-56.310 Technical Requirements for
Claims EDI Transmissions 69L-56.320 Claims EDI
Test to Production Status Requirements
112
69L-56.330 Electronic Formats for Reporting the
Employees 8th Day of Disability and the
Claim Administrators Knowledge of 8th Day of
Disability
(This section will eventually be repealed after
all current R1 trading partners implement
R3) 69L-56.500 Insurer Responsibilities Where
Third Party Services are Utilized
113
The following DWC paper forms currently being
filed with the Division will be replaced by
electronic transactions
DWC-1 First Report Of Injury or Illness DWC-12
Notice of Denial DWC-13 Claim Cost Report DWC-4
Notice of Action/Change DWC-49 Aggregate Claims
Administration Change Report
114
EDI filing requirements (i.e., when a claim
administrator must file these EDI transactions
with DWC) are in Rule 69L-56, F.A.C. Paper form
copies required to be sent to other parties will
still be required per Rule 69L-3, F.A.C.
115
How Will MTCs and Insurers Be Phased In for
Implementing EDI R3?
116
EDI Claims R3 Implementation
The Division has established by rule two
implementation schedules for phasing in all of
the MTCs required for R3 reporting

• The Primary Implementation Schedule includes
  MTCs for reporting the electronic equivalent
  of the DWC-1, 12, 13 49 some DWC-4 data.

• The Secondary Implementation Schedule includes
  MTCs that equate to most DWC-4s.

117
EDI Claims R3 Implementation
Again, implementation of EDI R3 applies to all
MTCs required by rule for all Dates of Injuries,
not just for dates of injuries occurring after
the Insurers R3 production implementation date.
Legacy claims are included in the mandate.
118
EDI Claims R3 Implementation
Paper forms previously filed do NOT need to be
re-submitted electronically.
119
EDI Claims R3 Implementation
The Division has divided insurers/self-insurers
into three test to production periods (tiers),
based on Insurer Code .

• Insurer Code s 102-199 and current
• R1 Trading Partners will implement first.

• Insurer Code s 200-599 will implement next.

• Insurer Code s 600-4999 and 8000-9999 will
  implement last.

120
EDI Claims R3 Implementation
If there are multiple subsidiary insurer entities
within an insurers corporate structure /
organization, the insurers compliance date for
the Primary Implementation Schedule will be based
on the lowest numeric value assigned to any of
the subsidiary insurer entities in the group.
121
For Example (Old Reliable Group) Old Reliable
Ins Co. 145 Old Reliable PC Co.
328 Old Reliable of Illinois 733
All insurers in the Old Reliable Group are
required to file electronically in the first
group of the Primary Implementation Schedule.
They must begin testing on 11-1-07.
122
EDI Claims R3 Implementation
Third Party Administrators (TPAs) are not
included in this list because they are not
Insurers. However, a TPA must be ready to
comply with the EDI filing requirements as soon
as their first Insurer client is required to
comply.
123
EDI Claims R3 Implementation
Third Party Administrators (TPAs) are not
required to implement all of their insurer
clients at the same time, but.
124
EDI Claims R3 Implementation
the 30 day initial late filing penalty waiver in
rule 69L-24.0231(d), is only applicable to the
claim administrator as a whole at the time it
first implements R3 EDI filings.
125
EDI Claims R3 Implementation
Therefore, if a claim administrator implements R3
EDI for different clients at different times, the
subsequent clients will not be granted a separate
30 day late filing penalty waiver.
126
Claims EDI Primary Implementation Schedule Phase
In
The first group (Insurer Code s 102-199) began
testing November 1, 2007, and are being phased
in to production beginning 1-31-08.
First Group Must Begin Testing 11
-1-2007
First Group Phased In Production 01-31-2008
127
Claims EDI Primary Implementation Schedule Phase
In
The second group (Insurer Code s 200-599) must
begin testing February 1, 2008, and be in
production no later than the last day of the 3rd
month after the testing period begins.
Second Group Must Begin Testing 2-1-2008
Second Group Must Be In Production 4-30-2008
128
Claims EDI Primary Implementation Schedule Phase
In
The third group (Insurer Code s 600-4999 and
8000-9999) must begin testing May 1, 2008, and be
in production no later than the last day of the
3rd month after the testing period begins.
Third Group Must Begin Testing 5-1-2008
Third Group Must Be In Production 7-31-2008
129
What Forms Will Be Required To Be
Electronically Submitted In The Claims EDI
Release 3 Primary Implementation Schedule?
130

• The Claims EDI R3 Primary Implementation Schedule
  will include the electronic form equivalents for
  
• First Report of Injury (DWC-1)
• Notice of Denial (DWC-12)
• Claim Cost Report (DWC-13)
• Aggregate Claims Administration Change
  Report (DWC-4 or DWC-49)
• Notice of Action/Change (certain fields)
  (DWC-4)

131
What MTCs Will Be Required in the Claims
EDI Release 3 Primary Implementation Schedule?
132
Claims EDI R3 Required MTCs

• The following Maintenance Type Codes (MTCs) are
  required to be implemented during the Primary
  Implementation Schedule for the
• First Report of Injury (FROI)
• MTCs 00, 01, 02, 04, AQ, AU
• (Definitions of MTCs are in the IAIABC R3
  Implementation Guide/Data Dictionary).

133
Claims EDI R3 Required MTCs

• The following Maintenance Type Codes (MTCs) are
  required to be implemented for the Primary
  Implementation Schedule for the
• Subsequent Report (SROI)
• MTCs IP, EP, AP, PY, PD, CD, VE, 02, 04,
  SA FN

134
FL requires both the FROI and SROI combination
filing to constitute the electronic form
equivalent of a DWC-1 reporting initial payment
or equivalent information.
135
Claims EDI R3 Required MTCs

• SROI Maintenance Type Codes (MTCs) required by
  FL to be filed with a FROI MTC (00 or AU) to
  report the initial payment or equivalent are
• IP, EP, PY, PD, CD, VE, AP

136
Some data elements from the DWC-4 will be
required to be sent during the Primary
Implementation Schedule, because of the design of
the record layout.
137
These required DWC-4 data elements are identified
in the EDI Rule 69L-56.304, F.A.C., and some
examples follow.
138
Example DWC-4 Changes Required in Primary
Implementation

• Claim Administrator Postal Code not due to
  change in claims administration
• Industry Code
• Manual Classification Code
• Employee SSN
• Employee First/Last Name, Last Name Suffix,
  Middle Name/Initial
• Date of Injury

139
Claims EDI R3 Secondary Implementation Schedule
Phase In
The insurer should begin testing the remainder of
DWC-4 related MTCs no later than 9 months after
the its compliance date associated with the
Primary Implementation Schedule, and be in
production status no later than 1 quarter after
the required testing start date.
140
Claims EDI R3 Secondary Implementation Schedule
Phase In
1st Groups (Insurer Code s 102-199)
Primary Implementation
Schedule compliance date
1-31-2008
First Group Must Begin Testing for the
Secondary Implementation Schedule
11-1-2008 First Group Must Be in Production
for the Secondary Implementation Schedule
1-31-2009
141
Claims EDI Secondary Implementation Schedule
Phase In
2nd Groups (Insurer Code 200-599)
Primary
Implementation Schedule compliance
date 4-30-2008
Second Group Must Begin Testing for the
Secondary Implementation Schedule 2-1-2009
Second Group Must Be in Production for the
Secondary Implementation Schedule 4-30-2009
142
Claims EDI Secondary Implementation Schedule
Phase In
3rd Groups (Insurer Code s 600-4999 and
8000-9999) Primary Implementation Schedule
compliance date 7-31-2008
Third Group Must Begin Testing for the
Secondary Implementation Schedule
5-1-2009 Third Group Must Be in Production
for the Secondary Implementation Schedule
7-31-2009
143
Claim Administrators can voluntarily send MTCs
required in the Secondary Implementation Schedule
(most DWC-4s) during the Primary Implementation
Schedule.
144
What MTCs Will Be Required in the Claims
EDI Release 3 Secondary Implementation
Schedule?
145
Claims EDI MTCs Required

• The following Maintenance Type Codes (MTCs) are
  required to be implemented for the Secondary
  Implementation Schedule for the
• Subsequent Report (SROI)
• 02, P7, S1-S8, CA, CB, AB, RB, ER

146
Crosswalk of MTCs to DWC Forms
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(No Transcript)
148
MTCs to DWC Forms
149
MTCs to DWC Forms
150
MTCs to DWC Forms
151
MTCs to DWC Forms
152
Not all MTC filing requirements set out in
Rule 69L-56, F.A.C., can be equated to a DWC
Form. See rule and FL Claims EDI Event Table
(also MTC Filing Instructions) for a complete
accounting of MTCs required by FL.
153
Questions?
154
How Will EDI Errors Be Communicated to Claim
Administrators?
155
The Division will acknowledge every EDI R3
transaction received with the standard EDI
Acknowledgement format AKC.
AKC Report
156
Transmissions received on or before 900 p.m.,
E.S.T., will be processed by DWC the same day the
transmission was sent. It will be acknowledged
the next calendar day (morning).
157
Transmissions received after 900 p.m. EST will
be processed by DWC the following calendar day.

It will be acknowledged
the day after the transmission is processed.
158
FL processes transmissions 7 days a week,
including holidays.
159
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.
160
FL does not use the TE
Transaction Accepted with Errors
Acknowledgement Code.
161
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)
162
The Claim Administrator will receive credit for
the date the transaction was originally received
by the Division.
163
FL provides EDI Claim Administrators the
capability of viewing all FROIs SROIs
received, via the on-line Claims EDI
Data Warehouse.
164
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
165
More detailed information regarding the on-line
Claims EDI Data Warehouse will be provided
later in the training.
Claims EDI Warehouse
166
Questions?
167
FL Trading Partner Tables
168
FL EDI Reporting requirements are defined in the
Trading Partner Tables

• Required
• Report(s)

• Data needed on the Report(s)

• Applied
• Editing

169
Trading Partner Tables
Instructions
(
170

• What is an Event?

171
Claim Business Events
Claim Event Flow in FL
with
9. Lump Sum Payment(s)
10. Periodic Reports
11. Changes (Non-Indemnity)
Benefits
4. Suspension of all Benefits
12. Cancel
8. Claim Closure
172

• 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 FLs requirements,
  including
• First Report of Injury events
• Subsequent Report events
• Periodic events

173
FL identifies all of the transactions
(MTCs) that are required for reporting specific
business events on its
Event Table.
174
Event Table
Interpreting the FL Event Table
Example Florida requires the submission of a
FROI MTC 00
for First Reports of Injury or Illness based on
the insurers mandate date
175
Event Table
Interpreting the FL Event Table
when disability is immediate continuous
lost time is greater than seven (7) days.
176
Event Table
Interpreting the FL Event Table
The filing must receive a TA within 21 calendar
days after the claim administrators knowledge of
the injury.
177
Event Table
Interpreting the FL Event Table
A DWC-1 or IA-1 (ACORD 4) form must also be sent
to the employee employer
178

• In addition to reporting typical business claim
  Events, FL requires the claim administrator to
  report the cost status of the claim via

Periodic (Claim Cost) Reports
179
POP QUIZ
180

• What is the Paper Equivalent of a
• Periodic Report for FL?

181
Answer DWC-13 Claim Cost Report
182
POP QUIZ
183

• What are the Periodic MTCs accepted by FL?

184
Answer
MTC SA FN
185
Event Table
FL Periodic Reports

• SA Sub-Annual Submitted every 6 months after
  the DOI, as defined on FLs Event Table.

• FN Final Submitted when Claim Administrator
  determines no further benefits will be paid.

186
Event Table

• In addition to the Event Table, FL describes its
  business events in the MTC Filing Instructions.
  This document assists claim administrators
  understand what MTCs to use in reporting
  required business events to FL.

MTC
Filing
Instructions
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(No Transcript)
188
FL MTC Filing Instructions
189
Questions?
190
FL BUSINESS SCENARIOS
191
(No Transcript)
192
FL SCENARIO ASSUMPTIONS
193
FL SCENARIO ASSUMPTIONS
General scenario assumptions are included in
the scenarios to assist in understanding the
sample data that is presented.
194
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).

195
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.

196
FL SCENARIO ASSUMPTIONS

• Scenarios are presented in uppercase text.
  However, data may be sent to FL in mixed case
  format.

• Payment of indemnity benefits is based
  upon a 5 day work week

• The Industry Code must be a 2002 or
  2007 NAICS code.

197
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.

198
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).

199
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.

200
FL SCENARIO PROFILES
201
FL Scenario Profiles

• Unless otherwise noted in the scenario narrative,
  the basic scenario profile information for all
  scenarios will be as
  follows.

202
FL Scenario Profiles

• Injured Employee
• Description Data
• Name John James Smith, Jr.
• SSN 324-55-6745
• DOI June 15, 2007
• DOB May 1, 1953
• Empmnt Status Full Time

203
FL Scenario Profiles

• Injured Employee
• Description Data
• Class Code 2802 (Carpenter)
• Days Worked/Week 5
• Wage 15.00
• Wage Period Hourly (FROI)

204
FL Scenario Profiles

• Employer/Insured
• Description Data
• Employer Acme Construction Inc.
• FEIN 74-6994235
• Physical Location 32 Meadowbrook Lane
• Anytown, FL 32399
• Industry (NAICS) 236116

205
FL Scenario Profiles

• Insurer/Claim Administrator
• Description Data
• Insurer Old Reliable Ins. Co.
• FEIN 78-5902378
• Average Wage 600.00
• Wage Period Weekly (SROI)
  

206
FL SCENARIOS

• A 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).

207
Questions?
208
FL SCENARIOS FOR MTCs REQUIRED IN THE PRIMARY
IMPLEMENTATION SCHEDULE
209
Complete FROI/SROI Combo SCENARIOMTC 00 with
IP
Disability Immediate Continuous Rule
69L-56.301(1)(a)1., F.A.C.
210
NEW CLAIM Lost Time Case Where Disability is
Immediate and Continuous

• If the Initial Payment of Indemnity Benefits will
  be made by the Claim Administrator, and
• Indemnity Benefits other than TP or IB or
  settlement will be paid, an
• Electronic First Report of Injury or Illness is
  due.

211
NEW CLAIM Lost Time Case Where Disability is
Immediate and Continuous
Send FROI 00 with SROI IP Due 21 Days after
Claim Administrators Knowledge of the
Injury Note Also provide FORM DWC-1 or IA-1 to
the employee employer.
212
To avoid late filing penalties for an Electronic
First Report of Injury or Illness, the EDI DWC-1
should be triggered immediately upon the CAs
disposition of the claim (payment or denial), to
allow time for correction of potential errors and
resubmission, and for subsequent
receipt/acceptance by the Division within the
filing due dates specified in Rule 69L-56, F.A.C.
213
FROI 00 Scenario Narrative

• Employee fell from ladder at employers warehouse
  on
  6/15/07.
• Employee broke his leg.
• Foreman witnessed the accident.
• Employee treated and released from the Emergency
  Room.

214
FROI 00 Scenario Narrative

• Employee earned 15.00 an hour working 40 hours a
  week.
• Employer reported injury to insurer on 6/17/07.

215
FROI MTC 00 SCENARIO
Claim Administrator reported the loss to DWC on
6/29/07.
216
FROI MTC 00 SCENARIO
Insurer is identified. Claim Administrator
details are provided (remainder are on R21).
217
FROI MTC 00 SCENARIO
Employer/Insured information is reported.
The Employers name is on the R21
The rest of the Employers address is on the R21
NAICS Code
218
FROI MTC 00 SCENARIO
If applicable, Policy Number should be reported,
but Effective Date Expiration Date are not
required.
219
FROI MTC 00 SCENARIO
Details of the accident are included.
Employee broke leg falling from a ladder.
220
FROI MTC 00 SCENARIO
Employer reported injury to claim administrator
on 6/17/07.
221
FROI MTC 00 SCENARIO
Details about injured employee are sent.
The rest of the Employees name and address is
on the R21
222
FROI MTC 00 SCENARIO
Date the initial disability began other FROI
fields must be reported on the SROI.
Manual Risk Class Code is only on the FROI.
223
FROI MTC 00 SCENARIO
Employee earned 15.00 an hour and worked 5 days
a week.
Employee has not returned to work.
224
FROI MTC 00 SCENARIO
FROI Companion Record - R21
225
FROI MTC 00 SCENARIO
Claim Administrator Claim Number is repeated in
the R21. It links the R21 companion to the
related 148.
226
FROI MTC 00 SCENARIO
Claim Administrator FEIN is sent.
Claim Administrator Name is sent,
and rest of the Claim Admin Address.
456 Main St
227
FROI MTC 00 SCENARIO
ID qualifier S.
Positions 232 to 246 contain a Social Security
Number.
228
FROI MTC 00 SCENARIO
Remainder of Employee name, address fields and
phone are here in the R21 record.
229
FROI MTC 00 SCENARIO
Type of Loss Code is reported on the SROI.
Employee has not returned to work.
230
FROI MTC 00 SCENARIO
Insured FEIN and Insured Name are reported.
231
FROI MTC 00 SCENARIO
Insurer Name and Insurer Type Code are reported.
232
FROI MTC 00 SCENARIO
Details of accident site
233
FROI MTC 00 SCENARIO
Employer Name, Physical address and contact
information.
234
FROI MTC 00 SCENARIO
Employer Mailing Address information is not
required.
235
FROI MTC 00 SCENARIO
Claim Type Code and EP Salary Indicator are to
be reported on the SROI.
236
FROI MTC 00 SCENARIO
Variable Segment Counters include Two
Accident/Injury Narratives, and One Witness
segment.
237
FROI MTC 00 SCENARIO
Accident description exceeds 50 characters two
segments are needed to send entire narrative
description.
238
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.

239
FROI MTC 00 SCENARIO
Foreman Jones was the only witness.
240
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.

241
Questions on the FROI?
242
Corresponding SROI MTC IP
243
MTC IP (Initial Payment)
The claim administrator has issued its first
payment of indemnity benefits (not a lump sum
payment/settlement.)
The Initial Payment transaction implies that
indemnity benefits are ongoing until suspended.
244
SROI IP Scenario Narrative

• On 6/29/07, the Claim Administrator issued the
  first indemnity check.
• Check covered TTD benefits from 6/23/07 through
  6/29/07 (Day 8-14).

245
SROI MTC IP SCENARIO
Initial Payment transaction is sent to the
Division on 6/29/07.
246
SROI MTC IP SCENARIO
Initial Date Disability Began is the day after
DOI because Employer paid for DOI.
Employee was a 5 day per week worker.
247
SROI MTC IP SCENARIO
Claim Admin Claim Number must be sent on every
record.
248
SROI MTC IP SCENARIO
No Jurisdiction Claim number required because IP
SROI is filed with 00 FROI.
249
SROI MTC IP SCENARIO
Claim Type indicates Lost Time case.
250
SROI MTC IP SCENARIO
No variable segments A49 ends at position 208.
251
SROI MTC IP SCENARIO
Claim Administrator Claim Number is repeated in
R22. It links the R22 companion to the related
A49.
252
SROI MTC IP SCENARIO
Claim Administrator information
253
SROI MTC IP SCENARIO
R22 includes additional employee information.
254
SROI MTC IP SCENARIO
These fields are either not required, or they
are reported on the FROI.
255
SROI MTC IP SCENARIO
These fields are not applicable to this claim,
except the Initial Date Last Day Worked.
256
SROI MTC IP SCENARIO
Current Date Disability Began should NOT be
defaulted to the same as the Initial Date Dis
Began. This is only populated if you have a 2nd
period of disability.
257
SROI MTC IP SCENARIO
Weekly Compensation Rate is 400 based on Average
Wage of 600 effective the Date of Injury.
258
SROI MTC IP SCENARIO
Type of Loss Code and Employment Status Code are
reported on the SROI.
259
SROI MTC IP SCENARIO
Additional wage information
260
SROI MTC IP SCENARIO
One Benefits segment and one Payment segment are
required on this claim.
261
SROI MTC IP SCENARIO
Temporary Total was the only benefit paid. MTC is
also in Ben segment for IP.
262
SROI MTC IP SCENARIO
Gross Net Weekly Amount 400/week (comp
rate), effective on the DOI.
263
SROI MTC IP SCENARIO
Initial payment reflected benefits were paid from
June 23 through June 29, 2007 (Day
8-14) for 1 week in the amount of 400.
264
SROI MTC IP SCENARIO
Ben Payment Issue Date is the date payment left
the CAs control, e.g., mailed (6-28-07), not
necessarily the system check issue date.
265
SROI MTC IP SCENARIO

• FL requires the reporting of the exact amount
  of the Claim Administrators initial payment of
  indemnity benefits on MTC IP therefore, the
  Payment segment must also be sent on the SROI,
  in accordance with the Element Requirement table.

266
SROI MTC IP SCENARIO
MTC IP requires a Payments segment. Payment
Reason Code Benefit Type Code.
267
SROI MTC IP SCENARIO
Payment information related to the Initial
Payment is captured in the Payments segment.
268
SROI MTC IP SCENARIO
Payment Issue Date Benefit Payment Issue Date
in Benefits Segment.
269
Questions?