1 florida division of workers compensation claims edi release 3 history and overview 2008 (review...

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Florida Division of Workers’ Florida Division of Workers’ CompensationCompensation

Claims EDI Claims EDI Release 3Release 3

History and History and Overview Overview

20082008(Review prior to attending (Review prior to attending EDI training or reviewing EDI training or reviewing

Business Business Training Training PowerPoint slides)PowerPoint slides)

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Rule Chapter 69L-Rule Chapter 69L-5656 of the of the

Florida Florida Administrative CodeAdministrative Code is the EDI Rule for is the EDI Rule for

Proof of Proof of Coverage and Coverage and

Claims (non-medical)Claims (non-medical)

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The EDI RuleThe EDI Rule

69L-56, F.A.C.69L-56, F.A.C.

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EDI Rule 69L-EDI Rule 69L-56,F.A.C. was 56,F.A.C. was

effective effective January 7, 2007.January 7, 2007.

It requires all It requires all insurers to insurers to

implement the implement the IAIABCIAIABC Claims EDI Claims EDI

Release 3 electronic Release 3 electronic format.format.

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EDI Rule 69L-56, EDI Rule 69L-56, F.A.C.F.A.C.This EDI Implementation This EDI Implementation

applies to applies to allall required required form filings for form filings for allall Dates Dates of Injuries, and not just of Injuries, and not just those injuries that occur those injuries that occur after the Insurer’s EDI after the Insurer’s EDI Implementation date. Implementation date. This includes legacy This includes legacy claims.claims.

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69L-56.00169L-56.001 Forms and Forms and InstructionsInstructions

69L-56.00269L-56.002 DefinitionsDefinitions

Rule 69L-56 Rule 69L-56 Rule Section Rule Section

OverviewOverview(Claim Administrators must be (Claim Administrators must be

familiar with the requirements of familiar with the requirements of this rule.)this rule.)

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69L-56.10069L-56.100 Proof of Proof of Coverage Coverage (POC) (POC) Electronic Reporting Electronic Reporting RequirementsRequirements69L-56.11069L-56.110 Technical Technical Requirements for POC EDI Requirements for POC EDI

TransmissionsTransmissions69L-56.20069L-56.200 Policy Policy Cancellation or Cancellation or Non-Non-renewal Requirementsrenewal Requirements69L-56.21069L-56.210 Time Periods Time Periods for Filing for Filing Electronic Electronic Policy InformationPolicy Information

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69L-56.30069L-56.300 Claims EDI Claims EDI Reporting Reporting Requirements Requirements and and Implementation Implementation SchedulesSchedules69L-56.30169L-56.301 Electronic First Electronic First Report Report of Injury or Illnessof Injury or Illness69L-56.3012 69L-56.3012 Electronic Electronic Notice of Notice of Denial and Denial and Rescinded DenialRescinded Denial69L-56.3013 69L-56.3013 Electronic Electronic Periodic Periodic Claim Cost Claim Cost ReportsReports

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69L-56.304 69L-56.304 Electronic Notice of Electronic Notice of Action or Action or Change, Including Change, Including Change in Claims Change in Claims Administration, Administration, Required by the Required by the Insurer’s Insurer’s PrimaryPrimary Implementation Implementation ScheduleSchedule

69L-56.3045 69L-56.3045 Electronic Notice of Electronic Notice of Action Action or Change, Suspensions, or Change, Suspensions, and and Reinstatement of Reinstatement of Indemnity Benefits Indemnity Benefits Required Required by the Insurer’s by the Insurer’s SecondarySecondary Implementation ScheduleImplementation Schedule

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69L-56.30769L-56.307 Electronic Electronic Cancellation Cancellation of Claimof Claim

69L-56.31069L-56.310 Technical Technical Requirements for Claims Requirements for Claims EDI EDI TransmissionsTransmissions

69L-56.32069L-56.320 Claims EDI Claims EDI Test to Test to Production Production Status Status RequirementsRequirements

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69L-56.33069L-56.330 Electronic Electronic Formats for Formats for Reporting the Reporting the Employee’s 8th Employee’s 8th Day of Day of Disability and the ClaimDisability and the Claim

Administrator’s Administrator’s Knowledge of Knowledge of 8th Day of 8th Day of Disability Disability (This section will eventually (This section will eventually be repealed after be repealed after all current R1 trading all current R1 trading partners implement R3)partners implement R3)

69L-56.50069L-56.500 Insurer Insurer Responsibilities Responsibilities Where Where Third Party Services Third Party Services are are UtilizedUtilized

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The following DWC paper forms The following DWC paper forms currently being currently being filed with the filed with the DivisionDivision will be replaced by will be replaced by electronic transactions:electronic transactions:DWC-1 First Report Of Injury or IllnessDWC-1 First Report Of Injury or Illness

DWC-12 Notice of DenialDWC-12 Notice of Denial

DWC-13 Claim Cost ReportDWC-13 Claim Cost Report

DWC-4 Notice of Action/ChangeDWC-4 Notice of Action/Change

DWC-49 Aggregate Claims DWC-49 Aggregate Claims Administration Change ReportAdministration Change Report

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EDI filing requirements EDI filing requirements (i.e., when a claim (i.e., when a claim administrator must file administrator must file these EDI transactions these EDI transactions with DWC) are in with DWC) are in Rule Rule 69L-56, F.A.C.69L-56, F.A.C.

Paper form copies Paper form copies required to be sent to required to be sent to other parties will still be other parties will still be required per required per Rule 69L-3, Rule 69L-3, F.A.C.F.A.C.

So Here’s A So Here’s A Little Little

Background Background On EDI …On EDI …

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On a National level, in 1990 the On a National level, in 1990 the IAIABC spearheaded a programIAIABC spearheaded a program

to utilize the concept of EDI for to utilize the concept of EDI for

Workers’ Compensation data.Workers’ Compensation data.

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What is the What is the IAIABC?IAIABC? The International Association The International Association

of Industrial Accident Boards of Industrial Accident Boards and Commissions.and Commissions.

A 93-year-old organization of A 93-year-old organization of jurisdictional workers’ jurisdictional workers’ compensation administrators compensation administrators and others interested in WC.and others interested in WC.

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What is EDI?What is EDI?Electronic Data InterchangeElectronic Data Interchange is the is the

electronic exchange of data electronic exchange of data between between businessbusiness trading partners trading partners (i.e., claim administrators to state (i.e., claim administrators to state agencies), in a standardized agencies), in a standardized format. format.

This does not include This does not include reporting by reporting by

Injured Workers!Injured Workers!

EDIEDI

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Developing an Electronic Developing an Electronic StandardStandard

Requires Bringing Together Requires Bringing Together the Important Participantsthe Important Participants

Jurisdictions

TPA’s Vendors

Carriers

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Developing a National Developing a National Standard through the Standard through the IAIABC EDI Development IAIABC EDI Development Committees was a Committees was a “consensus development” “consensus development” process that required process that required “give” and “take” from all “give” and “take” from all participants.participants.

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The end result is a national The end result is a national standard format for the standard format for the reporting of workers’ reporting of workers’ compensation data compensation data

electronically.electronically.

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IAIABC EDI Project IAIABC EDI Project BackgroundBackground19901990: : IAIABC membership IAIABC membership adopted IAIABC Committee’s adopted IAIABC Committee’s proposal to develop standards proposal to develop standards for communicating data for communicating data electronically between electronically between providers, payers, and state providers, payers, and state administrators via EDI.administrators via EDI.

19931993:: Claims Release 1 Claims Release 1 20002000:: Claims Release 2 (Iowa)Claims Release 2 (Iowa)2005:2005: Claims Release 3Claims Release 3

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FL DWC chose to FL DWC chose to implement the national implement the national standard for Proof of standard for Proof of Coverage and Claims Coverage and Claims reporting to provide claim reporting to provide claim administrators with a administrators with a consistent standard for consistent standard for electronic reporting across electronic reporting across multiple states.multiple states.

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The national standard The national standard format contains different format contains different terminology, edits and terminology, edits and various rules, such as various rules, such as sequencing rules, that sequencing rules, that must be followed and may must be followed and may be different from what you be different from what you are accustomed to in the are accustomed to in the paper reporting paper reporting environment.environment.

Where can you Where can you find the IAIABC find the IAIABC

R3 R3 ImplementatioImplementatio

n Guide & n Guide & Codes?Codes?

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The IAIABC The IAIABC Release 3Release 3 Claims EDI Claims EDI Implementation Guide Implementation Guide contains essential contains essential information for information for implementing EDI, implementing EDI, including the transaction including the transaction record layouts, data record layouts, data dictionary, business and dictionary, business and technical rules, national technical rules, national scenarios, etc.scenarios, etc.

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www.iaiabc.org

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http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3339

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The The Release 3Release 3 Claims Claims Implementation Guide can Implementation Guide can be purchased for $95 be purchased for $95 from the IAIABC’s from the IAIABC’s website: website: www.iaiabc.org, or it is free if your company is an IAIABC EDI Member. The The latest R3 latest R3 Guide is dated Guide is dated January 1, 2008. January 1, 2008.

www.iaiabc.org

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There There are are other other code code lists lists you you will will need. need. Click Click herehere

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STANDARD USAGE FOR STANDARD USAGE FOR ALL PRODUCTSALL PRODUCTS

(found on IAIABC EDI (found on IAIABC EDI webpage)webpage)

Country CodesCountry CodesState CodesState CodesIndustry Codes (NAICS 2002 or 2007)Industry Codes (NAICS 2002 or 2007)Nature of Injury CodesNature of Injury CodesCause of Injury CodesCause of Injury CodesPart of Body CodesPart of Body CodesPermanent Impairment Body Part Permanent Impairment Body Part

CodesCodes

Error Message DictionaryError Message DictionaryGlossaryGlossary

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Always sent as ’99’ Always sent as ’99’ for FLfor FL

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GlossaryGlossary

Glossary

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GlossaryGlossaryThe purpose of theThe purpose of the Glossary Glossary is to acquaint the is to acquaint the reader with easy-to-reader with easy-to-understand definitions of understand definitions of workers' compensation workers' compensation terms that are terms that are notnot defined defined in the R3 Dictionary as Data in the R3 Dictionary as Data Elements. Elements.

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GlossaryGlossary The Glossary defines terms The Glossary defines terms that are common to that are common to FROI/SROI, MED, and POC FROI/SROI, MED, and POC EDI reporting. EDI reporting.

Not all of the terms are Not all of the terms are directly related to one of directly related to one of the IAIABC EDI reporting the IAIABC EDI reporting products, but they are products, but they are commonly used in the commonly used in the business and data business and data reporting environment.reporting environment.

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Glossary ExampleGlossary Example

Alphabetical by term

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However, terms that However, terms that are specific to are specific to ‘approved’ Data ‘approved’ Data Elements for Claims, Elements for Claims, POC and Med POC and Med reporting will be reporting will be found in the Data found in the Data Dictionary section of Dictionary section of the respective IAIABC the respective IAIABC Implementation Implementation Guide.Guide.

FL Claims EDI FL Claims EDI WebpageWebpage

ClaimClaims EDIs EDI

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http://www.myfloridacfo.com/wc/

FL’s Claims EDI WebpageFL’s Claims EDI Webpage

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The Claims EDI Webpage is your The Claims EDI Webpage is your complete resource for all of DWC’s complete resource for all of DWC’s “Claims EDI” requirements“Claims EDI” requirements

Scroll Scroll Down Down for for much much more more infoinfo

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These are These are the the RequiremRequirement ent TablesTables

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If you haven’t already, you If you haven’t already, you should become familiar with should become familiar with FL’s requirement tables FL’s requirement tables (including updated supplement) (including updated supplement) to determine:to determine: When each When each transaction must transaction must be sent be sent (Event Table)(Event Table) Data Elements Data Elements required for required for each each transaction / MTC transaction / MTC (Element (Element Requirement Table)Requirement Table)


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(Cont’d)…(Cont’d)…

Review FL’s requirement Review FL’s requirement tables (including updated tables (including updated supplement) to determine: supplement) to determine: Edits that will reject the Edits that will reject the record record (Edit Matrix)(Edit Matrix)

The Population Restrictions Tab of The Population Restrictions Tab of the Edit Matrix will assist you in the Edit Matrix will assist you in trouble shooting why you received trouble shooting why you received a certain error.a certain error.


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FL Supplement Overview:FL Supplement Overview:

Tracks all monthly additions or Tracks all monthly additions or corrections to the requirement corrections to the requirement tables.tables.

Check periodically for Check periodically for updates to this updates to this Supplement.Supplement.

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The webpage also contains The webpage also contains helpful resource documents helpful resource documents including:including:FL EDI Migration Strategies FL EDI Migration Strategies MTC Filing InstructionsMTC Filing InstructionsFL R3 Business ScenariosFL R3 Business ScenariosFL Quick Code Reference GuideFL Quick Code Reference GuideTraining Questions & AnswersTraining Questions & AnswersMTC to Form CrosswalkMTC to Form CrosswalkCrosswalks of paper DWC Claims Crosswalks of paper DWC Claims Forms to Forms to EDI Data Elements EDI Data Elements


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Helpful ResourcesHelpful Resources

TraininTrainingg

Other Other ResourceResourcess

CrosswalCrosswalksks

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Crosswalk of Crosswalk of MTC’s MTC’s

to DWC Formsto DWC Forms

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See MTC to See MTC to Form Form Crosswalk Crosswalk which helps which helps identify what identify what MTC’s equate MTC’s equate to which DWC to which DWC forms.forms.

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MTC’s to DWC MTC’s to DWC FormsForms

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Not all MTC filing Not all MTC filing requirements set out in requirements set out in Rule Rule 69L-56, F.A.C., can 69L-56, F.A.C., can be be equated to a DWC equated to a DWC Form.Form.

See rule 69L-56 F.A.C. See rule 69L-56 F.A.C. and and “FL Claims EDI “FL Claims EDI Event Table”Event Table” (also (also “MTC Filing “MTC Filing Instructions”) for a Instructions”) for a complete accounting of complete accounting of MTC’s required by FL.MTC’s required by FL.

Acronyms Acronyms (see FL (see FL

Claims EDI Claims EDI webpage for webpage for

list)list)

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http://www.myfloridacfo.com/wc/edi_clms.html

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ACRONYMACRONYMExamples:Examples:

FTPFTP File Transfer Protocol File Transfer Protocol

FEIN FEIN Federal Employer Identification Federal Employer Identification Number Number

FROIFROI First Report of Injury First Report of Injury

GUI GUI Graphical User InterfaceGraphical User Interface

HTTHTTPP

Hyper Text Transfer Protocol Hyper Text Transfer Protocol

SROI SROI Subsequent Report of Injury Subsequent Report of Injury

URL URL Uniform Resource Locator Uniform Resource Locator

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Important and essential Important and essential information is contained in the R3 information is contained in the R3 Implementation Guide.Implementation Guide.

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It is recommended that It is recommended that someone within every someone within every company has access to the company has access to the Claims EDI R3 Claims EDI R3 Implementation Guide. Implementation Guide.

The requirements of this The requirements of this guide are incorporated by guide are incorporated by reference in the FL EDI reference in the FL EDI Rule 69L-56 F.A.C. Rule 69L-56 F.A.C.

Release 3 Release 3 Combined Combined Business & Business &

Technical Data Technical Data DictionaryDictionary

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The Release 3 Data The Release 3 Data DictionaryDictionary

Section 6 in Section 6 in the the

ImplementatImplementation Guideion Guide

Defines Defines all the all the data data elemenelements used ts used for EDI.for EDI.

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The IAIABC The IAIABC Release 3Release 3 Claims EDI Claims EDI Implementation Guide Implementation Guide contains the data contains the data dictionary, which defines dictionary, which defines each element that is each element that is required. required. It is It is recommended that this recommended that this section be saved to your section be saved to your desktop for ready desktop for ready reference. reference.

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This data This data dictionary should dictionary should be used in be used in conjunction with conjunction with the definitions the definitions found in 69L-56, found in 69L-56, F.A.C.F.A.C.

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Release 3 Data DictionaryRelease 3 Data Dictionary

Identifies the Identifies the Data Data NumberNumber (DN)(DN)

Gives the Gives the DefinitionDefinition of of the Data the Data ElementElement

Gives the Gives the Last Revision Last Revision DateDate of the Data of the Data ElementElement

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Release 3 Data DictionaryRelease 3 Data Dictionary

Gives the Gives the FormatFormat (i.e. 2 A/N = (i.e. 2 A/N = two characters alpha/numeric) two characters alpha/numeric)

Lists the Lists the Valid ValuesValid Values for for the DNthe DN Gives Gives DP DP (Data Population)(Data Population) RuleRule to to Help Identify Help Identify the Correct Use the Correct Use of the of the Data ElementData Element

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Release 3 Data Release 3 Data Dictionary (sample Dictionary (sample

entry)entry)

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EDIEDI TerminologyTerminology

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In R3 EDI, all WC In R3 EDI, all WC data is sent data is sent

electronically electronically

via a via a

FROI or SROI FROI or SROI transaction.transaction.

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What Is AWhat Is A

??

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First First Report ofReport of

Injury Injury (FROI)(FROI)

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Originally, the EDI First Report Originally, the EDI First Report of Injury Record was identified of Injury Record was identified by a Transaction Set ID of 'by a Transaction Set ID of '148148' ' and had a specific Record and had a specific Record Layout. Layout.

In Release 3, the 148 record In Release 3, the 148 record must be paired with a must be paired with a companion record - companion record - R21R21, FROI , FROI Companion Record to complete Companion Record to complete the First Report of Injury the First Report of Injury transaction.transaction.

Release 3 FROI Release 3 FROI TransactionTransaction

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This means the Release This means the Release 3 FROI transaction 3 FROI transaction

requires requires 2 records2 records to to communicate the First communicate the First Report Report event, the event, the

“148” & “R21”“148” & “R21” records.records.

Release 3 FROI Release 3 FROI TransactionTransaction

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First Report First Report

of Injuryof Injury

FROI =148 + FROI =148 + R21R21

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The FROI The FROI Flat FileFlat FileSection 2 in the Section 2 in the

Release 3 Release 3 Implementation GuideImplementation Guide

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FROI Flat File Record FROI Flat File Record Layout is found in Layout is found in Section 2 of the Section 2 of the

Implementation GuideImplementation Guide

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FROI Flat File (148) Record LayoutFROI Flat File (148) Record Layout

Data ElementsData Elements

FillerFiller

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FROI Companion Flat File (R21) Record LayoutFROI Companion Flat File (R21) Record Layout

Data ElementsData Elements

FillerFiller

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FROI R21 Variable SegmentsFROI R21 Variable Segments

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What Is AWhat Is A

??

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Subsequent Subsequent Report of Report of

InjuryInjury

(SROI)(SROI)

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Originally, the EDI Subsequent Originally, the EDI Subsequent Report of Injury Record was Report of Injury Record was identified by a Transaction Set identified by a Transaction Set ID of ‘ID of ‘A49A49' and had a specific ' and had a specific Record Layout. Record Layout.

In Release 3, the A49 must be In Release 3, the A49 must be pairedpairedwith a companion record - with a companion record - R22R22, , SROI Companion Record, to SROI Companion Record, to complete the SROI transaction.complete the SROI transaction.

Release 3 SROI Release 3 SROI TransactionTransaction

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This means the Release This means the Release 3 SROI transaction 3 SROI transaction

requires requires 2 records2 records to to communicate the communicate the

Subsequent Report Subsequent Report event, the event, the

“A49” & “A49” & “R22” “R22” records.records.

Release 3 SROI Release 3 SROI TransactionTransaction

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Subsequent Subsequent Report Report

of Injury of Injury

SROI = SROI = A49+R22A49+R22

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The SROI The SROI Flat FileFlat FileSection 2 in the Section 2 in the

Implementation GuideImplementation Guide

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SROI Flat File Record Layout SROI Flat File Record Layout is found in Section 2 of the is found in Section 2 of the Implementation GuideImplementation Guide

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Now Let’s Review Now Let’s Review Important Codes Important Codes Common To EDI Common To EDI

TransactionsTransactions

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Important CodesImportant Codes R3 Quick Code Reference R3 Quick Code Reference

Guide (see FL Claims EDI Guide (see FL Claims EDI webpage)webpage)

Maintenance Type CodesMaintenance Type Codes

Benefit Type CodesBenefit Type Codes

Other Benefit Type CodesOther Benefit Type Codes

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R3 Quick Code R3 Quick Code ReferenceReference

One Stop

Shopping for most codes

Found on Found on FL Claims FL Claims EDI EDI webpagewebpage

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What Is AnWhat Is An

??MTCMTC

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A code that defines A code that defines the specific purpose the specific purpose of each transaction of each transaction being transmitted.being transmitted.

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DWC Forms required DWC Forms required to be filed with the to be filed with the Division are Division are replaced by EDI replaced by EDI filings identified by filings identified by MTC codes.MTC codes.

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Most MTC codes equate Most MTC codes equate to a specific DWC Form to a specific DWC Form that will no longer be that will no longer be required to be filed with required to be filed with DWC. However the DWC DWC. However the DWC Form may still be Form may still be required to be sent to required to be sent to other parties other parties (e.g., DWC-1, (e.g., DWC-1, 4, 12).4, 12).

99

When an MTC code is When an MTC code is required in the Benefits required in the Benefits segment on the SROI, it segment on the SROI, it must be the same MTC must be the same MTC code sent at the Claim code sent at the Claim level on the SROI.level on the SROI.

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First First Report ofReport of

Injury Injury MTC’sMTC’s

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FL FROI MTC’s Include FL FROI MTC’s Include ::0000 – Original – Original

0404 – Total Denial – Total Denial

AUAU – Acquired First Report – Acquired First Report

AQAQ – Acquired Claim – Acquired Claim

0101 – Cancel (Claim Filed in Error) – Cancel (Claim Filed in Error)

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FL FROI MTC’s:FL FROI MTC’s:

ChangesChanges

0202 – Change– Change

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SubsequeSubsequent Report nt Report

MTC’sMTC’s

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FL SROI MTC’s:FL SROI MTC’s:

Initial Payment Initial Payment Equivalents:Equivalents:IPIP - Initial Payment- Initial Payment

EPEP – Employer Paid Salary – Employer Paid Salary in Lieu of Compin Lieu of Comp

PYPY – Payment– Payment

APAP - Acquired First Payment- Acquired First Payment

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Initial Payment Initial Payment Equivalents (cont’d):Equivalents (cont’d):

CDCD – Compensable – Compensable Death-No Known Death-No Known Dependents/PayeesDependents/Payees

VEVE - Volunteer- Volunteer

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FL SROI Report MTC’s:FL SROI Report MTC’s:

Denials:Denials:

0404 – Full Denial– Full Denial

PDPD – Partial – Partial Denial Denial (Indemnity (Indemnity Only & other required Only & other required partial denials).partial denials).

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Additions/ChangesAdditions/Changes

CBCB – Change in Benefit – Change in Benefit TypeType

ABAB – Add Concurrent – Add Concurrent BenefitBenefit


CACA – Change in Benefit – Change in Benefit AmountAmount

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ReinstatementsReinstatements

ERER – Employer Reinstatement– Employer Reinstatement

RBRB – Reinstatement of Benefits– Reinstatement of Benefits


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Full Suspensions Full Suspensions (of all Indemnity)(of all Indemnity)

S1S1 – RTW or Released to – RTW or Released to RTWRTW

S2 S2 - Medical Non-- Medical Non-ComplianceCompliance

S3S3 – Administrative Non-– Administrative Non-ComplianceCompliance


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S4S4 – Claimant Death– Claimant Death

S5 S5 - Incarceration- Incarceration

S6S6 – – Claimant’s Claimant’s Whereabouts Whereabouts UnknownUnknown


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S7S7 – Benefits Exhausted– Benefits Exhausted

S8 S8 – Jurisdiction Change– Jurisdiction Change


You should recognize these from the You should recognize these from the DWC-4 FormDWC-4 Form

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Partial Suspension Partial Suspension (of a concurrent (of a concurrent

benefit)benefit) P7P7 – Benefits – Benefits ExhaustedExhaustedFL’s only concurrent benefit type is FL’s only concurrent benefit type is

PT and PT Supplemental Benefits. If PT and PT Supplemental Benefits. If one benefit is suspended but the one benefit is suspended but the other benefit continues, a Partial other benefit continues, a Partial Suspension is filed.Suspension is filed.


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Periodic ReportsPeriodic Reports

SASA – Sub – Sub AnnualAnnualFor EDI R3, the Annual Claim For EDI R3, the Annual Claim Cost Report has been replaced Cost Report has been replaced with a Sub Annual report, with a Sub Annual report, due every 6 months from the due every 6 months from the Date of Injury until the claim is Date of Injury until the claim is closed.closed.


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FNFN – Final– Final

Periodic ReportsPeriodic Reports (cont’d)…(cont’d)…


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Changes Changes

0202 – Changes– Changes

EDI EDIFL SROI MTC’s:FL SROI MTC’s:

116

What are What are

Benefit Type Benefit Type Codes (BTC) ?Codes (BTC) ?

117

BTC’s are BTC’s are codes that identify the codes that identify the

type of type of indemnityindemnity benefits being paid. benefits being paid.

TT - TT -

050050TP - TP - 070070

IB - IB -

030030

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010010 – Fatal/Death – Fatal/Death

020020 – Permanent Total – Permanent Total

021021 – Permanent Total Supplemental – Permanent Total Supplemental

Benefit Type Benefit Type CodesCodes

030030 – Perm Partial Scheduled – Perm Partial Scheduled (Impairment (Impairment Income)Income)

040040 – Perm Partial Unscheduled – Perm Partial Unscheduled (Supplemental (Supplemental Income)Income)

050050 – Temporary Total – Temporary Total

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051051 – Temporary Total Catastrophic – Temporary Total Catastrophic

070070 – Temporary Partial – Temporary Partial


090090 – Permanent Partial – Permanent Partial DisfigurementDisfigurement

410410 – Voc Rehab Maintenance – Voc Rehab Maintenance

500500 – Unspecified Lump Sum – Unspecified Lump Sum Pmt/SettlementPmt/Settlement

5XX5XX – Specific Lump Sum – Specific Lump Sum Pmt/Settlement per Pmt/Settlement per Benefit Type Benefit Type Code (e.g., 510, 550, etc.)Code (e.g., 510, 550, etc.)

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210 – 210 – Employer Paid Fatal (Death)Employer Paid Fatal (Death)

230230 – Employer Paid Perm Partial – Employer Paid Perm Partial (IB’s)(IB’s)

240240 - Employer Paid Unspecified - Employer Paid Unspecified

242242 – Employer Paid Voc Rehab – Employer Paid Voc Rehab MaintenanceMaintenance

250250 – Employer Paid Temporary Total – Employer Paid Temporary Total

251251 – Employer Paid Temporary Total – Employer Paid Temporary Total CatastrophicCatastrophic

270270 – Employer Paid Temporary Partial – Employer Paid Temporary Partial


121

What are What are “Other “Other

Benefit Type” Codes Benefit Type” Codes (OBT’s)?(OBT’s)?

122

OBT’s are OBT’s are codes that represent the codes that represent the

type of type of non-indemnitynon-indemnity benefits being paid.benefits being paid.

311311 321321 370370

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300300 – Total Funeral Expenses – Total Funeral Expenses

310310 – Total Penalties – Total Penalties

311311 – Total – Total EmployeeEmployee Penalties Penalties

320320 – Total Interest – Total Interest

321321 – Total – Total EmployeeEmployee Interest Interest

Other Benefit Type Other Benefit Type Codes Codes (required by FL)(required by FL)

370370 – Total Other Medical – Total Other Medical

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380380 – Total Voc Rehab Evaluation – Total Voc Rehab Evaluation

390390 – Total Voc Rehab Education – Total Voc Rehab Education

400400 – Total Other Voc Rehab – Total Other Voc Rehab

430430 – Total Unallocated Prior Indemnity – Total Unallocated Prior Indemnity Benefits Benefits (acquired claims)(acquired claims)

475475 – Total Medical Travel Expenses – Total Medical Travel Expenses

Other Benefit Type Other Benefit Type Codes Codes (required by FL)(required by FL)

125

FL has reduced the FL has reduced the amount of OBT Codes amount of OBT Codes

required to be reported required to be reported for R3, because the for R3, because the majority of medical majority of medical

information is already information is already being reported to the being reported to the Division via another Division via another electronic format.electronic format.

300300 400400 475475

126

FL no longer requires FL no longer requires the reporting of the reporting of

Physician (Medical), Physician (Medical), Hospital, or Hospital, or

Pharmacy/Durable Pharmacy/Durable Medical Paid To Date Medical Paid To Date on the EDI Claim Cost on the EDI Claim Cost

“Periodic” report.“Periodic” report.

Other Benefit Type Other Benefit Type Codes Codes (not required by (not required by

FL)FL)

127

How Are MTC’s How Are MTC’s and Insurers and Insurers

Being “Phased Being “Phased In” for In” for

Implementing Implementing EDI R3?EDI R3?

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The Division has established The Division has established by rule two implementation by rule two implementation schedules for “phasing in” all schedules for “phasing in” all of the MTC’s required for R3 of the MTC’s required for R3 reporting: reporting:

The The PrimaryPrimary Implementation Implementation Schedule includes MTC’s for Schedule includes MTC’s for reporting the electronic reporting the electronic equivalent of the DWC-1, 12, 13 & equivalent of the DWC-1, 12, 13 & 49 & some DWC-4 data.49 & some DWC-4 data. The The SecondarySecondary Implementation Implementation Schedule includes MTC’s that Schedule includes MTC’s that equate to most DWC-4’s.equate to most DWC-4’s.

EDI Claims R3 EDI Claims R3 ImplementationImplementation

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EDI Claims R3 EDI Claims R3 ImplementationImplementationAgain, implementation Again, implementation

of EDI R3 applies to of EDI R3 applies to allall MTC’s required by rule MTC’s required by rule for for allall Dates of Injuries, Dates of Injuries, not just for dates of not just for dates of injuries occurring after injuries occurring after the Insurer’s R3 the Insurer’s R3 production production implementation date. implementation date.

Legacy claims are Legacy claims are included in the mandate.included in the mandate.

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EDI Claims R3 EDI Claims R3 ImplementationImplementationPaper forms Paper forms

previously filed previously filed with DWC do with DWC do NOT need to be NOT need to be re-submitted re-submitted electronically.electronically.

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The Division has divided The Division has divided insurers/self-insurers into three insurers/self-insurers into three

‘test to production’ periods (tiers), ‘test to production’ periods (tiers), based on Insurer Code #.based on Insurer Code #.

Insurer Code #’s Insurer Code #’s 102-199102-199 and currentand currentR1 Trading Partners R1 Trading Partners implemented first.implemented first. Insurer Code #’s Insurer Code #’s 200-599200-599

implemented next.implemented next.

Insurer Code #’s Insurer Code #’s 600-4999600-4999 and and 8000-99998000-9999 are implementing last. are implementing last.


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Third Party Administrators Third Party Administrators (TPAs) are not included in (TPAs) are not included in this list because they are this list because they are not ‘Insurers’. not ‘Insurers’.

However, a TPA must be However, a TPA must be ready to comply with the ready to comply with the EDI filing requirements as EDI filing requirements as soon as their first Insurer soon as their first Insurer client is required to client is required to comply.comply.


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Third Party Third Party Administrators Administrators (TPAs) are not (TPAs) are not required to required to implement all of implement all of their insurer clients their insurer clients at the same time, at the same time, but….but….


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……the 30 day initial late the 30 day initial late filing penalty waiver in filing penalty waiver in rule 69L-24.0231(d), is rule 69L-24.0231(d), is only applicable to the only applicable to the “claim administrator” “claim administrator” as a whole at the time as a whole at the time it first implements R3 it first implements R3 EDI filings.EDI filings.


135

Therefore, if a claim Therefore, if a claim administrator administrator implements R3 EDI for implements R3 EDI for different clients at different clients at different times, the different times, the subsequent clients will subsequent clients will not be granted a not be granted a separate 30 day late separate 30 day late filing penalty waiver.filing penalty waiver.


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The first groupThe first group (Insurer Code #s 102-199)(Insurer Code #s 102-199) began began testing November 1, 2007, and testing November 1, 2007, and were approved to begin a were approved to begin a scheduled phase in to production scheduled phase in to production beginning 1-31-08.beginning 1-31-08.

Claims EDI Claims EDI PrimaryPrimary Implementation Implementation Schedule Phase In:Schedule Phase In:

First Group Began Testing: First Group Began Testing: 11 11 -1-2007-1-2007First Group Phased In to First Group Phased In to Production beginning: Production beginning:

01-31-200801-31-2008

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The second groupThe second group ((Insurer Code #s 200-Insurer Code #s 200-

599)599) bbegan testing February 1, 2008, egan testing February 1, 2008, and were approved for production no and were approved for production no later than the last day of the 3later than the last day of the 3rdrd month month after the testing period began.after the testing period began.


Second Group Began Testing: Second Group Began Testing: 2-1-2-1-20082008Second Group In Production By:Second Group In Production By: 4-4-30-200830-2008

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The third group The third group ((Insurer Code #s 600-4999 Insurer Code #s 600-4999

and 8000-9999)and 8000-9999) began testing May 1, began testing May 1, 2008, and were approved for production 2008, and were approved for production no later than the last day of the 3no later than the last day of the 3rdrd month after the testing period began.month after the testing period began.


Third Group Began Testing: Third Group Began Testing: 5-1-20085-1-2008Third Group Must Be In Production: Third Group Must Be In Production:

7-31-20087-31-2008

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The Division has accepted The Division has accepted and approved an insurer’s and approved an insurer’s valid request for an valid request for an extension to a later tier, extension to a later tier, and has added a 4and has added a 4thth and and finalfinal Tier that requires Tier that requires successful testing and successful testing and production approval no production approval no later than 10-31-08. later than 10-31-08.

140

Please refer to EDI Please refer to EDI Business Training Business Training

PowerPoint slides located PowerPoint slides located on the Claims EDI webpage on the Claims EDI webpage for detailed instructional for detailed instructional training on EDI Release 3 training on EDI Release 3

implementation.implementation.

1 florida division of workers compensation claims edi release 3 history and overview 2008 (review...

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