1 Florida Division of Workers Compensation Claims EDI Release 3
Training 2008 Slide 2 2 Linda Yon FL DWC EDI Coordinator Your
Trainer Slide 3 3 Karen Kubie - DWC Claims EDI Lead Business
Analyst Karen Kubie - DWC Claims EDI Lead Business Analyst Kim
Wiley DWC EDI IT Project Manager Kim Wiley DWC EDI IT Project
Manager Janice Youngblood DWC EDI IT Consultant/Programmer Janice
Youngblood DWC EDI IT Consultant/Programmer Margaret Forsman - DWC
Claims EDI Business Analyst Margaret Forsman - DWC Claims EDI
Business Analyst Additional DWC Staff Slide 4 4 Tonya Granger - DWC
Lead EDI POC Analyst & Claims Analyst Tonya Granger - DWC Lead
EDI POC Analyst & Claims Analyst Debra Lee DWC EDI Claims
Analyst Debra Lee DWC EDI Claims Analyst Laura Cotner - DWC EDI
Claims and POC Analyst Laura Cotner - DWC EDI Claims and POC
Analyst Additional DWC Staff Slide 5 5 Rule Chapter 69L-56 of the
Florida Administrative Code is the EDI Rule for Proof of Coverage
and Claims (non-medical) Slide 6 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. Slide 7 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. Slide 8 So Heres A Little Background On EDI
Slide 9 9 On a National level, in 1990 the IAIABC spearheaded a
program to utilize the concept of EDI for Workers Compensation
data. Slide 10 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. Slide 11 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. 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 This does not include
reporting by Injured Workers! EDI Slide 12 12 Developing an
Electronic Standard Bringing Together the Important Participants
Jurisdictions TPAs Vendors Carriers Slide 13 13 Developing a
National Standard through the IAIABC EDI Development Committees was
a consensus development process that required give and take from
all participants. Slide 14 14 The end result is a national standard
format for the reporting of workers compensation data
electronically. Slide 15 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. 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 1993:Claims
Release 1 2000:Claims Release 2 (Iowa) 2000:Claims Release 2 (Iowa)
2005:Claims Release 3 2005:Claims Release 3 Slide 16 Where can you
find the IAIABC R3 Implementation Guide & Codes? Slide 17 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 www.iaiabc.org Slide 18 18 The Release 3 Claims
Implementation Guide contains the transaction record layouts, data
dictionary, business and technical rules, national scenarios, etc.
Slide 19 19 www.iaiabc.org Slide 20 20 Slide 21 21
http://www.iaiabc.org/EDI/implementation.asp Slide 22 22 STANDARD
USAGE FOR ALL PRODUCTS Country Codes Country Codes State Codes
State Codes Industry Codes (NAICS 2002 or 2007) Industry Codes
(NAICS 2002 or 2007) Nature of Injury Codes Nature of Injury Codes
Cause of Injury Codes Cause of Injury Codes Part of Body Codes Part
of Body Codes Permanent Impairment Body Part Codes Permanent
Impairment Body Part Codes Error Message Dictionary Error Message
Dictionary Glossary Glossary Slide 23 23 Slide 24 Glossary Glossary
Slide 25 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. Slide 26 26 Glossary The Glossary defines terms that
are common to FROI/SROI, MED, and POC EDI reporting. 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. 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. Slide 27 27 Glossary Alphabetical by term Slide 28 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. Slide 29
Acronyms (see your handout) Slide 30 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.
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. Slide 31 31 ACRONYM Examples: FTP File Transfer
Protocol FEIN Federal Employer Identification Number FROI First
Report of Injury GUI Graphical User Interface HTTP Hyper Text
Transfer Protocol SROI Subsequent Report of Injury URL Uniform
Resource Locator Slide 32 32 Slide 33 33 Slide 34 Release 3
Combined Business & Technical Data Dictionary Slide 35 35 The
Release 3 Data Dictionary Section 6 in the Implementation Guide
Slide 36 36 Release 3 Data Dictionary Identifies the Data Number
(DN) Identifies the Data Number (DN) Gives the Definition of the
Data Element Gives the Definition of the Data Element Gives the
Last Revision Date of the Data Element Gives the Last Revision Date
of the Data Element Slide 37 37 Release 3 Data Dictionary Gives the
Format (i.e. 2 A/N = two characters alpha/numeric) Gives the Format
(i.e. 2 A/N = two characters alpha/numeric) Lists the Valid Values
for the DN Lists the Valid Values for the DN Gives DP (Data
Population) Rule to Help Identify the Correct Use of the Data
Element Gives DP (Data Population) Rule to Help Identify the
Correct Use of the Data Element Slide 38 38 Release 3 Data
Dictionary Slide 39 39 http://www.myfloridacfo.com/wc/ FLs Claims
EDI Webpage Slide 40 40 FLs Claims EDI Webpage Slide 41 41 Slide 42
42 Slide 43 43 FL Supplement Overview: Tracks all monthly additions
or corrections to the requirement tables. Slide 44 44 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) FLs Claims EDI Webpage Slide 45 45
(Contd) Review FLs requirement tables (including updated
supplement) immediately to determine: Edits that will reject the
record (Edit Matrix) Edits that will reject the record (Edit
Matrix) FLs Claims EDI Webpage Slide 46 46 The FL Claims EDI
Webpage contains helpful resource documents including: FL EDI
Migration Strategies FL EDI Migration Strategies MTC Filing
Instructions MTC Filing Instructions FL R3 Business Scenarios FL R3
Business Scenarios FL Quick Code Reference Guide FL Quick Code
Reference Guide Training Questions & Answers Training Questions
& Answers MTC to Form Crosswalk MTC to Form Crosswalk
Crosswalks of paper DWC Claims Forms to EDI Data Elements
Crosswalks of paper DWC Claims Forms to EDI Data Elements FLs
Claims EDI Webpage Slide 47 47 Slide 48 48 Questions? Slide 49 49
In R3 EDI, all WC data is sent electronically via a FROI or SROI
transaction. Slide 50 50 What Is A ? Slide 51 51 First Report of
Injury (FROI) Slide 52 52 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. Release 3 FROI
Transaction Slide 53 53 This means the Release 3 FROI transaction
requires 2 records to communicate the First Report event, the 148
& R21 records. Release 3 FROI Transaction Slide 54 54 First
Report of Injury FROI =148 + R21 Slide 55 55 The FROI Flat File
Section 2 in the Release 3 Implementation Guide Slide 56 56 FROI
Flat File Record Layout Slide 57 57 FROI Flat File (148) Record
Layout Data Elements Filler Slide 58 58 FROI Companion Flat File
(R21) Record Layout Data Elements Filler Slide 59 59 FROI R21
Variable Segments Slide 60 60 If the Accident Description Narrative
segments are 50 characters each, and this Accident Description is
161 characters Slide 61 61 how many segments must be sent to report
the entire Accident Description Narrative? a. 1 Segment b. 2
Segments c. 3 Segments d. 4 Segments Slide 62 62 ANSWER = d (4
segments) DNData Element Name DataBegEnd 0038Accident/Injury
Description Narrative AS HELEN WAS LEAVING HER WORK SITE (BLDG 500)
SHE 16011650 0038Accident/Injury Description Narrative WAS WAITING
FOR HER HUSBAND TO PICK HER UP ON THE 16511700 0038Accident/Injury
Description Narrative STEPS OF THE BLDG. AS SHE LEANED AGAINST THE
RAIL 17011750 0038Accident/Injury Description Narrative ING &
FELL.17511800 Slide 63 63 What Is A ? Slide 64 64 Subsequent Report
of Injury (SROI) Slide 65 65 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. Release 3 SROI Transaction Slide 66 66 This
means the Release 3 SROI transaction requires 2 records to
communicate the Subsequent Report event, the A49 & R22 records.
Release 3 SROI Transaction Slide 67 67 Subsequent Report of Injury
SROI = A49+R22 Slide 68 68 The SROI Flat File Section 2 in the
Implementation Guide Slide 69 69 SROI Flat File Record Layout Slide
70 70 Now Lets Discuss Important Codes Common To EDI Transactions
Slide 71 71 Important Codes R3 Quick Code Reference Guide (see
handout) R3 Quick Code Reference Guide (see handout) Maintenance
Type Codes Maintenance Type Codes Benefit Type Codes Benefit Type
Codes Other Benefit Type Codes Other Benefit Type Codes Slide 72 72
R3 Quick Code Reference One Stop Shopping Included with your
handouts Slide 73 73 What Is An ? MTC Slide 74 74 Slide 75 75 A
code that defines the specific purpose of each transaction being
transmitted. Slide 76 76 DWC Forms required to be filed with the
Division are replaced by EDI filings identified by MTC codes. Slide
77 77 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).
Slide 78 78 First Report of Injury MTCs Slide 79 79 FL FROI MTCs
Include : 00 Original 04 Total Denial AU Acquired First Report AQ
Acquired Claim 01 Cancel (Claim Filed in Error) Slide 80 80 FL FROI
MTCs: Changes 02 Change Slide 81 81 Subsequent Report MTCs Slide 82
82 FL SROI MTCs: Initial Payment Equivalents: IP - Initial Payment
EP Employer Paid Salary in Lieu of Comp PY Payment AP - Acquired
First Payment Slide 83 83 FL SROI MTCs: Initial Payment Equivalents
(contd): CD Compensable Death-No Known Dependents/Payees VE -
Volunteer Slide 84 84 FL SROI Report MTCs: Denials: 04 Full Denial
PD Partial Denial (Indemnity Only & other required partial
denials). Slide 85 85 Additions/Changes CB Change in Benefit Type
AB Add Concurrent Benefit FL SROI MTCs: CA Change in Benefit Amount
Slide 86 86 Reinstatements ER Employer Reinstatement RB
Reinstatement of Benefits FL SROI MTCs: Slide 87 87 Full
Suspensions (of all Indemnity) S1 RTW or Released to RTW S2 -
Medical Non-Compliance S3 Administrative Non-Compliance FL SROI
MTCs: Slide 88 88 Full Suspensions (of all Indemnity) S4 Claimant
Death S5 - Incarceration S6 Claimants Whereabouts Unknown FL SROI
MTCs: Slide 89 89 Full Suspensions (of all Indemnity) S7 Benefits
Exhausted S8 Jurisdiction Change FL SROI MTCs: You should recognize
these from the DWC-4 Form Slide 90 90 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. FL SROI MTCs: Slide 91 91 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. FL SROI MTCs: Slide 92 92 FN Final Periodic
Reports (contd) FL SROI MTCs: Slide 93 93 Changes 02 Changes EDI FL
SROI MTCs: Slide 94 94 What are Benefit Type Codes (BTC) ? Slide 95
95 BTCs are codes that identify the type of indemnity benefits
being paid. TT - 050 TP - 070 IB - 030 Slide 96 96 010 Fatal/Death
020 Permanent Total 021 Permanent Total Supplemental Benefit Type
Codes 030 Perm Partial Scheduled (Impairment Income) 040 Perm
Partial Unscheduled (Supplemental Income) 050 Temporary Total Slide
97 97 051 Temporary Total Catastrophic 070 Temporary Partial
Benefit Type Codes 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.) Slide 98 98 210 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 Benefit Type Codes Slide 99 99 What are
Other Benefit Type Codes (OBTs)? Slide 100 100 OBTs are codes that
represent the type of non-indemnity benefits being paid. 311 321
370 Slide 101 101 300 Total Funeral Expenses 310 Total Penalties
311 Total Employee Penalties 320 Total Interest 321 Total Employee
Interest Other Benefit Type Codes (required by FL) 370 Total Other
Medical Slide 102 102 380 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 Other Benefit Type Codes (required by FL) Slide 103 103 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. 300 400 475
Slide 104 104 FL no longer requires the reporting of Physician
(Medical), Hospital, or Pharmacy/Durable Medical Paid To Date on
the EDI Claim Cost Periodic report. Other Benefit Type Codes (not
required by FL) Slide 105 105 Questions? Slide 106 106 What Is The
Claims EDI Mandate All About ? How Does It Affect FL WC Insurers?
Slide 107 107 69L-56.001Forms and Instructions
69L-56.002Definitions Rule 69L-56 Rule Section Overview Slide 108
108 69L-56.100Proof of Coverage (POC) Electronic Reporting
Requirements 69L-56.110Technical Requirements for POC EDI
Transmissions 69L-56.200Policy Cancellation or Non-renewal
Requirements 69L-56.210Time Periods for Filing Electronic Policy
Information Slide 109 109 69L-56.300Claims EDI Reporting
Requirements and Implementation Schedules 69L-56.301Electronic
First Report of Injury or Illness 69L-56.3012 Electronic Notice of
Denial and Rescinded Denial 69L-56.3013 Electronic Periodic Claim
Cost Reports Slide 110 110 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 Slide 111 111 69L-56.307Electronic
Cancellation of Claim 69L-56.310Technical Requirements for Claims
EDI Transmissions 69L-56.320Claims EDI Test to Production Status
Requirements Slide 112 112 69L-56.330Electronic 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-56.500Insurer Responsibilities Where Third Party
Services are Utilized Slide 113 113 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
Slide 114 114 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. Slide 115 115
How Will MTCs and Insurers Be Phased In for Implementing EDI R3?
Slide 116 116 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 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. The Secondary
Implementation Schedule includes MTCs that equate to most DWC-4s.
EDI Claims R3 Implementation Slide 117 117 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. Slide 118 118 EDI
Claims R3 Implementation Paper forms previously filed do NOT need
to be re- submitted electronically. Slide 119 119 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 Insurer Code #s 102-199 and current R1 Trading Partners
will implement first. Insurer Code #s 200-599 will implement next.
Insurer Code #s 200-599 will implement next. Insurer Code #s
600-4999 and 8000-9999 will implement last. Insurer Code #s
600-4999 and 8000-9999 will implement last. EDI Claims R3
Implementation Slide 120 120 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.
EDI Claims R3 Implementation Slide 121 121 For Example (Old
Reliable Group): Old Reliable Ins Co. = # 145 Old Reliable P&C
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. on 11-1-07. Slide 122 122 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. EDI Claims R3 Implementation Slide 123 123
Third Party Administrators (TPAs) are not required to implement all
of their insurer clients at the same time, but. EDI Claims R3
Implementation Slide 124 124 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. EDI Claims R3 Implementation Slide 125 125 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. EDI Claims R3
Implementation Slide 126 126 The first group (Insurer Code #s
102-199) began testing November 1, 2007, and are being phased in to
production beginning 1-31-08. Claims EDI Primary Implementation
Schedule Phase In: First Group Must Begin Testing: 11 -1-2007 First
Group Phased In Production: 01-31-2008 Slide 127 127 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 3 rd
month after the testing period begins. Claims EDI Primary
Implementation Schedule Phase In: Second Group Must Begin Testing:
2-1-2008 Second Group Must Be In Production: 4-30-2008 Slide 128
128 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 3 rd month after the testing period begins. Claims
EDI Primary Implementation Schedule Phase In: Third Group Must
Begin Testing: 5-1-2008 Third Group Must Be In Production:
7-31-2008 Slide 129 129 What Forms Will Be Required To Be
Electronically Submitted In The Claims EDI Release 3 Primary
Implementation Schedule? Slide 130 130 The Claims EDI R3 Primary
Implementation Schedule will include the electronic form
equivalents for: First Report of Injury (DWC-1) First Report of
Injury (DWC-1) Notice of Denial (DWC-12) Notice of Denial (DWC-12)
Claim Cost Report (DWC-13) Claim Cost Report (DWC-13) Aggregate
Claims Administration Change Report (DWC-4 or DWC-49) Aggregate
Claims Administration Change Report (DWC-4 or DWC-49) Notice of
Action/Change (certain fields) (DWC-4) Notice of Action/Change
(certain fields) (DWC-4) Slide 131 131 What MTCs Will Be Required
in the Claims EDI Release 3 Primary Implementation Schedule? Slide
132 132 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). Claims EDI R3 Required MTCs Slide 133 133 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 MTCs IP, EP, AP, PY, PD, CD, VE, 02, 04, SA & FN
Claims EDI R3 Required MTCs Slide 134 134 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. Slide 135 135 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
Claims EDI R3 Required MTCs Slide 136 136 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. Slide 137 137 These required DWC-4 data elements are
identified in the EDI Rule 69L-56.304, F.A.C., and some examples
follow. Slide 138 138 Claim Administrator Postal Code not due to
change in claims administration Claim Administrator Postal Code not
due to change in claims administration Industry Code Industry Code
Manual Classification Code Manual Classification Code Employee SSN
Employee SSN Employee First/Last Name, Last Name Suffix, Middle
Name/Initial Employee First/Last Name, Last Name Suffix, Middle
Name/Initial Date of Injury Date of Injury Example DWC-4 Changes
Required in Primary Implementation Slide 139 139 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. Claims EDI R3
Secondary Implementation Schedule Phase In: Slide 140 140 Claims
EDI R3 Secondary Implementation Schedule Phase In: 1 st 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
Slide 141 141 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 Slide 142 142 Claims EDI Secondary
Implementation Schedule Phase In: 3 rd 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 Slide 143 143
Claim Administrators can voluntarily send MTCs required in the
Secondary Implementation Schedule (most DWC-4s) during the Primary
Implementation Schedule. Slide 144 144 What MTCs Will Be Required
in the Claims EDI Release 3 Secondary Implementation Schedule?
Slide 145 145 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 Claims EDI MTCs Required Slide 146 146 Crosswalk
of MTCs to DWC Forms Slide 147 147 Slide 148 148 MTCs to DWC Forms
Slide 149 149 MTCs to DWC Forms Slide 150 150 MTCs to DWC Forms
Slide 151 151 MTCs to DWC Forms Slide 152 152 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. 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. Slide 153 153 Questions? Slide 154 154 How Will EDI Errors
Be Communicated to Claim Administrators? Slide 155 155 The Division
will acknowledge every EDI R3 transaction received with the
standard EDI Acknowledgement format: AKC. AKC Report Slide 156 156
Transmissions received on or before 9:00 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). Slide 157 157
Transmissions received after 9:00 p.m. EST will be processed by DWC
the following calendar day. It will be acknowledged the day after
the transmission is processed. Slide 158 158 FL processes
transmissions 7 days a week, including holidays. Slide 159 159 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. Slide 160 160 FL does not use the TE
Transaction Accepted with Errors Acknowledgement Code. Slide 161
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) Slide 162 162 The
Claim Administrator will receive credit for the date the
transaction was originally received by the Division. Slide 163 163
FL provides EDI Claim Administrators the capability of viewing all
FROIs & SROIs received, via the on-line Claims EDI Data
Warehouse. Slide 164 164 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 Slide 165 165 More detailed
information regarding the on-line Claims EDI Data Warehouse will be
provided later in the training. Claims EDI Warehouse Slide 166 166
Questions? Slide 167 FL Trading Partner Tables Slide 168 168 FL EDI
Reporting requirements are defined in the Trading Partner Tables:
1.Required Report(s) 2.Data needed on the Report(s) 3.Applied
Editing Slide 169 169 Trading Partner Tables Instructions ( MTC
Filing (FL Website) Reference (FL Website) FL Quick Code Slide 170
170 What is an Event? Slide 171 171 2. Initial Payment or
Equivalent or Equivalentwith 11. Changes (Non-Indemnity) 9. Lump
Sum Payment(s) 9. Lump Sum Payment(s) 1. Establish Claim 4.
Suspension of all Benefits 3. Changes to Benefits/Amnts Benefits
Claim Event Flow Claim Event Flow in FL Claim Business Events
10.Periodic Reports 12.Cancel 8. Claim Closure Slide 172 172 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 First Report of Injury events Subsequent Report
events Subsequent Report events Periodic events Periodic events
Slide 173 FL identifies all of the transactions (MTCs) that are
required for reporting specific business events on its FL
identifies all of the transactions (MTCs) that are required for
reporting specific business events on its Event Table. Slide 174
174 Example: Florida requires the submission of a FROI MTC 00 f or
First Reports of Injury or Illness based on the insurers mandate
date f or First Reports of Injury or Illness based on the insurers
mandate date Event Table Interpreting the FL Event Table Slide 175
175 when disability is immediate & continuous & lost time
is greater than seven (7) days. Event Table Interpreting the FL
Event Table Slide 176 176 The filing must receive a TA within 21
calendar days after the claim administrators knowledge of the
injury. Event Table Interpreting the FL Event Table Slide 177 177 A
DWC-1 or IA-1 (ACORD 4) form must also be sent to the employee
& employer Event Table Interpreting the FL Event Table Slide
178 178 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 Slide 179 179 Slide 180 180
What is the Paper Equivalent of a Periodic Report for FL? Slide 181
181 Answer: DWC-13 DWC-13 Claim Cost Report Slide 182 182 Slide 183
183 What are the Periodic MTCs accepted by FL? Slide 184 184
Answer: MTC SA & FN MTC SA & FN Slide 185 185 Event Table
FL Periodic Reports FN Final Submitted when Claim Administrator
determines no further benefits will be paid. FN Final Submitted
when Claim Administrator determines no further benefits will be
paid. SA Sub-Annual Submitted every 6 months after the DOI, as
defined on FLs Event Table. SA Sub-Annual Submitted every 6 months
after the DOI, as defined on FLs Event Table. Slide 186 186 In
addition to the Event Table, FL describes its business events in
theMTC Filing Instructions. This document assists claim
administrators understand what MTCs to use in reporting required
business events to FL. Event Table MTC Filing Instructions Slide
187 187 Slide 188 188 FL MTC Filing Instructions FL MTC Filing
Instructions Slide 189 189 Questions? Slide 190 190 FL BUSINESS
SCENARIOS Slide 191 191 Slide 192 192 FL SCENARIO ASSUMPTIONS Slide
193 193 General scenario assumptions are included in the scenarios
to assist in understanding the sample data that is presented.
General scenario assumptions are included in the scenarios to
assist in understanding the sample data that is presented. FL
SCENARIO ASSUMPTIONS Slide 194 194 The FL Scenarios were enhanced
from the IAIABC scenarios in the R3 Implementation Guide. 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).
FL SCENARIO ASSUMPTIONS Slide 195 195 Calculated Weekly
Compensation Amount is the Comp. Rate, and is 66 2/3% of the
Average Wage. 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. The statutory comp rate max is not
accurate per FL law. FL SCENARIO ASSUMPTIONS Slide 196 196
Scenarios are presented in uppercase text. However, data may be
sent to FL in mixed case format. Scenarios are presented in
uppercase text. However, data may be sent to FL in mixed case
format. FL SCENARIO ASSUMPTIONS The Industry Code must be a 2002 or
2007 NAICS code. The Industry Code must be a 2002 or 2007 NAICS
code. Payment of indemnity benefits is based upon a 5 day work week
Payment of indemnity benefits is based upon a 5 day work week Slide
197 197 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. 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. FL SCENARIO ASSUMPTIONS Slide 198 198 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). 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). FL SCENARIO ASSUMPTIONS Slide 199 199
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. 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. FL SCENARIO ASSUMPTIONS
Slide 200 200 FL SCENARIO PROFILES Slide 201 201 Unless otherwise
noted in the scenario narrative, the basic scenario profile
information for all scenarios will be as follows. FL Scenario
Profiles Slide 202 202 Injured Employee DescriptionData Name:John
James Smith, Jr. SSN:324-55-6745 DOI:June 15, 2007 DOB:May 1, 1953
Empmnt Status: Full Time FL Scenario Profiles Slide 203 203 Injured
Employee DescriptionData Class Code:2802 (Carpenter) Days
Worked/Week:5 Wage:$15.00 Wage Period:Hourly (FROI) FL Scenario
Profiles Slide 204 204 Employer/Insured DescriptionData
Employer:Acme Construction Inc. FEIN:74-6994235 Physical
Location:32 Meadowbrook Lane Anytown, FL 32399 Industry (NAICS):
236116 FL Scenario Profiles Slide 205 205 FL Scenario Profiles
Insurer/Claim Administrator DescriptionData Insurer:Old Reliable
Ins. Co. FEIN:78-5902378 Average Wage:$600.00 Wage Period:Weekly
(SROI) Slide 206 206 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). FL SCENARIOS Slide 207 207
Questions? Slide 208 208 FL SCENARIOS FOR MTCs REQUIRED IN THE
PRIMARY IMPLEMENTATION SCHEDULE Slide 209 209 Complete FROI/SROI
Combo SCENARIO MTC 00 with IP Disability Immediate & Continuous
Rule 69L- 56.301(1)(a)1., F.A.C. Slide 210 210 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 Indemnity Benefits other than TP or IB
or settlement will be paid, an Electronic First Report of Injury or
Illness is due. Electronic First Report of Injury or Illness is
due. Slide 211 211 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. Slide
212 212 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. Slide
213 213 FROI 00 Scenario Narrative Employee fell from ladder at
employers warehouse on 6/15/07. Employee fell from ladder at
employers warehouse on 6/15/07. Employee broke his leg. Employee
broke his leg. Foreman witnessed the accident. Foreman witnessed
the accident. Employee treated and released from the Emergency
Room. Employee treated and released from the Emergency Room. Slide
214 214 Employee earned $15.00 an hour working 40 hours a week.
Employee earned $15.00 an hour working 40 hours a week. Employer
reported injury to insurer on 6/17/07. Employer reported injury to
insurer on 6/17/07. FROI 00 Scenario Narrative Slide 215 215 FROI
MTC 00 SCENARIO Claim Administrator reported the loss to DWC on
6/29/07. Slide 216 216 Insurer is identified. Claim Administrator
details are provided (remainder are on R21). FROI MTC 00 SCENARIO
Slide 217 217 Employer/Insured information is reported. The
Employers name is on the R21 The rest of the Employers address is
on the R21 NAICS Code FROI MTC 00 SCENARIO Slide 218 218 If
applicable, Policy Number should be reported, but Effective Date
& Expiration Date are not required. FROI MTC 00 SCENARIO Slide
219 219 Details of the accident are included. Employee broke leg
falling from a ladder. FROI MTC 00 SCENARIO Slide 220 220 Employer
reported injury to claim administrator on 6/17/07. FROI MTC 00
SCENARIO Slide 221 221 The rest of the Employees name and address
is on the R21 Details about injured employee are sent. FROI MTC 00
SCENARIO Slide 222 222 Date the initial disability began &
other FROI fields must be reported on the SROI. Manual Risk Class
Code is only on the FROI. FROI MTC 00 SCENARIO Slide 223 223
Employee earned $15.00 an hour and worked 5 days a week. Employee
has not returned to work. FROI MTC 00 SCENARIO Slide 224 224 FROI
Companion Record - R21 FROI MTC 00 SCENARIO Slide 225 225 Claim
Administrator Claim Number is repeated in the R21. It links the R21
companion to the related 148. FROI MTC 00 SCENARIO Slide 226 226
Claim Administrator FEIN is sent. Claim Administrator Name is sent,
and rest of the Claim Admin Address. FROI MTC 00 SCENARIO 456 Main
St Slide 227 227 ID qualifier = S. Positions 232 to 246 contain a
Social Security Number. FROI MTC 00 SCENARIO Slide 228 228
Remainder of Employee name, address fields and phone are here in
the R21 record. FROI MTC 00 SCENARIO Slide 229 229 Type of Loss
Code is reported on the SROI. Employee has not returned to work.
FROI MTC 00 SCENARIO Slide 230 230 Insured FEIN and Insured Name
are reported. FROI MTC 00 SCENARIO Slide 231 231 Insurer Name and
Insurer Type Code are reported. FROI MTC 00 SCENARIO Slide 232 232
Details of accident site: FROI MTC 00 SCENARIO Slide 233 233
Employer Name, Physical address and contact information. FROI MTC
00 SCENARIO Slide 234 234 Employer Mailing Address information is
not required. FROI MTC 00 SCENARIO Slide 235 235 Claim Type Code
and EP Salary Indicator are to be reported on the SROI. FROI MTC 00
SCENARIO Slide 236 236 Variable Segment Counters include: Two
Accident/Injury Narratives, and One Witness segment. FROI MTC 00
SCENARIO Slide 237 237 Accident description exceeds 50 characters;
two segments are needed to send entire narrative description. FROI
MTC 00 SCENARIO Slide 238 238 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. 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. Slide 239 239 Foreman Jones was the only witness. FROI MTC
00 SCENARIO Slide 240 240 Variable Segment Population Rules for
FROI WITNESSES SEGMENT: No more than 5 witnesses per claim, and the
number of segments sent must equal theNumber of Witnesses segment
counter. No more than 5 witnesses per claim, and the number of
segments sent must equal theNumber of Witnesses segment counter.
Slide 241 241 Questions on the FROI? Slide 242 242 Corresponding
SROI MTC IP Slide 243 243 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. Slide 244 244 SROI IP Scenario Narrative On 6/29/07, the
Claim Administrator issued the first indemnity check. 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). Check
covered TTD benefits from 6/23/07 through 6/29/07 (Day 8-14). Slide
245 245 SROI MTC IP SCENARIO Initial Payment transaction is sent to
the Division on 6/29/07. Slide 246 246 Initial Date Disability
Began is the day after DOI because Employer paid for DOI. Employee
was a 5 day per week worker. SROI MTC IP SCENARIO Slide 247 247
Claim Admin Claim Number must be sent on every record. SROI MTC IP
SCENARIO Slide 248 248 No Jurisdiction Claim number required
because IP SROI is filed with 00 FROI. SROI MTC IP SCENARIO Slide
249 249 Claim Type indicates Lost Time case. SROI MTC IP SCENARIO
Slide 250 250 No variable segments; A49 ends at position 208. SROI
MTC IP SCENARIO Slide 251 251 Claim Administrator Claim Number is
repeated in R22. It links the R22 companion to the related A49.
SROI MTC IP SCENARIO Slide 252 252 Claim Administrator information:
SROI MTC IP SCENARIO Slide 253 253 R22 includes additional employee
information. SROI MTC IP SCENARIO Slide 254 254 These fields are
either not required, or they are reported on the FROI. SROI MTC IP
SCENARIO Slide 255 255 These fields are not applicable to this
claim, except the Initial Date Last Day Worked. SROI MTC IP
SCENARIO Slide 256 256 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 2 nd period of disability. SROI MTC IP
SCENARIO Slide 257 257 Weekly Compensation Rate is $400 based on
Average Wage of $600 effective the Date of Injury. SROI MTC IP
SCENARIO Slide 258 258 Type of Loss Code and Employment Status Code
are reported on the SROI. SROI MTC IP SCENARIO Slide 259 259
Additional wage information: SROI MTC IP SCENARIO Slide 260 260 One
Benefits segment and one Payment segment are required on this
claim. SROI MTC IP SCENARIO Slide 261 261 Temporary Total was the
only benefit paid. MTC is also in Ben segment for IP. SROI MTC IP
SCENARIO Slide 262 262 Gross & Net Weekly Amount = $400/week
(comp rate), effective on the DOI. SROI MTC IP SCENARIO Slide 263
263 Initial payment reflected benefits were paid from June 23
through June 29, 2007 (Day 8-14) for 1 week in the amount of $400.
SROI MTC IP SCENARIO Slide 264 264 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. SROI MTC IP SCENARIO Slide
265 265 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. 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. SROI MTC IP SCENARIO Slide 266 266 MTC
IP requires a Payments segment. Payment Reason Code = Benefit Type
Code. SROI MTC IP SCENARIO Slide 267 267 Payment information
related to the Initial Payment is captured in the Payments segment.
SROI MTC IP SCENARIO Slide 268 268 Payment Issue Date = Benefit
Payment Issue Date in Benefits Segment. SROI MTC IP SCENARIO Slide
269 269 Questions?
