florida division of workers’ compensation claims edi release 3 training february 12, 2014 day 2

Florida Division of Workers’

CompensationClaims EDI Release 3 Training February 12, 2014

Day 2

2

2014 Error Resolution Expectations MTC CA (Change in Benefit Amount) with A/C/R Segments (Adjustment, Credit, Redistribution) Proper Reporting and Calculation of Gross and Net Weekly Amounts Lump Sum Payment & Settlements

(cont’d…)

Discussion Topics

3

Recent Law Update and Court Case Decision

Updated IAIABC Data Elements

Acquired Claims

New IAIABC Data Element Employer Paid Salary Prior to Acquisition Code ‘E’

Discussion Topics

4

2014 Error Resolution

Expectations

5

Error Resolution ExpectationsIn the past, the EDI Team has

conducted webinars, teleconferences and on-site visits at the Division in an effort to assist Trading Partners with submitting claims successfully.

6

Error Resolution ExpectationsThis year, the EDI Team

will take a more active approach to our Triage Assistance to reduce the overall error rejection percentages.

7

The EDI Team will be contacting entities with high rejection rates andentities with multiple rejections and/or a high volume of Missing Sub-Annuals (SA).

8

If we identify your company as falling into either of these categories, the EDI Team will be contacting you to schedule a teleconference with your EDI staff, your vendor (if applicable) and me (Linda Yon).

9

We will develop an action plan with timelines to reduce errors and/orthe repetitious filing of transactions (where the error itself has not been addressed).

10

If you or your company would like help with reducing the rate of rejectionsand the EDI Team has yet to reach out to you, we encourage you to contact us to set up a personalized session(s) for more direct assistance.

11

EDI Triage Assistance could include

review of:

Basic EDI training FROI/SROI combo filings Claims EDI Warehouse

navigation Specific Maintenance Type

Codes Event vs. Sweep Benefit

Segments Gross Weekly Amount

calculations or Direct explanation of rejected

filings, etc…

12

If you would like to schedule a conference or webinar session with the team, you may do so by submitting an email to: [email protected] and a member of the team will contact you.

13

MTC CA(Change in Amount)

14

MTC CA(Change in Amount)

If the Net Weekly Amount increases or decreases due to:A change to the Average Weekly Wage which affected the Compensation RateThe recalculation of the Gross Weekly Amount, orThe application of adjustments or credits,

an MTC CA transaction should be sent to the Division.

15

MTC CA is sent when:

Indemnity benefits are currently being paid and the Net Weekly Amount changes due to a re-calculation of the Gross Weekly Amount or an application of adjustments and/or credits…

OR…

16

MTC CA is also sent when: The Net Weekly Amount changes

after a suspension and an adjustment check is issued for the same previously paid period of indemnity.

17

MTC CA is also sent when:

The Net Weekly Amount changes due to the change in a Benefit Adjustment or Credit Weekly Amount OR

Due to the ending of an adjustment or credit.

18

MTC CA should not be sent when:

The Average Weekly Wage (AWW) or Concurrent Employer Wage changes but the Net Weekly Amount does not change (i.e. Comp Rate is at the max for the current year).

In this case, an MTC ‘02’ should be filed instead.

19

MTC CA is not required to be sent when:

The Net Weekly Amount payable for BTC 070 (Temporary Partial) fluctuates due to variations in the employee’s weekly earnings.

The Net Weekly Amount payable for BTC 030 (Impairment Income Benefits) changes due to the employee’s weekly work status/income.

20

POP QUIZ:What MTC is filed when you need to report a change in AWW/CR, but the Gross/Net Weekly

Amount is not changed?

21

ANSWER:

SROI 02

22

Questions RegardingMTC CA

23

Adjustments, Credits and Redistributions

(A/C/R Segments)

24

An Adjustment/Credit/Redistribution (A/C/R) Segment should always and only be included on each SROI transaction when:

The A/C/R is currently being applied to the Benefits Segment that is being reported

ORThe A/C/R is ending

25

A/C/R Segments are also reported on Sub-Annuals (MTC SA) when still being applied to a BTC that is currently being paid.

26

A/C/R Segments are not required to be reported on subsequent transactions if the A/C/R has already ended at the time of the current filing event.

27

A Benefit A/C/R End Date is only sent when an adjustment, credit or redistribution has ended or benefits are suspended (MTC S1-7).

28

However, if A/C/R Segments have not ended at the time of the current filing, A/C/R information must continue to be reported on all SROIs until the A/C/R has ended.

An A/C/R end date is not required if the claim has been subsequently denied/settled.

29

Benefit Adjustments

30

Benefit Adjustment CodeThe Benefit Adjustment Code is a codeidentifying reductions or increases applied to the Gross Weekly Amount resulting in a new Net Weekly Amount for the specific benefit type noted.

Format: 4 A/N (BNNN)B = Benefit Adjustment

Code NNN = Benefit Type Code (e.g. V050)

31

Benefit Adjustment Code

Some commonly used Benefit Adjustment Codes include:

S = Social Security Disability V = Safety Violation E = Employer Provided Pension (Grice)

32

The Benefit Adjustment Start Date is the first date of the uninterrupted period in which the current Benefit Adjustment Weekly Amount was applied to the Benefit Type Code.

Benefit Adjustment Start Date

33

The Benefit Adjustment End Date is the last date through which the benefit adjustment was applied to the Benefit Type Code.

If the Benefit Adjustment is ongoing, the Benefit Adjustment End Date is left blank.

Benefit Adjustment End Date

34

Benefit Adjustment Weekly AmountThe Benefit Adjustment

Weekly Amount is the weekly amount of the benefit adjustment corresponding to the Benefit Adjustment Code.

35

Let’s take a look at a claim scenario where there is an adjustment for a Safety Violation. A Safety Violation adjustment is for the life of the claim, so the claim administrator continued to report the A/C/R Segment without a Benefit Adjustment End Date.

36

Average Wage (AWW) = $600

Calculated Weekly Compensation Amount (Comp Rate) = $400

Gross Weekly Amount for TTD Benefits = $400

Safety Violation (V050) Benefits reduced by 25% per week ($100)

Example with Safety Violation Adjustment

37

The injured worker was employed by the City of DQC as a chemist and burned her hands while mixing chemicals.

38

The injured worker failed to wear protective gloves as required when mixing chemicals;

therefore, the safety violation was applied to the weekly benefits.

Date of Injury = 5/18/12Initial Date Disability Began

= 5/19/12

39

BTCBenefit

TypeMTC

Gross Weekly

Amt.

Gross Eff. Date

Net Weekly

Amt.

Net Eff. Date

Start Date

Through Date

Weeks

Days

Amt. Paid

Payment Issue Date

050TEMPORARY

TOTALIP 400.00 5/19/12 300.00 5/19/12 5/26/12 6/1/12 1 0 300.00 6/1/12

00/IP:

Seg # ACR Code ACR DescriptionBen Type

CodeStart Date End Date Weekly Amount

1 V Safety Violation 050 5/26/12 $100.00

Number of Benefit A/C/R Segments: 001

On 6/1/12, the claim administrator filed the 00/IP reporting the initial payment of TT (050) andthe Benefit Adjustment Code for the safety violation (V050).

40

The Benefit Adjustment has not yet ended so the claim administrator must report the A/C/R Segment without the Benefit Adjustment End Date.




41

POP QUIZ:By what percentage

are indemnity benefits reduced

if the injured worker violates a safety

regulation?

42

ANSWER:

25%

43

Let’s take a look at the same claim with the next event – Change in Benefit Type.

44

On 6/29/12, the claim admin filed an MTC CB reporting the change in benefits from TT (050) to TP (070) …

BTCBenefit

TypeMTC

Gross Weekly

Amt.

Gross Eff. Date

Net Weekly

Amt.

Net Eff. Date

Start Date

Through Date

Weeks

Days

Amt. Paid

Payment Issue Date

050TEMPORARY

TOTALCB 400.00 5/19/12 300.00 5/19/12 5/19/12 6/15/12 4 0 1200.00

070TEMPORARY

PARTIALCB 384.00 6/16/12 288.00 6/16/12 6/16/12 6/29/12 2 0 576.00

MTC CB:

45

ending the Benefit Adjustment Segment for TT (V050) and beginning the Benefit Adjustment Segment for TP (V070).

On 6/29/12, the claim administrator filed an MTC CB reporting the change in benefits from TT (050) to TP (070),

BTCBenefit

TypeMTC

Gross Weekly

Amt.

Gross Eff. Date

Net Weekly

Amt.

Net Eff. Date

Start Date

Through Date

Weeks

Days

Amt. Paid

Payment Issue Date

050TEMPORARY

TOTALCB 400.00 5/19/12 300.00 5/19/12 5/19/12 6/15/12 4 0 1200.00

070TEMPORARY

PARTIALCB 384.00 6/16/12 288.00 6/16/12 6/16/12 6/29/12 2 0 576.00

MTC CB:



1 V Safety Violation 050 5/19/12 6/15/12 $100.00



46

Questions RegardingAdjustments

47

Benefit Credits

48

Benefit Credit Code

The Benefit Credit Code identifies a reduction that is applied to the Gross Weekly Amount to yield a new Net Weekly Amount, to recoup monies previously paid.

Values:

C = Overpayment P = Advance

49

Benefit Credit Start DateThe Benefit Credit Start Date is the first date of the uninterrupted period in which the current Benefit Credit Weekly Amount was applied to the Benefit Type Code.

50

Benefit Credit End DateThe Benefit Credit End Date is the last date through which the benefit credit was applied to the Benefit Type Code.

If the Benefit Credit is ongoing, the Benefit Credit End Date is left blank.

51

Benefit Credit Weekly Amount

The Benefit Credit Weekly Amount is the weekly amount of the benefit credit corresponding to the Benefit Credit Code.

52

Let’s take a look at a Benefit Credit scenario with an overpayment (Benefit Credit Code-C). The credit ended during the second event (after the 00/IP), so the claim administrator reported the A/C/R Segment with the Benefit Credit End Date.

53

Benefit Credit Example:

DOI = 5/18/12 IDDB = 5/19/12

Average Wage (AWW) = $325 (estimated wages)

Calculated Weekly Compensation Amount (Comp Rate) = $216.68

Gross Weekly Amount = $216.68 (TT rate)

Payment Amount = $216.68

The 00/IP was filed paying day 8-14 (1 wk) with a Payment Amount of $216.68.

54


On 6/30/12, the claim administrator received the injured worker’s actual wages from the employer reflecting an AWW of $300 and Comp Rate of $200.

By the time the actual wages were received, the injured worker had been overpaid by $100.08 (6 weeks).

55


Benefits can be reduced by no more than 20%* per week to recoup an overpayment. ($40 in this example)

*F.S. 440.15(12) - Repayment

56


On 7/13/12, the claim administrator filed an MTC CA reflecting: New AWW Calculated Weekly Comp Amount Gross Weekly Amount Net Weekly Amount Payment for weeks 1 through 8 AND Benefit Credit Code ‘C’ (Overpayment), recouping 20% ($40) of the weekly indemnity benefits for the overpayment.

57

First Event: The MTC CA is sent to report the recoupment of the overpayment ($100.08)

Dates of service overpaid 5/19/12 - 6/29/12 (6 wks)

58

Second Event:

Another MTC CA is sent reporting the end of the recoupment, and changing the Net Weekly Amount due to a new Credit Weekly Amount.

The Net Weekly Amount for the last week was reduced by $20.08 (not $40) as this was the balance of the overpayment…

59

…The Benefit Credit End Date is reported since the overpayment was recouped in full.

60

Third Event:

Another MTC CA is sent to report:The new Net Weekly AmountNew Net Effective Date and the advancement of the Benefit Period Through Date for TT benefits.

The A/C/R Segment is no longer required to be reported as the overpayment credit ended on the previous transaction.

61

If an ACR Segment ends, an MTC CA must be sent to:

Report the end date of the adjustment or credit and

Update the Net Weekly Amount and Net Weekly Amount Effective Date

62

POP QUIZ:True or False

If an injured worker is overpaid indemnity benefits,

payment of the total amount overpaid may not exceed 20% of the injured worker’s biweekly payment.

63

ANSWER:

TRUEF.S. 440.15(12) -

Repayment

64

Questions RegardingCredits

65

Redistributions

66

Benefit Redistribution CodeThe Benefit Redistribution

Code identifies that a portion of the Net Weekly Amount is being directed to another party on behalf of the employee or beneficiary, but which does not reduce the Gross Weekly Amount or affect the Net Weekly Amount.

67

The Benefit Redistribution Code used in FL is:

H = Court Ordered Lien

68

Benefit Redistribution Code ‘H’ is applicable where a portion of the injured employee’s payment is reduced/re-directed for payment of child support.

This code is also applicable for payment to a nursing home or assisted living facility on behalf of the injured worker, per alegal agreement.

69

Benefit Redistribution Start Date

The Benefit Redistribution Start Date isthe first date of the uninterrupted periodin which the current Benefit Redistribution Weekly Amount was applied to the Benefit Type Code.

70

Benefit Redistribution End DateThe Benefit Redistribution End

Date isthe last date through which the benefit redistribution was applied to the Benefit Type Code.

If the Benefit Redistribution is ongoing, the Benefit Redistribution End Date is left blank.

71

Benefit Redistribution Weekly AmountThe Benefit Redistribution

Weekly Amount is the weekly amount of benefit redistribution corresponding to the Benefit Redistribution Code.

72

Let’s take a look at a claim scenario where the Benefit Redistribution Code ‘H’ (Court Ordered Lien) was reported.The redistribution did not end so the claim administrator continued to report the A/C/R Segment without a Benefit Redistribution End Date.

73

Benefit Redistribution Example:

Average Wage (AWW) = $600

Calculated Weekly Compensation Amount (Comp Rate) = $400

Gross & Net Weekly Amount for TTD Benefits = $400

Due to a court order, benefits were reduced by 50% for payment of child support. ($200)

74

Example with Redistribution:

Gross Weekly Amt for TTD Benefits = $400

Net Weekly Amt for TTD Benefits = $400

Net Weekly Amt is NOT reduced to $200 because the same weekly amount is being paid by the claim administrator;

however, a portion ($200) of the Net Weekly Amount ($400) is being redistributed to another party.

Benefit Redistribution Amount = $200

75

BTCBenefit

TypeMTC

Gross Weekly

Amt.

Gross Eff. Date

Net Weekly

Amt.

Net Eff. Date

Start Date

Through Date

Weeks

Days

Amt. Paid

Payment Issue Date

050TEMPORARY

TOTALCA 400.00 5/19/13 400.00 5/19/13 5/19/13 6/29/13 6 0 $2400.00



1 H Court Ordered Lien 050 6/16/13 $200.00


MTC CA:

On 6/29/13, the claim admin filed an MTC CAwith the Benefit Redistribution Code ‘H’ (Court Ordered Lien) reporting that effective 6/16/13, a portion of the injured worker’s check was being sent to the appropriate entity for payment of child support.

76

In this scenario, the redistribution has not ended so the claim administrator must continue to report the A/C/R Segmentwithout the Benefit Redistribution End Date.

77

Questions RegardingRedistributions

78

Top Errors Affecting Claim Administrators

Continued…

79

Error #5:

GROSS WEEKLY AMOUNT IS > $.05 UNDER CALC GROSS WEEKLY AMOUNT (0174-045)

80

This error most commonly occurs whenthe Gross Weekly Amount for IB (030) benefits is reported as greater than $0.05 underthe jurisdiction calculated Gross Weekly Amount.

Common Errors Received By Claim Administrators:


81

FL Claims R3 Edit Matrix FL Calculation (Proprietary Tab)

82

This is a screenshot of the Errors Tab displayed in the Claims EDI Warehouse.

83

The following scenario is an example of when this Gross Weekly Amount error occurs…

Date of accident = 7/24/11 AWW = $663.45 C/R = $442.30 IRTW = 7/25/11 (Actual) (Day after acc) IDDB = 8/5/11 (out of work for surgery) 00/IP sent on 8/18/11 reporting the initial payment of TT (050) benefits.

84

The injured worker was “released” to Return To Work again on 9/2/11and he earned pre-injury wages.This should be reported as the Latest RTW Status DateThis Latest RTW Status Date was not reported on a SROI 02 prior to the next event - MTC CB.

85

The injured worker reached MMI on 9/28/11 (with 3% PIR). The claim administrator filed an MTC CB on 10/12/11. The Latest RTW Status Date of 9/2/11 was not sent on the CB.

86

The CB reported the change from TT (050) to IB (030) benefits with the Gross and Net Weekly Amounts as $165.83 (which is 50% of 75% of the Comp Rate – or 37.5%).

87

The MTC CB rejected with the error “Gross Weekly Amount is > $.05 Under Calc Gross Weekly Amount”.

In this scenario, our program is expecting BTC 030 to be paid at the higher rate($331.74 which is 75% of the CR)because it appears the injured worker is still out of work as the Latest RTW Status Date information was not reported.

88

The claim administrator will need to report the Latest RTW Status Date and corresponding RTW fields on the MTC CB transaction, along with the MMI & PI information.

89

This same Gross Weekly Amount error also occurs when a Current Date Disability Began is sent in conjunction with the initiation of IB (030) benefits.



90

FL has submitted a request to the IAIABC to modify the definition of Current Date Disability Beganin order to clarify that it is not used solely to report the initiation or change to Impairment Income Benefits (030).



91

POP QUIZ:What EDI document contains information

regarding the jurisdiction calculated Gross Weekly Amount?

92

ANSWER:The Edit Matrix

The Jurisdiction Calculated Weekly Amount can be found

on the FL Calculation (Proprietary)

Tab.

This document is located on the Division’s website:

http://www.myfloridacfo.com/Division/WC/EDI/Clms_EDI.htm

93

Questions Regarding Error #5:

GROSS WEEKLY AMOUNT IS > $.05 UNDER CALC GROSS WEEKLY

AMOUNT

94

Error #6:

GROSS WEEKLY AMOUNT IS > $.05 OVER CALC GROSS WEEKLY AMOUNT (0174-045)

95

This error most commonly occurs when the Gross Weekly Amount for IB (030) benefits is reported as greater than $0.05 over the jurisdiction calculated Gross Weekly Amount.

Common Errors Received By Claim Administrators

GROSS WEEKLY AMOUNT IS > $.05 OVER CALC GROSS WEEKLY AMOUNT (0174-

045)

96

This error most often occurs when the Gross Weekly Amount for IB (030) benefits is reported as the Comp Rate.

Effective 10/1/2013, an edit was added to Gross Weekly Amount. If the Gross Weekly Amount was reported the same as the Comp Rate, the transaction will reject.

Keep in mind, the Gross (and Net) Weekly Amounts should never be reported as the Comp Rate for IB (030) benefits.

97

POP QUIZ:

True or FalseGross and Net Weekly

Amounts are calculated at the same rate for BTC 050 (TT) and

BTC 030 (IB).

98

ANSWER:

FALSE

TT (050) benefits = 66 2/3% of AWW

IB (030) benefits = 75% or 37.5% of C/R

99

Questions Regarding Error #6

GROSS WEEKLY AMOUNT IS > $.05 OVER CALC GROSS WEEKLY

AMOUNT

100

Error #7:

NET WEEKLY AMOUNT MUST CHANGE VIA CA, CB, RB or AP (0087-059)

101

This error commonly occurs whenthe Net Weekly Amount reported on a Suspension (Sx) or Sub-Annual (SA) transaction has been changed and does not match the value previously reported.


NET WEEKLY AMOUNT MUST CHANGE VIA CA, CB, RB or AP (0087-059)

102

The Net Weekly Amount is not required to be reported on a Sub-Annual (SA) or Final (FN) transaction; however, if the MTC SA or FN is present in the Benefit Segment, it will be treated as an “Event” Benefit Segment and both the Gross and Net Weekly Amounts will be edited.

103

The Net Weekly Amount should be changed on a MTC CA – Change in Benefit Amount.

The Net Weekly Amount can change on one of the following MTCs if in conjunction with another applicable event: CB - Change in Benefit Type, RB - Reinstatement of Benefits, AP - Acquired/Payment…

104

In the past, trading partners were allowed to change the Net Weekly Amount on a SROI ‘02’ (Change) if they were not approved to send “secondary” MTCs.

At this time, all trading partners in production are approved to send “primary and secondary” MTCs; therefore, trading partners are no longer permitted to change the Net Weekly Amount on a SROI 02.

105

All references to the FL “primary and secondary” implementations in the FL Claims EDI R3 Edit Matrix will be removed in the next Rule revision.

106

POP QUIZ:

What MTC should be sent to report a

change in benefit amount?

107

ANSWER:

MTC CA

108

Questions Regarding Error #7

NET WEEKLY AMOUNT MUST CHANGE VIA CA, CB, RB or AP

109

MTC Review

110

Handouts will be passed out for this portion of the training…

111

Lump Sum Payments/Settle

ments

112

Lump Sum Payment/Settlement CodesThere are two types of Lump Sum Payment/Settlement Codes;Lump Sum Payments (which do not limit future liability) and Settlements (that do limit future liability).

113

NS

AS AW

AD

Lump Sum Payment Codes

AgreementStipulated

Award

AdvanceNon-SpecifiedPayment

114

A lump sum payment that is not being fully advanced, stipulated, awarded or settled, and does not apply to another LSP/S Code.

NSNon-Specified Lump Sum Payment

This does not limit future liability.

Lump Sum Payment Code ‘NS’

115

A Lump Sum Payment for Impairment Income Benefits (BTC 030), would be an example of a Non-Specified Lump Sum Payment (NS).

116

A Lump Sum Payment /Settlement Code is currently not required to be reported with a lump sum payment of IB’s; however, effective September 1, 2014, the Lump Sum Payment /Settlement Code NS will be required on the MTC PY for the reporting of 030 benefits in a lump sum.

117

A lump sum payment agreed upon by the parties of one or more benefit types for a disputed period of disability.

ASAgreement Stipulated


Lump Sum Payment Code ‘AS’

118

An adjudicated lump sum payment of one or more benefit types for a disputed period of disability.

AWAward


Lump Sum Payment Code ‘AW’

119

ADA lump sum payment of benefits in advance of when it is due.

This may be recouped as a weekly credit against future benefits not to exceed 20%.

Advance

Lump Sum Payment Code ‘AD’

120

If a rate and time period are specified for the lump sum payment, the Benefit Type Code/Payment Reason Code 0xx (vs. 5xx) series would be used.

If a rate and time period are not specified, the Benefit Type Code/Payment Reason Code 5xx series will be used.

121

SF SPSettlement Full

(washout)

Settlement Partial

Settlement Codes

122

A settlement agreed upon by all parties parties to end past, present and future liability of all benefits.

SF

No future indemnity or medical benefits are due.

Settlement Full (washout)

BTC 500 is required.

Settlement Code ‘SF’

123

A settlement agreed upon by all parties to: Settle all indemnity benefit type codes, but not medical. Settle all medical, but not indemnity.

Settlement PartialSP

Settlement Code ‘SP’

124

If all indemnity was previously settled and medical is now being settled, this should be reported as a Settlement Full (SF) rather than Settlement Partial (SP) because the claim is now fully settled.

Settlement Codes

125

Lump sum payments/settlements must be reported using the MTC Code “PY”. Lump sum payment/settlement transactions must have a Payments segment and a Benefits segment, unless Reduced Benefit Amt Code = S or N.

126

When the Lump Sum Payment/Settlement Code = SP or SF, Payment Reason Code must = 500, 524 or 501 for the most recent Payment Issue Date.

When the Lump Sum Payment/Settlement Code = SF, Payment Reason Code must = 500 or 524 or 500/524 is previously on file.

127

For FL, a Payments segment is always sent on an MTC ‘IP’ or a ‘PY’, unless Reduced Benefit Amount Code = S or N.

128

The indemnity benefits represented by the Payment Reason Code in the Payments segment

are also included in the Benefits segment with the corresponding Benefit Type Code.

BTCBenefit

TypeMTC

Gross Weekly Amt.

Gross Eff. Date

Net Weekly Amt.

Net Eff. Date

Start Date

Through Date

Weeks

Days

Amt. Paid

Ben Payment Issue Date

500UNSPEC

LUMP SUM PAY

PY 5/26/12 5/26/12 0 0 1500.00 5/26/12

Seg #

Pymnt Reason Code

Payee Amount Start DateThrough

DatePayment Issue

Date

1 500 Andrew Attorney & Associates 500 5/26/12 5/26/12 5/26/12

Lump Sum Payment/Settlement Codes

An Award/Order Date is required for all Lump Sum Payment/Settlements

unless the Lump Sum Payment/Settlement code equals:

AD (Advance < $2,000), or NS (Non-specified Payment) or BTC = 030 (IB) or BTC = 530 (Settlement of IB)

129

130

If indemnity benefits are ongoing following the Payment transaction, the next applicable transaction should then be filed (e.g., IP, AP, RB), to ensure their isn’t a sequencing problem.

Lump Sum Payment/Settlement Codes

131

For example:

An IP must follow a PY if the claim administrator has paid the lump sum amount (e.g. Award) and is now making an initial payment of ongoing indemnity benefits.

IP after PY

132

Lump Sum Payment followed by a later Settlement

for the same Benefit Type Code

(PY after PY)

133

Lump Sum Payments followed by a Settlement of same Benefit

Type CodeWhen an Advance, Award or Stipulated Agreement was previously reported with Benefit Type Code 500

AND a Full or Partial Settlement with Benefit Type Code 500 is now being reported…

134

… the Benefit Type Amount Paid for the 5xx BTC will include the Award or Stipulated Agreement amount as well as the new Settlement amount.

The Payment Amount in the Payments segment will only be the amount of the most recent Settlement Amount.

135

Lump Sum Payments/Settlements Covering

More Than 1 DOI

136

Settlements covering more than one Date of

InjuryA Full Settlement may involve more than one date of injury,

but the settlement amount (Payment Amount) will only be reported on one PY transaction.

137

If one or more claims (including Medical Only claims) were settled as part of another date of injury,

a PY, with the Reduced Benefit Amount Code ‘S’, is required to be sent for each claim, to report the settlement of that injury.

138

Only 1 claim will have the Settlement amount, and all others are reported with RBAC ‘S’.

Note: A FROI 00 will have to be sent with any DOI not previously reported to the Division.

Settlements covering more than one Date of

Injury

139

Reduced Benefit Amount Code ‘S’(Claim Settled Under

Another DOI)

140

PROPER USE OF REDUCED BENEFIT AMOUNT CODE ‘S’

(CLAIM SETTLED UNDER ANOTHER DOI)

The Reduced Benefit Amount Code ‘S’ should be reported via an MTC PY if a claim is settled and the settlement dollars for this claim are paid and reported underanother date of injury.

141

The presence of RBAC Code ‘S’ means that a ‘Payment’ segment will not be present on the transaction and a ‘Benefits’ segment will only be present on the transaction if

indemnity benefits had been paid for this date of injury prior to the settlement…

142

… The Award/Order Dates and Lump Sum Payment/Settlement Code (SF – Settlement Full) would be the same for all files.

143

Reduced Benefit Amount Code ‘N’

(No Money Settlement)

144

PROPER USE OF REDUCED BENEFIT AMOUNT CODE ‘N’

(NO MONEY SETTLEMENT)

The Reduced Benefit Amount Code “N”should be reported via an MTC PY if a claim was part of a ‘No Money Settlement’.

An example of a “No Money Settlement” includes a settlement with no dollars being paid, due to a waiver of a lien orforgiveness of an overpayment.

145

The presence of RBAC Code ‘N’ means

a ‘Payment’ segment will not be present on the transaction and

a ‘Benefits’ segment will only be present on the transaction if

indemnity benefits had been paid for this date of injury prior to the settlement…

146

… The Award/Order Date and Lump Sum Payment/Settlement Code (SF – Settlement Full) should be reported.

147

Questions?

148

Recent Law Change

149

Temporary Total Catastrophic benefits are paid to injured employees who have:

Sustained loss of arm, leg, hand or foot Been rendered a paraplegic, paraparetic, quadriplegic or quadriparetic or Lost sight in both eyes

Temporary Total Catastrophic (TTC)

150

In the past, Temporary Total Catastrophic (TTC) benefits were paid at the increased Comp Rate (80% of the Average Weekly Wage rather than 66 2/3%) for 26 weeks after the injury and subject to a max Comp Rate of $700.

151

Effective July 1, 2013, the $700 max Comp Rate cap was removed.Temporary Total Catastrophic benefits are now to be paid at 80% of the injured worker’s Average Weekly Wage, and are no longer subject to a maximum Comp Rate.

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Court Case Decision Escambia County

School Board v. Tina Vickery-Orso

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Comp Rate Calculation

The DCA decision in the case of Escambia County School Board v. Tina Vickery-Orso (1st DCA Case No. 12-4813)clarified the manner in which an injured worker’s comp rate is to be calculated.

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Previous calculation method:

AWW x .6667 (66 2/3%)

New calculation method:

(AWW x 2)/3

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There have not been any changes made to the Edit Matrix involving the new calculation of the Comp Rate. Our edits have been relaxed to allow for the minor difference between both calculation methods.

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A claim administrator can elect to continue using the previous calculation method (AWW x .6667) or use the new method (AWW x 2)/3).

The Division will accept either method submitted.

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2014 Updated IAIABC Release 3

Data Elements

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Claim Administrator Claim Number

(DN 0015)

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Claim Administrator Claim Number

(DN 0015) The definition of Claim Administrator Claim Number was updated to clarify that this number should be unique for each claim in the claim administrator’s system.

Therefore, a claim administrator should not report more than one claim with the same claim number.

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The Data Processing (DP) Rule for this definition was also updated to ensure that the Employee SSN is not reported as, or embedded in, the claim number.

This prevents confidentiality or redaction issues for states that must produce public records.

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In April 2013, the Division implemented edits to prevent the reporting of an Employee’s SSN in the Claim Administrator Claim Number field. The Division must take every precaution to avoid the accidental release of the employee’s SSN when a claim number is provided as part of a public records request.

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Benefit Payment Issue Date

(DN 0192)&

Payment Issue Date (DN 0195)

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Benefit Payment Issue Date (DN 0192) and Payment Issue

Date (DN 0195)The definitions for Benefit

Payment Issue Date & Payment Issue Date were

updated to include Electronic Fund

Transfer (EFT) payments made by the claim

administrator to an injured employee.

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The new definition for Benefit Payment Issue

Date and Payment Issue

Date is…

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…the date when the check that initiated the Maintenance Type Code (MTC) is officially surrendered during business hours to a letter delivery organization, is available for pickup per agreement with the employee orthe date the funds are available to the employee, if the payment is made by Electronic Funds Transfer (EFT).

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Benefit Payment Issue Date and Payment Issue Date are applicable to the following Maintenance Type Codes (MTCs):

IP - Initial Payment PY - Payment Report AP - Acquired/Payment and

RB - Reinstatement of Benefits

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If the claim administrator is opting to pay an injured employee via EFT, the claim administrator should be familiar with the bank’s process to ensure that the Payment Issue Date is reported accurately (the date the funds are available to the employee).

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Questions

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Open Discussion Questions/Issues

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Acquired Claims

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An acquired claim is anyexisting claim (open or closed) that was transferred to a new claim administrator.

Acquired Claims

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Acquired Claims

Keep in mind that any new claim occurring after the date of the acquisition is not considered acquired;therefore, the Division would expect the applicable First Report of Injury or Illness to be filed.

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To report an acquired claim, the new claim administrator is required to file an MTC AQ transaction for the following:

All open lost time claims

Any lost time claim closed within five years prior to the date of acquisition.

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If the new claim administrator files an MTC AQ

and the transaction rejects because the First Report of Injury or Illness (paper or EDI) has not been filed with the Division,

the new claim administrator must file a FROI AU with SROI (AP or other applicable SROI).

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Reminder: Even if the prior claim administrator did not file the First Report of Injury or Illness (paper or EDI) with the Division,the new claim administrator is still required to file the FROI because the insurer is ultimately responsible for the claim.

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Once the FROI MTC AQ accepts and an initial payment is made by the new claim administrator, a SROI AP (as opposed to a SROI IP) should be filed.

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All prior indemnity benefits paid by the previous claim administrator must be reported under Other Benefit Type (OBT) Code 430 (Total Unallocated Prior Indemnity Benefits).

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Florida does not require the acquiring claim administrator to report OBT Code 440 (Total Unallocated Prior Medical), as those costs are collected via the Division’s Medical EDI program.

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If the claim was closed at the time of acquisition and the acquiring claim administrator does not intend to make any future payments to the injured worker, once the FROI MTC AQ is accepted, no additional transactions will be due and the claim will remain closed in the Division’s database.

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If a new claim administrator acquires a claim,and the administration of that claim remains in the same claim system

(e.g. merger), the new claim administrator can send a FROI 02 (as opposed to an MTC AQ) to update the claim administrator information.

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The claim administrator will need to coordinate this with the EDI team prior to submitting the FROI 02 transactions.

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In this FROI 02 situation, any additional benefits reported on a future SROI would still be sent in the Benefit Segmentand no OBT 430 (Total Unallocated Prior Indemnity Benefits) would be present because the claim administrator is using the same system that was used prior to the acquisition.

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POP QUIZ:True or False

Once the FROI AQ accepts and an initial payment is made by the new claim administrator, a SROI IP

should be filed.

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ANSWER:

FALSE

MTC AP (Acquired/Payment)

should be filed because this is the first payment made by the acquiring claim administrator.

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New 2014 IAIABC Release 3 Data Element

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This is a code that indicates that Employer Paid ‘Unspecified’ Benefits,(Benefit Type Code (BTC) 240), were the only benefits paid prior to an acquisition.

Employer Paid Salary Prior to Acquisition Code ‘E’ (DN 0203)

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Why is this code needed?

Benefit Type Amount Paid (total money paid to date for a Benefit Type) cannot be required for Benefit Type Code 240 in accordance with the IAIABC standard; Therefore, there are no monies to carry over into OBT 430 (Total Unallocated Prior Indemnity Benefits).

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When a claim administrator acquires a claim,the total of all indemnity monies paid by the prior claim administrator (other than BTC 240) would now be reported under Other Benefit Type (OBT) Code 430.

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If BTC 240 was the only benefit paid prior to the acquisition, there will be no monies to reallocate to OBT Code 430.

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In the past, the IAIABC standard indicated that the OBT Code and Amount for 430 should be present on an AP,and had not taken into account the instance where only BTC 240 was reported prior to an acquisition,and no dollars would be reportable to reallocate into OBT 430. This was causing rejections…

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The Employer Paid Salary Prior to Acquisition Code ‘E’ was created to address this issue and explain why OBT 430 is not present on the acquiring payment transaction.

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Florida began accepting the Employer Paid Salary Prior to Acquisition Code ‘E’ on September 25, 2013.

Even though this code is not required, the use of it will eliminate a rejection when reporting a claim that has been acquired and only BTC 240 had previously been reported.

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If you are a claim administrator that does not acquire claims or salary in lieu of comp claims, you do not need to worry about this new data element.

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Questions

Thank You

florida division of workers’ compensation claims edi release 3 training february 12, 2014 day 2

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