1 sroi mtc 04 full denial after payment electronic notice of denial edi dwc-12 equivalent required...

1

SROI MTC 04SROI MTC 04Full Denial after Full Denial after

PaymentPayment

Electronic Notice of Electronic Notice of Denial Denial

EDI DWC-12 Equivalent required EDI DWC-12 Equivalent required to beto be filed with the Division per filed with the Division per

RuleRule 69L-56.3012(1), 69L-56.3012(1), F.A.C.F.A.C.

2

SROI 04SROI 04 - Full Denial after - Full Denial after PaymentPayment

EDI DWC-12 EquivalentEDI DWC-12 Equivalent

A A SROI 04SROI 04 should be filed if should be filed if no further indemnity or no further indemnity or medical benefits will be paidmedical benefits will be paid, , and/or the entire and/or the entire compensability of the claim is compensability of the claim is denied following the Initial denied following the Initial Payment (or Payment (or equivalent).equivalent).

3

SROI 04SROI 04 - Full Denial after - Full Denial after PaymentPayment


You would You would notnot send a SROI send a SROI PD with a new PD Code in PD with a new PD Code in this situation. this situation.

The The current status of the current status of the denial is required to be denial is required to be reportedreported; thus, if ; thus, if no further no further indemnity and medical will indemnity and medical will be paidbe paid, this is a Total , this is a Total Denial, not a Partial Denial. Denial, not a Partial Denial.

4

A A SROI 04SROI 04 acts like a acts like a suspension when suspension when benefit(s) are being benefit(s) are being terminated at the time of terminated at the time of the denial.the denial.

• Therefore, an Sx is not Therefore, an Sx is not required after the 04 required after the 04 before filing an FN.before filing an FN.

SROI 04 DENIAL SROI 04 DENIAL RULESRULES

5

In general, a In general, a SROI 04SROI 04 is expected to report is expected to report all of the previously all of the previously reported BTC’s and at reported BTC’s and at least the same least the same amount of $ amount of $ previously reported …previously reported …


6

… … However, we were However, we were made aware of a filing made aware of a filing situation where this did situation where this did not hold true, and not hold true, and therefore submitted an therefore submitted an

IRRIRR to solicit a to solicit a change change to the to the standard…standard…


7

Scenario:Scenario: After having After having filed an AQ, the filed an AQ, the acquiring Claim Admin acquiring Claim Admin decided to deny decided to deny payment of all further payment of all further indemnity and medical indemnity and medical benefits and filed a benefits and filed a SROI 04…SROI 04…

Pending IRRPending IRR

8

……But the SROI 04 But the SROI 04 rejected because our rejected because our program edits expected program edits expected to see the same BTC’s to see the same BTC’s previously reported. previously reported.

The prior BTC’s were The prior BTC’s were correctly reported under correctly reported under OBT 430, but OBT 430, but because because OBT’s are “X” OBT’s are “X” on the ERT for SROI on the ERT for SROI 04…04…


9

… … our program did not take our program did not take these benefits into account. these benefits into account.

We have therefore We have therefore requested that the ERT be requested that the ERT be changed to allow OBT’s to changed to allow OBT’s to be evaluated on a SROI 04.be evaluated on a SROI 04.

Note:Note: U Until then, we will apply ntil then, we will apply special processing if this special processing if this situation occurs. situation occurs.


10

SROI MTC PD SROI MTC PD

Partial Denial after Partial Denial after PaymentPayment

EDI DWC-12 Equivalent EDI DWC-12 Equivalent required to berequired to be filed with filed with DWC per Rule DWC per Rule 69L-69L-

56.3012(2), F.A.C.56.3012(2), F.A.C.

11

SROI PDSROI PD - Partial Denial after - Partial Denial after

PaymentPayment Electronic DWC-12 Electronic DWC-12

EquivalentEquivalent

A ‘standalone’ A ‘standalone’ SROI PDSROI PD should be filed if should be filed if indemnity benefits are indemnity benefits are denied (in whole or part) denied (in whole or part) following the report of following the report of Initial Payment.Initial Payment.

12

SROI PDSROI PD - Partial Denial after - Partial Denial after

PaymentPayment Electronic DWC-12 Electronic DWC-12

EquivalentEquivalent

The The SROI PD SROI PD must include:must include:

• Partial Denial Code Partial Denial Code A, B, E, or A, B, E, or G,G, and and

• Denial Reason Narrative. Denial Reason Narrative.

13

POP QUIZ:POP QUIZ:If a Full (Total Denial) or If a Full (Total Denial) or Indemnity Only Denied Indemnity Only Denied First Report of Injury or First Report of Injury or Illness was filed, and you Illness was filed, and you subsequently rescind the subsequently rescind the denial,denial, what MTC is used what MTC is used to report the Electronic to report the Electronic Notice of Denial Notice of Denial Rescission?Rescission?

14

ANSWER:ANSWER: To report a rescission of To report a rescission of a previous denial of a previous denial of

indemnity:indemnity:

SROI IP, EP, ER, RB, AP,SROI IP, EP, ER, RB, AP, oror

PD,PD, or or 0202

with ‘Denial Rescission Date’with ‘Denial Rescission Date’

15

Electronic Denial Electronic Denial RescissionRescission


AA SROI SROI PYPY will also rescind will also rescind a denial if Denial Rescission a denial if Denial Rescission Date is sent, but Date is sent, but

• Denial Rescission DateDenial Rescission Date is is not requirednot required on a PY with on a PY with Lump Sum Lump Sum Payment/Settlement Code Payment/Settlement Code SF or SP SF or SP (full settlements)…(full settlements)…

16

Electronic Denial Electronic Denial RescissionRescission


… … But if the PY reports, But if the PY reports, for example, an Advance, for example, an Advance, Denial Rescission DateDenial Rescission Date should be included, should be included, andand an an IP would also be IP would also be required to report required to report ongoing payment of ongoing payment of indemnity.indemnity.

17

Payment AfterPayment After DDenial enial

(Electronic (Electronic Notice of Denial Notice of Denial

Rescission)Rescission)EDI DWC-12 Equivalent EDI DWC-12 Equivalent

required to berequired to be filed with the filed with the Division per Rule Division per Rule 69L-69L-

56.3012(6), F.A.C.56.3012(6), F.A.C.

18

A SROIA SROI IP (or IP (or equivalent), RB, PD, AP, equivalent), RB, PD, AP, or 02or 02 should be filed if should be filed if you are you are rescinding a Full rescinding a Full Denial.Denial.

Note:Note: SROI SROI 0202 is used to is used to rescind if no indemnity is rescind if no indemnity is payable at the time of payable at the time of rescission.rescission.

Payment After Denial Payment After Denial (Denial Rescission) (Denial Rescission)

19


A SROI A SROI IP, RB, or 02IP, RB, or 02 should should be filed if you are be filed if you are rescinding a rescinding a Partial DenialPartial Denial (where some or (where some or all indemnity benefits all indemnity benefits previously denied will now be previously denied will now be paid).paid).

•Again,Again, SROI 02SROI 02 is used to is used to rescind if no indemnity is rescind if no indemnity is payable at the time of payable at the time of rescission.rescission.

20

Whichever MTC is used to Whichever MTC is used to rescind, the Denial Rescission rescind, the Denial Rescission Date must be included. Date must be included.

Recap:Recap: The The Denial Rescission Denial Rescission DateDate equates to the date you equates to the date you took the action to rescind the took the action to rescind the denial, NOT the effective date denial, NOT the effective date from which benefits will be from which benefits will be paid. paid.

Payment After Denial Payment After Denial (Denial Rescission)(Denial Rescission)

21

If a denial notice is If a denial notice is not ‘on file’ (e.g., PD not ‘on file’ (e.g., PD rejected), you will not rejected), you will not be able to file a denial be able to file a denial rescission transaction rescission transaction (e.g., IP). (e.g., IP).


22

DWC edits do not allow DWC edits do not allow an IP to rescind the an IP to rescind the denial if the Denial denial if the Denial Rescission Date on the Rescission Date on the IP is IP is prior toprior to the the ‘effective date’, a/k/a ‘effective date’, a/k/a MTC Date of the PD.MTC Date of the PD.


23

This may become an issue This may become an issue since the R3 transaction does since the R3 transaction does not have an actual date field not have an actual date field that identifies when the Partial that identifies when the Partial Denial was ‘effective’ - FL uses Denial was ‘effective’ - FL uses the MTC Date of the PD for the MTC Date of the PD for this purpose. this purpose.

The PD MTC Date may be later The PD MTC Date may be later than the date you initially took than the date you initially took action to partially deny if the action to partially deny if the PD rejected multiple times...PD rejected multiple times...


24

For example:For example:

PD sent with MTC Date PD sent with MTC Date of 12/17/09; PD rejected; of 12/17/09; PD rejected;

IP sent on 12/18/09 with IP sent on 12/18/09 with Denial Rescission Date of Denial Rescission Date of 12/17/09; IP rejected …12/17/09; IP rejected …


25

… …

PD PD re-sentre-sent with MTC Date of with MTC Date of 12/30/09; PD accepted. 12/30/09; PD accepted.

IP IP re-sent re-sent with Denial Rescission with Denial Rescission Date of 12/17/09; IP rejects since Date of 12/17/09; IP rejects since Denial Rescission Date is prior to Denial Rescission Date is prior to the effective date of the PD (MTC the effective date of the PD (MTC Date of 12/30/09.)Date of 12/30/09.)

Therefore, the IP must be re-sent Therefore, the IP must be re-sent with Denial Rescission Date on or with Denial Rescission Date on or after 12/30/09.after 12/30/09.


26

This issue will be forwarded This issue will be forwarded to the IAIABC for resolution, to the IAIABC for resolution, e.g., changing ‘Full Denial e.g., changing ‘Full Denial Effective Date’ to ‘Denial Effective Date’ to ‘Denial Effective Date’ so there will Effective Date’ so there will be one (unchanging) date to be one (unchanging) date to compare to Denial compare to Denial Rescission Date.Rescission Date.


27

Questions?Questions?

28

ChangeChange

in Benefit in Benefit AmountAmount

29

SROI CA - Change in Benefit SROI CA - Change in Benefit AmountAmount


A SROI A SROI CA, CA, EDI DWC-4 EDI DWC-4 Equivalent,Equivalent, is required to be is required to be filed with DWCfiled with DWC iif the f the Net Net Weekly AmountWeekly Amount increases or increases or decreasesdecreases due to the due to the recalculation of the Gross recalculation of the Gross Weekly Amount, or due to the Weekly Amount, or due to the application of adjustments or application of adjustments or credits.credits.

See Rule 69L-56.3045(2), F.A.C.See Rule 69L-56.3045(2), F.A.C...

30



If you receive a wage If you receive a wage statement (after the 00/IP) statement (after the 00/IP) that either raises or lowers that either raises or lowers the AWW/CR and therefore the AWW/CR and therefore changes the Gross/Net changes the Gross/Net Weekly Amounts, ifWeekly Amounts, if not also not also changing benefitschanging benefits, you , you would file a CA.would file a CA.

31



MTC “CA” is typically used when:MTC “CA” is typically used when:

• Indemnity benefits are currently Indemnity benefits are currently being paid, being paid,

• The The Net Weekly Amount changesNet Weekly Amount changes due to re-calculationdue to re-calculation of the Gross of the Gross Weekly Amount or application of Weekly Amount or application of adjustments and/or credits, …adjustments and/or credits, …

32

SROI CA - Change in Benefit AmountSROI CA - Change in Benefit Amount EDI DWC-4 EquivalentEDI DWC-4 Equivalent

… … Additionally, you would also file a CA in relation to Additionally, you would also file a CA in relation to non-current non-current benefits where a suspension benefits where a suspension (Sx) was previously filed, after which the (Sx) was previously filed, after which the Net Weekly Amount Net Weekly Amount changed.changed.•Additional adjustment check to EE must be for the Additional adjustment check to EE must be for the same period of indemnity previously paid same period of indemnity previously paid (i.e., end dates (i.e., end dates

cannot advance.) cannot advance.)

33

SROI CA - Change in Benefit AmountSROI CA - Change in Benefit Amount EDI DWC-4 EquivalentEDI DWC-4 Equivalent

MTC “CA” is MTC “CA” is NOTNOT used when: used when:

• The Average Wage or The Average Wage or Concurrent Employer Wage Concurrent Employer Wage changes, but changes, but the Net Weekly the Net Weekly Amount does not change.Amount does not change. (Comp Rate at max) (Comp Rate at max)

• MTCMTC “02” “02” should be filed should be filed

instead.instead.

34



Also, FL does not require Also, FL does not require MTC CA to be filed each MTC CA to be filed each time the payment rate time the payment rate for TP (070) changes due for TP (070) changes due to fluctuations in the to fluctuations in the EE’s earnings.EE’s earnings.

35



However, Rule 69L-56 will However, Rule 69L-56 will be amended to require be amended to require SROI CA to report a change SROI CA to report a change in Net Weekly Amount for in Net Weekly Amount for IB (030) when IB payment IB (030) when IB payment rate changes due to wage rate changes due to wage fluctuations (per court case fluctuations (per court case discussed earlier.)discussed earlier.)

36

Caveats andCaveats andTips for Tips for

Successfully Successfully Filing Filing SROI MTC SROI MTC

CACA

37

If you are trying to file a If you are trying to file a CA, but a Suspension CA, but a Suspension transaction (Sx) was transaction (Sx) was filed in filed in error:error:

• Do Do not not file an RBfile an RB to get to get around the edit that around the edit that indicates an RB should indicates an RB should have been filed after the have been filed after the Sx… Sx…

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CAFiling of CA

38

• … … Instead, contact the Instead, contact the EDI Team for special EDI Team for special processing assistance. processing assistance.

• We will manually We will manually remove the suspension remove the suspension status from DWC’s status from DWC’s

database and re-database and re-process the CA.process the CA.


39


One error we are seeing One error we are seeing a lot for SROI CA filings a lot for SROI CA filings is:is:

NBR OF BENEFITSNBR OF BENEFITS SHOULD NOT BE SHOULD NOT BE >> WHAT IS WHAT IS

ON FILEON FILE

40


• This means the CA This means the CA contained a BTC(s) that contained a BTC(s) that was not previously was not previously reported. reported.

• A A CBCB will need to be filed will need to be filed to ‘introduce’ the new to ‘introduce’ the new BTC. BTC.

41

Conversely, the error..Conversely, the error..

BEN TYPE CODEBEN TYPE CODE PREVIOUSLY PREVIOUSLY REPORTED NOT SENT ON SROIREPORTED NOT SENT ON SROI

… … is occurring where a is occurring where a BTC(s) ‘on file’ is missing BTC(s) ‘on file’ is missing from the CA.from the CA.


42

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CAFiling of CA If the wrong BTC was If the wrong BTC was previously reported and never previously reported and never actually paid, you will need to actually paid, you will need to file an 02 with the “R” code to file an 02 with the “R” code to reclassify those benefits. reclassify those benefits.

• In this case a CA is not In this case a CA is not needed because you are needed because you are totally replacing the prior totally replacing the prior benefit with a new BTC and benefit with a new BTC and new Net.new Net.

43

BENEFIT TYPE AMOUNTBENEFIT TYPE AMOUNT PAID PAID

< PREVIOUSLY REPORTED < PREVIOUSLY REPORTED

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CAFiling of CAAnother error occurring Another error occurring frequently for SROI CA frequently for SROI CA filings is:filings is:

44

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CAFiling of CAA A reductionreduction in either the in either the number of BTC’s or the number of BTC’s or the amount paid for a BTC must amount paid for a BTC must be ‘explained’ by reporting:be ‘explained’ by reporting:

• Reduced Benefit Amount Reduced Benefit Amount Code ‘R’Code ‘R’ (Reclassification), or (Reclassification), or

• Recovery CodeRecovery Code, or, or• AdjustmentAdjustment, or, or

• CreditCredit information. information.

45


46

Let’s now discuss Let’s now discuss Adjustments, Adjustments,

Credits & Credits & Redistributions Redistributions

(A/C/R’s)(A/C/R’s)

47

NET < FL CALC GROSS AMT NET < FL CALC GROSS AMT MINUS ADJ/CREDIT MINUS ADJ/CREDIT

AMTSAMTS andand

NET $.05 OVER FL CALC GROSS NET $.05 OVER FL CALC GROSS MINUS ADJ/CREDIT MINUS ADJ/CREDIT

AMTSAMTS

The below errors (addressed The below errors (addressed earlier) also occur when the earlier) also occur when the Gross Weekly Amount Gross Weekly Amount (computed by DWC) (computed by DWC) minus the minus the Adj or Credit Amount sentAdj or Credit Amount sent does does not equal the Net Weekly not equal the Net Weekly Amount reported:Amount reported:

48

• If Net Weekly Amt is If Net Weekly Amt is differentdifferent from the from the Gross Weekly Amount, the Gross Weekly Amount, the applicable applicable Adjustment or Adjustment or Credit information must be Credit information must be sent.sent.

Net Weekly AmountNet Weekly AmountThe Net Weekly Amount The Net Weekly Amount equals the Gross Weekly equals the Gross Weekly Amount Amount minus any applicable minus any applicable adjustments or creditsadjustments or credits for the for the corresponding benefit type.corresponding benefit type.

49

Benefit Adjustment Benefit Adjustment CodesCodesDefinition:Definition: A code that A code that

identifies reductions applied identifies reductions applied to the Gross Weekly Amount to the Gross Weekly Amount resulting in resulting in a new Net Weekly a new Net Weekly AmountAmount for a specific benefit for a specific benefit type.type.

Format:Format: 4 A/N 4 A/N (B(BNNNNNN))

BB = Benefit Adjustment = Benefit Adjustment Code Code

NNNNNN = Benefit Type Codes = Benefit Type Codes

50

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

Benefit Adjustment Benefit Adjustment Start DateStart Date

51

Definition:Definition: The last date The last date through which the benefit through which the benefit adjustment was applied to adjustment was applied to the Benefit Type Code.the Benefit Type Code.

• If the Benefit If the Benefit Adjustment is ongoing, Adjustment is ongoing, the Benefit Adjustment the Benefit Adjustment End Date is End Date is blankblank..

Benefit Adjustment End Benefit Adjustment End DateDate

52

Definition:Definition: The The weeklyweekly amount of benefit amount of benefit adjustment adjustment corresponding to the corresponding to the Benefit Adjustment Code.Benefit Adjustment Code.

Benefit Adjustment Benefit Adjustment Weekly AmountWeekly Amount

53

Benefit Adjustment Benefit Adjustment Example Example (Scenario 6-B-4 (Scenario 6-B-4

on web):on web):

Average Wage (AWW) = Average Wage (AWW) = $600$600

Calculated Weekly Compensation Calculated Weekly Compensation Amount (Comp Rate) = Amount (Comp Rate) = $400$400

Gross Weekly Amount for TTD Gross Weekly Amount for TTD Benefits = Benefits = $400$400

Social Security Offset - Benefits Social Security Offset - Benefits reduced by reduced by $100$100 per week per week

54

Example with Social Security Example with Social Security Offset:Offset:

Gross Weekly Amt for PT Benefits Gross Weekly Amt for PT Benefits = = $400$400

Net Weekly Amt for PT Benefits = Net Weekly Amt for PT Benefits = $300$300

Benefit Adjustment Weekly Amt = Benefit Adjustment Weekly Amt = $100$100

55

BenefitsBenefits Segment for BTC (020) Segment for BTC (020) affected by change (other BTC’s affected by change (other BTC’s are ‘sweeps’):are ‘sweeps’):

56

A/C/R Segment of A/C/R Segment of TransactionTransaction

57

Benefit Credit Benefit Credit CodesCodesDefinition:Definition: A code identifying a A code identifying a

reduction that is applied to reduction that is applied to the Gross Weekly Amount to the Gross Weekly Amount to yield a new Net Weekly yield a new Net Weekly Amount Amount to recoup moniesto recoup monies previously paid.previously paid.

Values:Values:

CC = = Overpayment Overpayment PP = Advance= Advance

58

Benefit Credit Example:Benefit Credit Example:


Calculated Weekly Calculated Weekly Compensation Amount (Comp Compensation Amount (Comp Rate) = Rate) = $400$400

Gross Amount for TTD Benefits Gross Amount for TTD Benefits = = $400$400

Overpayment occurred – Overpayment occurred – Benefits reduced by Benefits reduced by $80$80 per per week to recoup overpayment.week to recoup overpayment.

59

Example with Credit Example with Credit Adjustment:Adjustment:

Gross Weekly Amt for TTD Gross Weekly Amt for TTD = = $400$400

Net Weekly Amt for TTD = Net Weekly Amt for TTD = $320$320

Benefit Credit Amount = Benefit Credit Amount = $80$80

60

Benefit Redistribution Benefit Redistribution CodeCode Definition:Definition: A code identifying A code identifying

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

Values:Values:

• ‘ ‘H’H’ = Court Ordered Lien = Court Ordered Lien (e.g., child (e.g., child support)support)

61

Benefit Redistribution Benefit Redistribution CodeCode ‘ ‘H’H’ is also applicable is also applicable

where a portion of the EE’s where a portion of the EE’s payment (e.g. PT ) is payment (e.g. PT ) is reduced/re-directed to a reduced/re-directed to a nursing home, assisted nursing home, assisted living facility, per a legal living facility, per a legal agreement.agreement.

62

Benefit Redistribution Benefit Redistribution Example:Example:


Calculated Weekly Calculated Weekly Compensation Amount (Comp Compensation Amount (Comp Rate) = Rate) = $400$400

Gross & Net Weekly Amount for Gross & Net Weekly Amount for TTD Benefits = TTD Benefits = $400$400

Court ordered benefits to be Court ordered benefits to be reduced by reduced by 50% to pay for 50% to pay for assisted living costs per legal assisted living costs per legal agreement.agreement.

63

Example with Example with Redistribution:Redistribution:

Gross Weekly Amt for TTD Gross Weekly Amt for TTD Benefits = Benefits = $400$400

Net Weekly Amt for TTD Net Weekly Amt for TTD Benefits = Benefits = $400$400 (NOT reduced (NOT reduced to $200 because the same to $200 because the same weekly amount is being paid; weekly amount is being paid; a a portion of the Net $400 is just portion of the Net $400 is just being redistributed to another being redistributed to another partyparty.).)

Benefit Redistribution Amount Benefit Redistribution Amount = = $200$200..

64

A/C/R SegmentsA/C/R SegmentsA/C/R segment should A/C/R segment should

always and only be always and only be included in each SROI included in each SROI transaction when:transaction when:

• ACR is currently being ACR is currently being appliedapplied to the to the Benefits Benefits segment that is being segment that is being reported; or reported; or •ACR is ending.ACR is ending.

65

A/C/R SegmentsA/C/R SegmentsACR’s are also reported ACR’s are also reported

on Periodics (SA, FN) on Periodics (SA, FN) when still being applied to when still being applied to a BTC that is currently a BTC that is currently being paid. being paid.

66

A/C/R SegmentsA/C/R Segments

ACR’s ACR’s previously reported previously reported (via paper or EDI) and (via paper or EDI) and ended before you moved to ended before you moved to R3 or are now endedR3 or are now ended at the at the time of the current filing time of the current filing (i.e., where ACR End Date (i.e., where ACR End Date was previously sent) are was previously sent) are notnot required required to be to be reported on subsequent reported on subsequent transactions (e.g., transactions (e.g., Periodics.)Periodics.)

67

A/C/R SegmentsA/C/R Segments However, ifHowever, if A/C/R SegmentA/C/R Segment data continues to be applied data continues to be applied after you move to R3 and is after you move to R3 and is continuing at the time of the continuing at the time of the current filing, A/C/R current filing, A/C/R information must continue to information must continue to be reported on SROI’s until be reported on SROI’s until the A/C/R is ended or the the A/C/R is ended or the claim is denied/settled.claim is denied/settled.

68


Types of ACR’s to be Types of ACR’s to be reported are identified reported are identified in the in the Value TableValue Table worksheet of FL’s Edit worksheet of FL’s Edit Matrix. Matrix.

69


The Benefit ACR End The Benefit ACR End Date is only populated Date is only populated when the adjustment, when the adjustment, credit or redistribution credit or redistribution has ended or benefits has ended or benefits are suspended (Sx).are suspended (Sx).

70

SCENARIO:SCENARIO:SROI MTC CASROI MTC CA

Change in AmountChange in Amount

With Benefit With Benefit Adjustment and Adjustment and

Overpayment CreditOverpayment Credit

71

SROI MTC CA ScenarioSROI MTC CA Scenario Change in Amount w/Benefit Adj. Change in Amount w/Benefit Adj.

and O/P (Scenario 6-B-2 on web)and O/P (Scenario 6-B-2 on web)

00/IP filed reporting 00/IP filed reporting payment of TT (050) payment of TT (050) benefits.benefits.

Further investigation Further investigation revealed EE did not use a revealed EE did not use a safety device required by safety device required by the employer.the employer.

72


and O/Pand O/P Net Weekly Amount was reduced Net Weekly Amount was reduced

to $300 (25% of $400 = $100) due to $300 (25% of $400 = $100) due to the application of a to the application of a Benefit Benefit Adjustment for a Safety Violation, Adjustment for a Safety Violation, andand

The Net Weekly Amount was The Net Weekly Amount was further reduced to $250 due to further reduced to $250 due to the application of a $50/wk the application of a $50/wk overpayment creditoverpayment credit..

73

These changes reduced the Net These changes reduced the Net Weekly Amount from $400 to Weekly Amount from $400 to $300, resulting in an overpayment $300, resulting in an overpayment of $100.of $100.

The claim administrator will take a The claim administrator will take a credit of $50 for each of the next credit of $50 for each of the next two weeks, thus further reducing two weeks, thus further reducing the Net to $250. the Net to $250.


and O/Pand O/P

74

On 7/13/07, the Claim Admin. On 7/13/07, the Claim Admin. issues a check for the 2nd issues a check for the 2nd installment of TT benefits installment of TT benefits (waiting wk + weeks 3 & 4),(waiting wk + weeks 3 & 4),

and and

Reports the change in the Reports the change in the weekly TT payment rate to DWC weekly TT payment rate to DWC by sending SROI MTC by sending SROI MTC “CA”.“CA”.


and O/Pand O/P

75

Claim Admin. Sends SROI “CA” on Claim Admin. Sends SROI “CA” on 7/13/07 to report the change in 7/13/07 to report the change in

Net/Gross Amounts.Net/Gross Amounts.

Partial Display of SROI Record Layout – (only pertinent DN’s displayed)


and O/Pand O/P

76

Comp Rate remains at Comp Rate remains at $400.00 $400.00 (two thirds of (two thirds of

Average Wage)Average Wage)


and O/Pand O/P

77


and O/Pand O/P

78Effective Date of Credit (beginning of TT Effective Date of Credit (beginning of TT week 3)week 3)


and O/Pand O/P

79


and O/Pand O/P

80


and O/Pand O/P

81

When the next check is When the next check is issued, the Claim Admin. issued, the Claim Admin. will need to send another will need to send another “CA” transaction to the “CA” transaction to the Division to report a new Net Division to report a new Net Weekly Amount of Weekly Amount of $300$300 effective effective 7-14-077-14-07, due to the , due to the ending of the OP Credit.ending of the OP Credit.


and O/Pand O/P

82

QUESTIONS?QUESTIONS?

83

POP QUIZ:POP QUIZ:

What MTC is filed What MTC is filed when you when you

need to need to report a report a change in AWW/CR, but change in AWW/CR, but the Gross/Net Weekly the Gross/Net Weekly

Amount is not Amount is not changed?changed?

84

Answer:Answer:

SROI MTC 02SROI MTC 02

85

MTC 02 (as opposed to a MTC 02 (as opposed to a CA) is CA) is required required to report to report changes changes to a DN in the to a DN in the Benefit or ACR segment, Benefit or ACR segment, whenwhen the benefit will the benefit will continue to be paid at the continue to be paid at the same statutory maximum same statutory maximum weekly rate. This is because weekly rate. This is because there is there is NO CHANGE TO NO CHANGE TO THE NET WEEKLY AMOUNT. THE NET WEEKLY AMOUNT.

MTC 02 ChangeMTC 02 Change

86

An An 0202 is also required to be is also required to be filed with the Division if:filed with the Division if:

• A DN designated as A DN designated as “Y”, “Y”, “YC”, “Y“YC”, “Y11”, “Y”, “Y22”, “Y”, “Y33”, ”, “Y“Y44”,”, “fy”“fy” or or “FY”“FY” in the in the FROI/SROI 02 columns of FROI/SROI 02 columns of the FL Element the FL Element Requirement Table (ERT) Requirement Table (ERT) changes.changes.

See Rules 69L-See Rules 69L-56.30456.304, & 69L-, & 69L-56.56.30453045, F.A.C., F.A.C.


87

This equates to many more This equates to many more electronic notices of change electronic notices of change than were formerly required than were formerly required to be reported to DWC via to be reported to DWC via the paper Form DWC-4. the paper Form DWC-4.

• Only the 02’s required in Only the 02’s required in Rule Rule 69L-69L-56.30456.304,, F.A.C. F.A.C. represent EDI DWC-4 represent EDI DWC-4 equivalents.equivalents.


88

If your system is If your system is notnot set set up to auto-trigger MTC 02 up to auto-trigger MTC 02 filings on the basis of a filings on the basis of a change to all of the change to all of the designated DN’s, you designated DN’s, you should review the should review the Element Requirement Element Requirement Table to determine which Table to determine which 02 changes are 02 changes are required to be required to be reported.reported.


89

MTC 02 Change MTC 02 Change Processing Processing

RulesRules

90

Change Processing RulesChange Processing RulesTransaction UsageTransaction Usage

MTC 02MTC 02 (Change) (Change) transaction is intended to: transaction is intended to: •Allow Claim Administrators Allow Claim Administrators to to correctcorrect data previously data previously reported erroneously and/or, reported erroneously and/or,

•Allow Claim Administrators Allow Claim Administrators to to updateupdate previously previously reported data.reported data.

91

02

Change Processing RulesChange Processing RulesTransaction UsageTransaction Usage

MTC “02”MTC “02” should should notnot be be used to report used to report a change in a change in data where data where other other transactions transactions are intended are intended to serve that to serve that purpose.purpose.

CACBABRB

P7

92

Change Processing RulesChange Processing Rules Transaction UsageTransaction Usage

If a data element designated If a data element designated as as

FY, fy, Y, YFY, fy, Y, Y11, Y, Y22, Y, Y33, Y, Y44 or YC or YC in in the the MTC 02MTC 02 column of the ERT is column of the ERT is changed, the Claim changed, the Claim Administrator must trigger an Administrator must trigger an “02”“02” (Change) transaction, (Change) transaction, unless another MTC applies.unless another MTC applies.

93


If a DN designated as If a DN designated as NN11 in in the the 0202 column of the ERT is column of the ERT is changed, you can send an 02 changed, you can send an 02 (Change) unless another MTC (Change) unless another MTC applies; applies; • However, an However, an “02”“02” is not is not required every time the required every time the value in this field changes …value in this field changes …

94


Example:Example: Benefit Type Amount Paid is Benefit Type Amount Paid is designated as designated as NN1 :1 :

• If you have reported it incorrectly, If you have reported it incorrectly, you should file an you should file an MTC 02MTC 02 ; ;

• However, if the Benefit Type However, if the Benefit Type Amount Paid changes/increases Amount Paid changes/increases because you paid another bi-because you paid another bi-weekly check, we do not need or weekly check, we do not need or want an want an MTC 02.MTC 02.

95

Change Processing RulesChange Processing RulesFlorida has expanded on the ERT standard Florida has expanded on the ERT standard Requirement Codes for Requirement Codes for MTC 02MTC 02. .

See sample of MTC 02 legend at bottom of SROI ERT.See sample of MTC 02 legend at bottom of SROI ERT.

96



0202

97

Send Send MTC “02”MTC “02” (Change) transactions (Change) transactions at the appropriate time at the appropriate time to avoid transactionsto avoid transactions rejecting, i.e. ...rejecting, i.e. ...

Caveats and Tips for Successful Caveats and Tips for Successful Filing of 02Filing of 02

98

… … changes to certain DN’s changes to certain DN’s can’t just ‘show up’ on any can’t just ‘show up’ on any MTC - the change must be MTC - the change must be purposely changed first via purposely changed first via MTC 02MTC 02. . • For example, changes to For example, changes to RTW-related data must be RTW-related data must be reported via reported via MTC 02MTC 02 (or other (or other appropriate MTC)appropriate MTC) before before sending an MTC SA sending an MTC SA transaction containing the transaction containing the new RTW data.new RTW data.


99

Analyze Analyze Florida’s Florida’s Element Requirement Element Requirement TableTable and and Edit MatrixEdit Matrix to learn how data to learn how data element(s) will be element(s) will be processed on processed on MTC 02MTC 02 Change transactions.Change transactions.


100

Important: The Important: The JCNJCN sent on the SROI sent on the SROI MTC MTC 0202 must matchmust match the JCN the JCN ‘on file’ for the ‘on file’ for the existing existing SSN/DOI.SSN/DOI.


101

One of the most frequently One of the most frequently occurring errors we are seeing occurring errors we are seeing for both FROI and SROI 02 filings for both FROI and SROI 02 filings is where the JCN is not even is where the JCN is not even sent.sent. •JCN is always required for an JCN is always required for an 02 filing.02 filing.

•You may want to review your You may want to review your system to ensure it enforces system to ensure it enforces the JCN for MTC 02 filings.the JCN for MTC 02 filings.


102

If a data element has a If a data element has a “Y“Yxx” on both the FROI ” on both the FROI and SROI, an and SROI, an “02”“02” can can be sent on either the be sent on either the FROI or SROI. FROI or SROI.


103

The MTC 02 The MTC 02 mustmust be be included included in the Benefit in the Benefit segmentsegment in order for in order for the DWC’s program to the DWC’s program to process any changes to process any changes to the Benefits, OBT, the Benefits, OBT, Payments, or ACR Payments, or ACR segments sent on the segments sent on the 02.02.


104

Changes to data elements report Changes to data elements report designated as designated as “N”, “NA” or “X”“N”, “NA” or “X” on on FL’s Element Requirement Table FL’s Element Requirement Table reported via MTC 02 reported via MTC 02 will will notnot be be edited/loaded to DWC’s database.edited/loaded to DWC’s database.


105

Also, invalid data sent Also, invalid data sent on an on an MTC 02MTC 02 will not will not overlay existing ‘good’ overlay existing ‘good’ data on DWC’s database.data on DWC’s database.


106

Data previously required Data previously required or reported on another or reported on another transaction will be transaction will be expected to be included expected to be included on the on the MTC 02MTC 02 transaction. transaction.


107


Exception:Exception:

• If you previously reported If you previously reported the wrong BTC, you can file the wrong BTC, you can file an 02 to show a total an 02 to show a total reclassification of one BTC reclassification of one BTC to another BTC e.g., to another BTC e.g., correctingcorrecting TT (050) to TP (070). TT (050) to TP (070).

• RBAC “R” must be included.RBAC “R” must be included.

108

When sending an 02 to report When sending an 02 to report a correction, be sure to update a correction, be sure to update the MTC Date. the MTC Date.

• MTC Date should not be MTC Date should not be older than 7 days from the older than 7 days from the date the transaction is being date the transaction is being sent (any MTC) – this will sent (any MTC) – this will reject. reject.


109

DWC compares the current DWC compares the current transaction to the ‘current’ transaction to the ‘current’ filing on its system: filing on its system:

• If DWC processes/accepts a If DWC processes/accepts a current transaction with an current transaction with an older MTC Date (within the 7 older MTC Date (within the 7 days leeway allowed), that days leeway allowed), that filing would be compared to filing would be compared to the filing that preceded it …the filing that preceded it …


110

… … based on the MTC date and based on the MTC date and not the date the transaction not the date the transaction was actually sent to / received was actually sent to / received by DWC. by DWC.

• This may result in filing This may result in filing errors. For example …errors. For example …


111

SROI 02-Recvd 7/11/2008-MTC Date SROI 02-Recvd 7/11/2008-MTC Date 7/11/087/11/08

(Contained (Contained 11 BTC) BTC)SROI PY-Recvd 7/12/2008-MTC Date SROI PY-Recvd 7/12/2008-MTC Date 7/7/1010/08/08 (Contained 2 BTC’s)(Contained 2 BTC’s)SROI FN-Recvd 7/12/2008-MTC Date SROI FN-Recvd 7/12/2008-MTC Date 7/12/087/12/08 (Contained 2 BTC’s)(Contained 2 BTC’s)

The FN rejected because the The FN rejected because the “current” benefit form being “current” benefit form being compared to the FN is the SROI 02 compared to the FN is the SROI 02 (most recent MTC Date prior to FN) (most recent MTC Date prior to FN) which only had 1 BTC segment. MTC which only had 1 BTC segment. MTC FN can not introduce a new BTC.FN can not introduce a new BTC.

112

Florida will Florida will notnot be setting data be setting data to spaces based on MTC 02 to spaces based on MTC 02 (absence of/removing data).(absence of/removing data).

If a data element was If a data element was reported in error and needs to reported in error and needs to be be removedremoved (vs. changed), (vs. changed), contact the Claims EDI Team contact the Claims EDI Team for special handling. for special handling.


113

If a data element is If a data element is changed and changed and not requirednot required (NA), per FL’s Element (NA), per FL’s Element Requirement Table for the Requirement Table for the particular MTC being particular MTC being reported, but is reported, but is sent on that MTC, that data sent on that MTC, that data element element will will notnot be be edited/loadededited/loaded to the to the Division’s database Division’s database because it is because it is not requirednot required (e.g., Nmbr Days (e.g., Nmbr Days Worked/Week sent on MTC Worked/Week sent on MTC SA). SA).


114


To change these To change these data elements, data elements, you must send an you must send an MTC 02.MTC 02.

115

Also, a particular Also, a particular MTC/filing may have been MTC/filing may have been accepted (TA’d) even accepted (TA’d) even where a “non-required” where a “non-required” data element was sent data element was sent invalid or in error.invalid or in error.

• In this case, if a In this case, if a subsequent MTC 02 is subsequent MTC 02 is filed and contains… filed and contains…


116

… … the same invalid data the same invalid data from the previous MTC from the previous MTC that TA’d, the that TA’d, the 0202 may now may now reject or receive an reject or receive an error… error…


117

This is because a This is because a jurisdiction can not tell jurisdiction can not tell what is changing on an what is changing on an 02, and can not identify 02, and can not identify on the 02 what data on the 02 what data elements are required for elements are required for the circumstances of that the circumstances of that claim;claim;Therefore Therefore EVERY field on EVERY field on an 02 must be editedan 02 must be edited. .


118

Also, if an Also, if an 0202 TA’d, but a TA’d, but a subsequent MTC/filing subsequent MTC/filing TR’d for ‘Mandatory Field TR’d for ‘Mandatory Field Not Present’ error (001), Not Present’ error (001), you may wonder why the you may wonder why the earlier 02 did not reject earlier 02 did not reject for this same error… for this same error…


119

(cont’d…) (cont’d…) • Again, because we can Again, because we can not designate which not designate which fields are “required” on fields are “required” on an 02, we can not run all an 02, we can not run all of the presence edits of the presence edits (- 001) on MTC 02.(- 001) on MTC 02.


120

Recap:Recap:

MTC 02 must be included MTC 02 must be included in the Benefits segmentin the Benefits segment (therefore making it an (therefore making it an “Event” Benefits segment ) “Event” Benefits segment ) in order for DWC’s program in order for DWC’s program to process any changes to to process any changes to the Benefit, Payment, OBT the Benefit, Payment, OBT or A/C/R segments data or A/C/R segments data reported on the 02.reported on the 02.


121

If you are filing an MTC If you are filing an MTC 0202 to change the date the first to change the date the first payment was mailed, you payment was mailed, you must include a Payment must include a Payment segment and report the segment and report the revised “Payment Issue revised “Payment Issue Date” (vs. Benefit Payment Date” (vs. Benefit Payment issue Date”. ) issue Date”. )


122

SUS EFF DATE CANT BE REPTD SUS EFF DATE CANT BE REPTD UNLESS MTC = S1-S8 P7, UNLESS MTC = S1-S8 P7, andand

SUS EFF DT ON MTC 02 BUT NO S1-SUS EFF DT ON MTC 02 BUT NO S1-S8 OR P7 PREV FILED , S8 OR P7 PREV FILED , andand

NUMBER OF SUSPENSION NUMBER OF SUSPENSION NARRATIVES MUST NOT BE > 0 NARRATIVES MUST NOT BE > 0

Caveats and Tips for Successful Caveats and Tips for Successful Filing of 02Filing of 02 Most errors occurring on Most errors occurring on SROI 02 filings are:SROI 02 filings are:

123


• These errors basically These errors basically indicate that there is no indicate that there is no prior suspension notice prior suspension notice (paper or EDI) on file with (paper or EDI) on file with DWC, so we cannot DWC, so we cannot process an 02 that is process an 02 that is reporting a Suspension reporting a Suspension Effective Date for the first Effective Date for the first time.time.

124

We are also seeing errors We are also seeing errors for:for:RED BEN AMT CODE R RED BEN AMT CODE R

IS NOT APPLICABLE IS NOT APPLICABLE


125

• Reduced Benefit Reduced Benefit Amount Code ‘R’Amount Code ‘R’ can not can not be initially reported on a be initially reported on a SROI 02 if MTC 02 is not SROI 02 if MTC 02 is not at the Benefit Level.at the Benefit Level.


126

SROI SROI MTC “02”MTC “02”

Reporting a Benefit Reporting a Benefit Redistribution for Child Redistribution for Child SupportSupport (after Initial Payment)(after Initial Payment)

127

Benefit Redistribution for Benefit Redistribution for Child SupportChild Support A SROI 02 is filed if a A SROI 02 is filed if a portion of the Net Weekly portion of the Net Weekly Amount is being directed to Amount is being directed to another party due to a another party due to a court ordered lien, such as court ordered lien, such as for child support. for child support.

• See Rule 69L-56.3045(1)See Rule 69L-56.3045(1)(b), F.A.C.(b), F.A.C.

128

MTC CA does not apply MTC CA does not apply in this situation because in this situation because the Net Weekly Amount is the Net Weekly Amount is unchanged. unchanged.

Benefit Redistribution for Benefit Redistribution for Child SupportChild Support

129

SCENARIO: SCENARIO:

SROI MTC 02SROI MTC 02

Reporting a Benefit Reporting a Benefit

Redistribution for Child Redistribution for Child

SupportSupport (after Initial (after Initial Payment)Payment)

130

Reporting a Benefit Redistribution for Reporting a Benefit Redistribution for Child SupportChild Support

Court-ordered child support Court-ordered child support in the amount of $50/week in the amount of $50/week has been assessed has been assessed against the employee’s WC against the employee’s WC benefits. Amount is to be benefits. Amount is to be paid directly paid directly to employee’s ex-to employee’s ex-wife.wife.

131


If time permits,If time permits, we will fill out we will fill out the Benefit and ACR segment the Benefit and ACR segment live. live.

The following slide is the IP The following slide is the IP transaction that immediately transaction that immediately preceded the Benefit preceded the Benefit Redistribution. Redistribution.

132

Benefit Segment last reported Benefit Segment last reported to DWC for IP:to DWC for IP:

IIPP

2007072007071313

1313,,000000

44

160001600000

$1,600.0$1,600.0002007062920070629 June 29, June 29,

20072007

133


The Benefit Redistribution is The Benefit Redistribution is now to be reported at the time now to be reported at the time the next bi-weekly payment is the next bi-weekly payment is sentsent. .

Please complete the Please complete the Benefit and ACR segment Benefit and ACR segment to report this event. to report this event.

134

Now lets build the Benefit Now lets build the Benefit and ACR Segments for a and ACR Segments for a

Redistribution of BenefitsRedistribution of Benefits

135

Variable Segment Counters

0288 Number of Benefits 01

0283 Number of Payments 00

0282Number of Other Benefits 00

0289 Nmbr of Benefit ACR 001

0284 Number of Recoveries 00

0285Number of Reduced Earnings 00

136

0275Number of Concurrent Employers 00

0277Number of Full Denial Reason Code 00

0276Number of Denial Reason Narratives 00

0287Number of Suspension Narratives 00

137

Benefits 1 Occ

0085 Benefit Type Code 050 Temporary Total

0002Maintenance Type Code 02 Change

0174 Gross Weekly Amt 00000040000 $400.00

0175Gross Weekly Amount Eff. Date 20070615

June 15, 2007

0087 Net Weekly Amount 00000040000 $400.00

0211Net Weekly Amount Effective Date 20070615

June 15, 2007

0088Benefit Period Start Date 20070616

June 16, 2007

138

0089Benefit Period Through Date 20070727

July 27, 2007

0090Benefit Type Claim Weeks 0006

0091Benefit Type Claim Days 0

0086Benefit Type Amount Paid 00000240000 $2,400.00

0192Benefit Payment Issue Date N/A

139

Benefit ACR 1 Occurrence

0130

Benefit Redistribution Code H050

Court Ordered

Lien

0131

Benefit Redistribution Start Date 20070714

July 14, 2007

0132 Benefit Redistribution End Date

Blank because redistribution is

continuing

0133

Benefit Redistribution Weekly Amount 00000005000 $50.00

140

Reporting Benefit Reporting Benefit Redistribution for Child Redistribution for Child Support (after initial Support (after initial payment):payment):If the lien for Child Support If the lien for Child Support ends and indemnity is ends and indemnity is ongoing, MTC 02 should be ongoing, MTC 02 should be sent with a Benefit sent with a Benefit Redistribution segment Redistribution segment reflecting an End Date.reflecting an End Date.

If all indemnity is being If all indemnity is being suspended, the Benefit suspended, the Benefit Redistribution segment Redistribution segment reflecting an End Date can be reflecting an End Date can be sent on the Sx. sent on the Sx.

141

An MTC 02 with Benefit An MTC 02 with Benefit Redistribution Code H Redistribution Code H (Court Ordered Lien) would (Court Ordered Lien) would also be sent if the courts also be sent if the courts determined that the claim determined that the claim administrator should administrator should redirect a portion of the redirect a portion of the claimant’s benefits to pay claimant’s benefits to pay for assisted for assisted living costs, etc. living costs, etc.

142


143

What MTC should What MTC should be filed when you be filed when you

are changing from are changing from TT to TP TT to TP

benefits and …benefits and …

Pop Quiz:Pop Quiz:

144

… … there is a there is a retroactive change in retroactive change in AWW/CR that affected AWW/CR that affected what you paid in TT? what you paid in TT?

Pop Quiz:Pop Quiz:

145

Answer: Answer: “CB”“CB”

Both the change in Both the change in amount and change in amount and change in benefit type can be benefit type can be accomplished on the CB accomplished on the CB alone.alone.

146

SROI MTC CBSROI MTC CB -- Change in Benefit Change in Benefit

TypeType

Electronic Notice of Electronic Notice of Action/ChangeAction/Change

Electronic DWC-4 Equivalent Electronic DWC-4 Equivalent Required to be filed with DWC Required to be filed with DWC per Ruleper Rule 69L-56.3045(3), 69L-56.3045(3),

F.A.C.F.A.C.

147

Change in Benefit Change in Benefit TypeType


SROI CBSROI CB should be filed if should be filed if indemnity benefits are indemnity benefits are continuing continuing without without interruptioninterruption, but the , but the Benefit Type being paid Benefit Type being paid changes to a different changes to a different Benefit Type.Benefit Type.

148

POP QUIZ:POP QUIZ:

What is the due What is the due date for filing a date for filing a

SROI CB with the SROI CB with the Division?Division?

149

SROI CBSROI CB should be should be received/accepted by received/accepted by DWC on or before DWC on or before 14 14 days after the date days after the date paymentpayment (for the new (for the new Benefit Type)Benefit Type) was was mailedmailed by the Claim by the Claim Administrator. Administrator.

ANSWER:ANSWER:

150

Change in Benefit TypeChange in Benefit TypeEDI DWC-4 EquivalentEDI DWC-4 Equivalent

Changed from 14 days from Changed from 14 days from ‘knowledge of change in ‘knowledge of change in benefits’ to benefits’ to ‘14 days after ‘14 days after payment mailed’payment mailed’ because because some Clm Admin.’s systems some Clm Admin.’s systems would not auto-trigger a new would not auto-trigger a new report / MTC until pymnt was report / MTC until pymnt was actually issued. actually issued.

• Rule will be revised to reflect Rule will be revised to reflect change.change.

151


Because the Because the requirement to report a requirement to report a change in benefitschange in benefits did not did not previously exist for previously exist for paper, a DWC FORM DWC-paper, a DWC FORM DWC-4 is 4 is not requirednot required to be to be provided to the employee provided to the employee or employer.or employer.

152


SROI CBSROI CB is typically used when: is typically used when:

Indemnity benefits are currently Indemnity benefits are currently being paid,being paid,

A A newnew Benefit Type Code begins, Benefit Type Code begins,

The The previousprevious Benefit Type Code ends Benefit Type Code ends or is reclassified,or is reclassified,

There is no break in benefit periods.There is no break in benefit periods.

SROI CB - Change in Benefit SROI CB - Change in Benefit TypeType


For Example:For Example:

154



Reminder:Reminder: Since Since CBCB is an is an “Event” “Event” BenefitsBenefits segment, if segment, if there have been multiple there have been multiple benefit periods for the BTC benefit periods for the BTC that benefits are being that benefits are being changed ‘to’, the Start Date changed ‘to’, the Start Date is the first date of the is the first date of the uninterrupteduninterrupted period of period of payments for that BTC … payments for that BTC …

155



• If that same BTC was If that same BTC was paid for a prior disability paid for a prior disability period, the Start Date period, the Start Date should should notnot be reported as be reported as the initial date of the first the initial date of the first payment period for that payment period for that BTC. BTC.

156



• The Benefit Period Start The Benefit Period Start Date of the BTC that Date of the BTC that benefits are changing benefits are changing ‘from’ should be reported ‘from’ should be reported as the latest Start Date as the latest Start Date where there are multiple where there are multiple payment periods. It is an payment periods. It is an Event Benefits segment.Event Benefits segment.

157



Normally, MTC “CB” requires Normally, MTC “CB” requires twotwo““EventEvent Benefit” segments Benefit” segments to to report changes in data to the report changes in data to the two benefits affected by the two benefits affected by the MTC “CB” transaction:MTC “CB” transaction:

• The Benefit Type that is The Benefit Type that is endingending, , andand

• The Benefit Type that is The Benefit Type that is beginningbeginning..

Therefore…Therefore…

158

… … unless your system does unless your system does it for you automatically, you it for you automatically, you need to include MTC CB in need to include MTC CB in only the two Benefits only the two Benefits Segments where you are Segments where you are changing benefits ‘from’ changing benefits ‘from’ and ‘to’. and ‘to’.

Errors occur when the MTC Errors occur when the MTC is put on the wrong BTC.is put on the wrong BTC.

159



Exception:Exception: There will only There will only be one Event Benefit be one Event Benefit Segment on the CB if:Segment on the CB if:

• BTC is ‘exchanged’ for BTC is ‘exchanged’ for another BTC another BTC ((e.g., reclassify e.g., reclassify all IB’s previously paid to PT),all IB’s previously paid to PT), or or

• BTC is changed to a BTC is changed to a different BTC different BTC (e.g., correcting (e.g., correcting all TT to TP) …all TT to TP) …

160



… … In this case, the In this case, the ‘disappearance’ of the ‘disappearance’ of the previously reported BTC previously reported BTC that was entirely that was entirely converted/reclassified converted/reclassified would need to be explained would need to be explained via the via the Reduced Benefit Reduced Benefit Amount Code “R”Amount Code “R” (Reclassification of (Reclassification of Benefits.)Benefits.)

161

This is a good This is a good juncture to go into juncture to go into more detail about more detail about Reduced Benefit Reduced Benefit Amount Code “R”.Amount Code “R”.

162

Reduced Benefit Reduced Benefit Amount CodeAmount Code““R”R” should should onlyonly be sent be sent when:when:

•All or part of a All or part of a BTC BTC previously reported was previously reported was actually actually reclassified to reclassified to another BTCanother BTC, or , or

• TheThe wrong BTCwrong BTC was was previously reportedpreviously reported and and needs to be needs to be corrected to a corrected to a different BTC.different BTC.

163

Reduced Benefit Reduced Benefit Amount Code Amount Code “R”“R” will will explain why there are explain why there are fewer or differentfewer or different BTC’s on the current BTC’s on the current transaction than transaction than were previously were previously reported.reported.

164

Once reported, Once reported, Reduced Benefit Reduced Benefit Amount CodeAmount Code “R”“R” (or (or any RBAC) must be any RBAC) must be sent on all sent on all subsequent subsequent transactions. transactions.

165

If If Reduced Benefit Reduced Benefit Amount Code Amount Code “R”“R” (Reclassification)(Reclassification) was was reported in errorreported in error, DWC , DWC can remove the code can remove the code from its system upon from its system upon request request (email (email [email protected])[email protected])

166

To minimize these To minimize these requests, DWC instituted requests, DWC instituted edits to preclude the edits to preclude the acceptance of acceptance of Reduced Reduced Benefit Amount Code Benefit Amount Code “R”“R” under certain under certain circumstances, including:circumstances, including:

• 00/IP’s (can’t reclassify 00/IP’s (can’t reclassify benefits not previously sent), benefits not previously sent), andand

• Where BTC’s are unchanged Where BTC’s are unchanged from BTC’s previously from BTC’s previously reported.reported.

167

If the current If the current transaction transaction TA’s TA’s and includes and includes Reduced Reduced Benefit Amount CodeBenefit Amount Code “R”“R” ( (Reclassification)Reclassification) , , but but one or more BTC’s one or more BTC’s were inadvertently left were inadvertently left off the transactionoff the transaction……

168

… … only the BTC’s only the BTC’s reported reported on the on the current transaction will current transaction will be used by DWC’s be used by DWC’s program when program when processing/comparing processing/comparing BTC’s on future BTC’s on future transactions.transactions.

169

This means that This means that due to due to the the presence of the “R” presence of the “R” code, DWC’s program code, DWC’s program did not question the did not question the ‘disappearance’ of a ‘disappearance’ of a BTC(s). BTC(s).

If the ‘missing” BTC(s) If the ‘missing” BTC(s) shows up on a future shows up on a future transaction…transaction…

170

… … that that transaction will transaction will reject, and the reject, and the ‘missing’ BTC(s) will ‘missing’ BTC(s) will have to be re-have to be re-introduced / re-introduced / re-reported via one or reported via one or more CB’s.more CB’s.

171

If you receive the If you receive the error message, error message, Reduced Benefit Reduced Benefit Amount Code Amount Code Missing;Missing; this does this does notnot always mean that always mean that the code is applicable the code is applicable and should be sent …and should be sent …

172

… … In some cases, this In some cases, this error is generated error is generated because one or more because one or more BTC’s previously BTC’s previously reported were reported were accidentally left off accidentally left off the current the current transaction (as we just transaction (as we just mentioned) …mentioned) …

173

… … in which case you in which case you will need to add the will need to add the missing BTC and re-missing BTC and re-send the transaction.send the transaction.

• Here, you would Here, you would not not report the Reduced report the Reduced Benefit Amount Code, Benefit Amount Code, even though the error even though the error message implies it is message implies it is missing.missing.

174

You should only re-You should only re-file and include a file and include a ‘missing’ ‘missing’ Reduced Reduced Benefit Amount Code Benefit Amount Code “R”“R” only if the lower $ only if the lower $ amount or # of BTC’s amount or # of BTC’s reported was correct.reported was correct.

175

Example:Example:

MTC SA reported BTC 050 MTC SA reported BTC 050 (TT) and 070 (TP);(TT) and 070 (TP);

Subsequent MTC CA was Subsequent MTC CA was filed to report a change in filed to report a change in the Net Wkly Amount for the Net Wkly Amount for 050 but 070 was left off 050 but 070 was left off the CA …the CA …

176

Example (continued):Example (continued):

MTC CA rejected for the MTC CA rejected for the errors:errors:

• ““Nbr of Benefits < Nbr of Benefits < Previous”, Previous”, and and

• “ “Reduced Benefit Amount Reduced Benefit Amount Code Missing” …Code Missing” …

177

… … If all prior BTC 070 If all prior BTC 070 had been reclassified to had been reclassified to BTC 050, then the ‘R’ code BTC 050, then the ‘R’ code would be applicable to ‘fix’ would be applicable to ‘fix’ the CA. the CA.

But if BTC 070 was But if BTC 070 was accidentally left off, the CA accidentally left off, the CA would need to be re-sent would need to be re-sent with both 070 and 050, in with both 070 and 050, in which case you do which case you do notnot include the ‘missing’ R include the ‘missing’ R code. code.

178

Sending the Reduced Sending the Reduced Benefit Amount Code when Benefit Amount Code when not appropriate causes not appropriate causes edit errors edit errors downstream, since downstream, since the presence of this code the presence of this code allows BTC’s to drop off and allows BTC’s to drop off and resets the benefit picture resets the benefit picture on DWC’s database. on DWC’s database.

• For example ... For example ...

179

… … When SA becomes due When SA becomes due and correctly reports all and correctly reports all BTC’s paid to date, the SA BTC’s paid to date, the SA will reject for the error:will reject for the error:

Nbr of Benefits should not Nbr of Benefits should not be > what it on file.be > what it on file.

This may require multiple This may require multiple subsequent transactions to subsequent transactions to fix the benefit picture.fix the benefit picture.

180

We continue to see We continue to see the the “R”“R” code used when code used when it is absolutely it is absolutely inappropriate (i.e., inappropriate (i.e., where there has been no where there has been no change in benefit types change in benefit types and amounts). and amounts).

DWC will be adding DWC will be adding more edits to preclude more edits to preclude acceptance of a filing acceptance of a filing when the “R” code is when the “R” code is N/A.N/A.

181

FL has also requested FL has also requested the appropriation of the appropriation of another another Reduced Benefit Reduced Benefit Amount Code – “E” Amount Code – “E” (Expense Reduction)(Expense Reduction) to to explain a ‘less than explain a ‘less than previous’ Benefit Type previous’ Benefit Type Amount Paid $ for the Amount Paid $ for the following following circumstance: …circumstance: …

182

… … Indemnity benefits have Indemnity benefits have been suspended & no been suspended & no further indemnity is further indemnity is expected to be paid; andexpected to be paid; and

Claim Admin. has incurred Claim Admin. has incurred an an overpayment and will overpayment and will not be recovering or not be recovering or offsetting against future offsetting against future benefitsbenefits (e.g., due to late (e.g., due to late receipt of receipt of revised wage revised wage information that resulted in a information that resulted in a new, lower AWW/CR)new, lower AWW/CR) … …

183

… … Since NCCI requires Since NCCI requires un-recovered un-recovered overpayments to be overpayments to be classified as an expense classified as an expense vs. a true cost of the vs. a true cost of the claim, some Claim claim, some Claim Administrator’s systems Administrator’s systems (no vendor) therefore …(no vendor) therefore …

184

… … write the excess write the excess amount paid to an amount paid to an expense category for expense category for purposes of reporting to purposes of reporting to NCCI, NCCI, and only record and only record the amount actually the amount actually ‘due and owing’ in the ‘due and owing’ in the Benefit Type Amount Benefit Type Amount Paid field.Paid field.

185

… … Rule 69L-56.3045(2), Rule 69L-56.3045(2), F.A.C., requires a CA “F.A.C., requires a CA “If If the Net Weekly Amount the Net Weekly Amount changes from the amount changes from the amount previously reportedpreviously reported due to due to a revised Average Wagea revised Average Wage (e.g., wage statement, (e.g., wage statement, discontinuation of fringe discontinuation of fringe benefits), or due to the benefits), or due to the application of a Benefit application of a Benefit Adjustment Code or Adjustment Code or Benefit Credit Code…”.Benefit Credit Code…”.

186

So, when the Claim Admin. So, when the Claim Admin. sends a ‘CA’ to report sends a ‘CA’ to report the revised the revised AWW/CR/Gross/Net Weekly AWW/CR/Gross/Net Weekly Amounts, the CA rejects Amounts, the CA rejects because a lower Benefit because a lower Benefit Type Amount Paid is Type Amount Paid is reported compared to the reported compared to the previous amount (and previous amount (and nothing is present on the nothing is present on the transaction to transaction to ‘excuse/explain’ the lower ‘excuse/explain’ the lower amount.)amount.)

187

An IRR has been submitted An IRR has been submitted asking for: asking for:

• Guidance on what value Guidance on what value should be reported for should be reported for Benefit Type Amount Paid, Benefit Type Amount Paid, i.e., cumulative amount ‘paid’ i.e., cumulative amount ‘paid’ or ‘due’ based on the current or ‘due’ based on the current IAIABC definition of this field, IAIABC definition of this field, and and

• The addition of a new RBAC The addition of a new RBAC “E” “E” (Expense Reduction”). (Expense Reduction”).

188



Going back to an earlier Going back to an earlier example where benefits example where benefits were changed from TT (050) were changed from TT (050) to IB (030): to IB (030):

• The CB reporting BTC The CB reporting BTC 030 will also need to 030 will also need to include a include a Permanent Permanent Impairments SegmentImpairments Segment..

189

TheThe Permanent Permanent ImpairmentsImpairments Segment Segment consists of the following consists of the following data elements:data elements:

• PI Body Part Code, andPI Body Part Code, and

• Permanent Impairment Permanent Impairment PercentagePercentage

““PERMANENT PERMANENT IMPAIRMENTS” IMPAIRMENTS”

SEGMENT:SEGMENT:

190

FL requires that all PI ratings FL requires that all PI ratings are reported with are reported with PI Body Part PI Body Part Code 99.Code 99.

““PERMANENT IMPAIRMENTS” PERMANENT IMPAIRMENTS” SEGMENTSEGMENT

191

““PERMANENT IMPAIRMENTS” PERMANENT IMPAIRMENTS” SEGMENTSEGMENT

The The SROISROI “Permanent “Permanent Impairment Body Part CodeImpairment Body Part Code”” should not be confused with the should not be confused with the FROI Part of Body Code. FROI Part of Body Code.

• There are 2 separate tables There are 2 separate tables for these codes; although many for these codes; although many of the codes are similar, the of the codes are similar, the SROI PI Body Part CodeSROI PI Body Part Code uses an uses an expanded 3 character format expanded 3 character format (used by other states) while the (used by other states) while the FROI Part of Body CodeFROI Part of Body Code is only 2 is only 2 characters.characters.

192

Since only one overall Since only one overall (whole body) Permanent (whole body) Permanent Impairment Body Part Code Impairment Body Part Code of of ‘99’‘99’ is allowed by FL,is allowed by FL, there will only be one PI there will only be one PI Segment (Number of Segment (Number of Occurrences = ‘01’) and Occurrences = ‘01’) and therefore only one therefore only one Permanent Impairment Permanent Impairment PercentagePercentage per filing. per filing.

PERMANENT IMPAIRMENTS PERMANENT IMPAIRMENTS SEGMENT SEGMENT

193

If the EE’s doctor initially If the EE’s doctor initially assigns one PI rating and assigns one PI rating and subsequently assigns subsequently assigns additional impairment, the additional impairment, the Permanent Impairment Permanent Impairment PercentagePercentage must still must still report report oneone overall PI rating overall PI rating (not just the additional (not just the additional impairment percentage.)impairment percentage.)

PERMANENT IMPAIRMENTS PERMANENT IMPAIRMENTS SEGMENT SEGMENT

194

Permanent Impairment Permanent Impairment PercentagePercentage ( (including 0%)including 0%) must be reported if: must be reported if:

•MMI Date is sent and MMI Date is sent and DOI > 7/1/90, or DOI > 7/1/90, or

•PI Body Part Code is PI Body Part Code is present.present.

““PERMANENT IMPAIRMENTS” PERMANENT IMPAIRMENTS” SEGMENT:SEGMENT:

195

Basically, MMI and PI % Basically, MMI and PI % are now both are now both requiredrequired if if one or the other is sentone or the other is sent, , even if the PI % = 0.even if the PI % = 0.

We We DODO want 0% PI ratings want 0% PI ratings reported, although they reported, although they were not previously were not previously required on paper.required on paper.

““PERMANENT PERMANENT IMPAIRMENTS” IMPAIRMENTS”

SEGMENT:SEGMENT:

196

Although not part of the Although not part of the Permanent Impairment Permanent Impairment SegmentSegment, , Date of Date of Maximum Medical Maximum Medical ImprovementImprovement is required if is required if any of the following are any of the following are reported:reported:

• IB’s IB’s (030, 230, 530 & (030, 230, 530 & DOI DOI >> 7/1/90)7/1/90)

• SB’s SB’s (040 & (040 & DOI DOI > > 7/1/90)7/1/90)

• PI Rating PI Rating Exception:Exception: BTC 500 (Final BTC 500 (Final Settlement)Settlement)

197

Permanent Impairment Permanent Impairment Minimum Payment Minimum Payment

Indicator Indicator If the specific MMI date or PI If the specific MMI date or PI rating is not initially known, rating is not initially known, you may report the you may report the Permanent Permanent Impairment Minimum Payment Impairment Minimum Payment IndicatorIndicator as “Y” as “Y” until MTC FN.until MTC FN.

• At FN, MMI/PI rating will At FN, MMI/PI rating will only be excused if claim is only be excused if claim is settled in full (‘washed out’.) settled in full (‘washed out’.)

198



CBCB

199

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CBFiling of CB Recap:Recap: FL allows a CB FL allows a CB to add a new benefit to add a new benefit type that was type that was improperly left off a improperly left off a previously accepted previously accepted filing filing (providing that a (providing that a suspension was not the suspension was not the last reported claim event.last reported claim event.

200

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CBFiling of CB When the Change in When the Change in Benefits Benefits also involves a also involves a corresponding change in corresponding change in the weekly amountthe weekly amount and a and a new BTC will be paid, you new BTC will be paid, you do do notnot need to file a CA need to file a CA and a CB. and a CB.

• You should report both You should report both types of changes on the types of changes on the same SROI CB.same SROI CB.

201

NO SROI ER OR RB NO SROI ER OR RB PREVIOUSLY ON FILE PREVIOUSLY ON FILE

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CBFiling of CB We are seeing a lot of We are seeing a lot of CB’s reject for the CB’s reject for the following error:following error:

202

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CBFiling of CB

• This error is generated This error is generated when a CB is sent after a when a CB is sent after a Sx (Suspension) has been Sx (Suspension) has been filed, but a SROI RB (or filed, but a SROI RB (or ER) has not been filed to ER) has not been filed to report the resumption of report the resumption of benefits following the benefits following the suspension.suspension.

203

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CBFiling of CB When changing from TT to When changing from TT to IB benefits, you do not need IB benefits, you do not need to first file an S1 to report to first file an S1 to report suspension of TT due to suspension of TT due to RTW. RTW.

• The CB ‘ends’ the TT The CB ‘ends’ the TT benefits and ‘begins’ the benefits and ‘begins’ the IB benefits;IB benefits;

• RTW info should be RTW info should be included on the CB (vs. included on the CB (vs. filing a separate S1)…filing a separate S1)…

204


... An Sx is not ... An Sx is not applicable because applicable because Suspension Suspension transactions are only transactions are only required when you are required when you are suspending suspending ALLALL indemnity benefits, .indemnity benefits, .

205


We are also seeing a lot We are also seeing a lot of CB rejections for the of CB rejections for the error:error:

BTC ENDING MUST HAVE BEEN BTC ENDING MUST HAVE BEEN

REPTDREPTD

• Unless you are adding a new Unless you are adding a new BTC for the waiting week not BTC for the waiting week not previously reported, you can’t previously reported, you can’t report a change from a BTC report a change from a BTC that was not already on file …that was not already on file …

206


… … So, you will need to So, you will need to file a CB to introduce file a CB to introduce the BTC you are trying the BTC you are trying to change benefits to change benefits from. from.

207


• If you are sending a CB If you are sending a CB to report the payment of to report the payment of a different BTC for the a different BTC for the waiting week, we are waiting week, we are often seeing this same often seeing this same error error ((BTC ENDING MUST BTC ENDING MUST HAVE BEEN REPTD) HAVE BEEN REPTD) when when either the IDDB is either the IDDB is incorrect or the BTC Start incorrect or the BTC Start Date is incorrect.Date is incorrect.

208


• DWC’s program doesn’tDWC’s program doesn’t allow the reporting of anallow the reporting of an earlier BTC unless it earlier BTC unless it occurred during the occurred during the waiting week, in which waiting week, in which case, the IDDB should case, the IDDB should equal the Start Date for equal the Start Date for the BTC being reported in the BTC being reported in the earliest segment.the earliest segment.

209

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CBFiling of CB Another error Another error frequently occurring for frequently occurring for CB’s is:CB’s is:

CURRENT DATE CURRENT DATE DISABILITY BEGAN DISABILITY BEGAN

MISSINGMISSING

210

Caveats and Tips for Successful Caveats and Tips for Successful Filing of CBFiling of CB• A A Current Date Current Date Disability BeganDisability Began (CDDB) (CDDB) is required for a CB if you is required for a CB if you are reporting a are reporting a Current Current Last Day WorkedLast Day Worked and and starting a type of starting a type of total total disabilitydisability e.g., DB (010), e.g., DB (010), PT (020), TT (050).PT (020), TT (050).

211

But if you are changing to But if you are changing to BTC 030 (IB) or reporting ‘IB BTC 030 (IB) or reporting ‘IB (030) Only’:(030) Only’:

• “ “Current Date Disability Current Date Disability Began” (CDDB) should Began” (CDDB) should notnot be be sent in relation to the start of sent in relation to the start of IB’s if there has been no IB’s if there has been no break in disability periods...break in disability periods...


212

• … … For example, if IB’s For example, if IB’s immediately follow TP and immediately follow TP and there is no break in the there is no break in the period of disability benefitsperiod of disability benefits being paid (e.g., TP ends being paid (e.g., TP ends 3/3 and IB’s start 3/4), by 3/3 and IB’s start 3/4), by definition, you would not definition, you would not report CDDB since IB’s are report CDDB since IB’s are not associated with anot associated with a ‘subsequent period of ‘subsequent period of disability’…disability’…


213

• … … If your system If your system requires CDDB even when requires CDDB even when it is not applicable, you it is not applicable, you will need to report a will need to report a RTW RTW => IB Start Date=> IB Start Date so that so that DWC can determine the DWC can determine the EE is still working (since EE is still working (since CDDB implies a change in CDDB implies a change in work status and a later work status and a later period of disability.)period of disability.)


214

Note:Note: IRR was recently IRR was recently submitted requesting the ERT submitted requesting the ERT for Current RTW be changed on for Current RTW be changed on an RB from “X” to “IA”:an RB from “X” to “IA”:

• DWC needs to apply the DWC needs to apply the correct IB payment rate based correct IB payment rate based on the presence of RTW data. on the presence of RTW data.

• RB is sent (vs. CB) when RB is sent (vs. CB) when there is a break between the there is a break between the end of TT, TP and the end of TT, TP and the resumption of IB after MMI/PI resumption of IB after MMI/PI is obtained. is obtained.

215

Many CB’s are also Many CB’s are also rejecting for the error:rejecting for the error:

INITIAL RTW DATE MUST BE INITIAL RTW DATE MUST BE CHANGED VIA AN 02 OR S1CHANGED VIA AN 02 OR S1

• If required by MTC, Initial If required by MTC, Initial Return to Work Date (IRTW) Return to Work Date (IRTW) must match IRTW date must match IRTW date previously reported.previously reported.


216

Because there is so Because there is so much confusion on much confusion on reporting Initial reporting Initial and Current RTW and Current RTW Dates, this is a good Dates, this is a good point to discuss all of point to discuss all of the Initial and Current the Initial and Current date fields, and date fields, and afterwards complete afterwards complete another SROI another SROI scenarioscenario ... ...

217

Initial Dates Initial Dates

vs. vs.

Current DatesCurrent Dates

218

Initial Dates vs. Current Initial Dates vs. Current DatesDates

The followingThe following “Initial”“Initial” date values date values should not should not changechange unless reported unless reported incorrectly (send 02): incorrectly (send 02):

• Initial Initial Date Last Day Date Last Day WorkedWorked, , • Initial Initial Date Disability Date Disability BeganBegan

219


“ “Initial RTW”Initial RTW” can can change (via 02) if:change (via 02) if:

• Reported incorrectly, or Reported incorrectly, or • RTW Type Code and/or RTW Type Code and/or Physical Restrictions Physical Restrictions Indicator changes, but a Indicator changes, but a subsequent period of subsequent period of disability has not occurred.disability has not occurred.

220


FL will FL will notnot be be implementing the IAIABC implementing the IAIABC DP Rule that allows the MTC DP Rule that allows the MTC Date on the 02 to be used Date on the 02 to be used as an estimate of when the as an estimate of when the subsequent RTW Type Code subsequent RTW Type Code and/or Physical Restrictions and/or Physical Restrictions Indicator took effect if a Indicator took effect if a revised IRTW is not sent on revised IRTW is not sent on the 02.the 02.

221


To clarify:To clarify:

For example, if RTW Type For example, if RTW Type Code “R” and Physical Code “R” and Physical Restrictions “Y” were Restrictions “Y” were reported in conjunction reported in conjunction with the Initial RTW Date, with the Initial RTW Date, and you and you subsequently subsequently learn learn the date the EE actually the date the EE actually RTW RTW (although not required to be (although not required to be reported to DWC if payments were reported to DWC if payments were not based on this change),not based on this change), or … or …

222

… … the the Phys Restrictions Phys Restrictions changed, the changed, the Initial RTW Initial RTW Date,Date, RTW Type Code RTW Type Code (Actual), and Physical (Actual), and Physical Restrictions Indicator can be Restrictions Indicator can be changed on the 02.changed on the 02.

• Do Do notnot report this ‘revised report this ‘revised Initial RTW as a ‘Current RTW’. Initial RTW as a ‘Current RTW’.

Note: Both the Initial and Note: Both the Initial and ‘revised’ Initial RTW dates are ‘revised’ Initial RTW dates are stored by DWC.stored by DWC.

223


If you If you misreported misreported the the Physical Restrictions Physical Restrictions Indicator, you would not Indicator, you would not revise the IRTW date:revise the IRTW date:

• Here, you would only Here, you would only need to change the need to change the Physical Restrictions Physical Restrictions Indicator via MTC 02.Indicator via MTC 02.

224


““Current” date values Current” date values represent a represent a second period second period of disabilityof disability (not reported if (not reported if disability periods are disability periods are continuous.)continuous.)

• Current Date Last Day Current Date Last Day Worked, Worked, • Current Date Disability Current Date Disability Began, &Began, &• Current Return To Work Current Return To Work Date)Date)

225


Current RTWCurrent RTW - - TThe first he first occurrence of CRTW must be occurrence of CRTW must be associated with a subsequent associated with a subsequent period of disability;period of disability;

• Afterwards, FL will also Afterwards, FL will also accept changes to accept changes to CRTWCRTW when there has been a when there has been a change in change in RTW Type CodeRTW Type Code and/or and/or Physical Restrictions Physical Restrictions Indicator.Indicator.

226


““Current” date values Current” date values should be updated each should be updated each time a new date is time a new date is applicable to that field.applicable to that field. Do Do not not populate populate “Current” date values with “Current” date values with “Initial” date“Initial” date values. values.

227


228

Now, we will Now, we will complete a SROI complete a SROI for for Scenario Scenario

6-C-4 (New)6-C-4 (New) in your in your

Handouts…Handouts…

229

Electronic Notice of Action or Electronic Notice of Action or

ChangeChange SCENARIO 6-C-4SCENARIO 6-C-4

SROI CBSROI CB (TT to TP) (TT to TP)Change in BenefitsChange in Benefits

TT and TP with Initial and TT and TP with Initial and Current Values and Current Values and

ReclassificationReclassification

230

The following scenario is based on our The following scenario is based on our interpretation of the IAIABC R3 interpretation of the IAIABC R3 definitions. We believe that there are definitions. We believe that there are problems with certain definitions given problems with certain definitions given the actual implementation of EDI R3, the actual implementation of EDI R3, when there are multiple periods of when there are multiple periods of disability with different benefit types disability with different benefit types being paid.being paid.

We have created this scenario in an We have created this scenario in an effort to explain our interpretation. effort to explain our interpretation.

We DO believe our interpretation (using We DO believe our interpretation (using the actual language of the definitions) the actual language of the definitions) may not match the original “intent” of may not match the original “intent” of these DN’s. these DN’s.

231

Benefits Segment for CB filed 11/20/09. Benefits Segment for CB filed 11/20/09. This is the transaction sent This is the transaction sent

prior to the one you will now fill out.prior to the one you will now fill out.

232

0001 Transaction Set ID A49 Subsequent Report

0002 Maint. Type Code CB Change in Benefit

0003Maint. Type Code Date 20091202

Dec. 2, 2009

0004 Jurisdiction Code FL

0006 Insurer FEIN 785902378

0014Claim Administrator Postal Code 379921223

0055Employee Number of Dependents N/A

0069Pre-Existing Disability Code N/A

233

0063 Wage Period Code N/A

0064Number of Days Worked Per Week N/A

Reported on the IP

0056Initial Date Disability Began N/A

Reported on the IP

0070

Date of Maximum Medical Improvement N/A

0072Current Return to Work Date

0057Employee Date of Death N/A

20091114Nov. 14,

2009

234

0031 Date of Injury 20090615June 15,

2009

0015Claim Administrator Claim Number WC1256782

0074 Claim Type Code N/AReported on the IP

0026 Insured Report Number N/A

0005Jurisdiction Claim Number 06152001

0073 Claim Status Code N/A

0075Agreement To Compensate Code N/A

235

Variable Segment Counters for A49

0078 Number of Permanent Impairments 00

0082 Number of Death Dependent/Payee Relationships 00

End A49 Elements

0076

Date Claim Administrator Notified of Employee Representation N/A

0077 Late Reason Code N/A

236

R22 Data Elements

0001 Transaction Set ID R22

0298 Date Claim Administrator Had Knowledge of Lost Time (Clm Admin’s Knowledge of 8th Day of Dis for FL)

0015Claim Administrator Claim Number WC1256782

0295 MTC Correction Code N/A

0296MTC Correction Code Date N/A

0186 Juris Branch Off Code N/A

N/A – Reported on the IP

237

0187Claim Administrator FEIN 785902378

0188 Claim Administrator Name

OLD RELIABLE INSURANCE COMPANY

0140 Claim Administrator Claim Rep Name

Angie,,Adjuster Angie Adjuster

0137 Claim Admin. Claim Rep Phone Number

8505551111 (850) 555-1111

0138Claim Admin. Claim Rep E-mail Address N/A

0139Claim Admin. Claim Rep Fax Number N/A

238

0270 Employee ID Type Qualifier

S Social Security Number

0042 Employee SSN 324556745

0043 Employee Last Name SMITH

0044Employee First Name JOHN

0045Employee Middle Name/Initial J

0255Employee Last Name Suffix JR

239

0052Employee Date of Birth 19530501 May 1, 1953

0054Employee Marital Status Code N/A

0151Employee Education Level N/A

0213Employee Number of Entitled Exemp N/A

0201Anticipated Wage Loss Indicator N/A

0202Reduced Benefit Amount Code R Reclassification

240

0314 Insured FEIN N/AReported on

the FROI

N/AReported on

the FROI

N/AReported on

the FROI

0016 Employer FEIN

0023Employer Physical Postal Code

0158Employee Tax Filing Status Code N/A

0146Death Result Of Injury Code N/A

0292Insolvent Insurer FEIN N/A

241

0228Return To Work with Same Employer Ind Y Yes

0281

Date Employer Had Knowledge of Date of Disability N/A

0212Non-Consecutive Period Code

0172Estimated Gross Weekly Amount Ind N/A

0145Current Date Last Day Worked

0144Current Date Disability Began

9/07/09 – Unchanged per IAIABC definition of DN

9/08/09 – Unchanged per IAIABC definition of DN

BBenefit Period

242

0065Initial Date Last Day Worked N/A

Reported on FROI

0189Return To Work Type Code A Actual

0224Physical Restrictions Ind. Y Yes

0193 Suspension Eff Date N/A

0199 Full Denial Eff Date N/A

0196Denial Rescission Date N/A

0294 Partial Denial Code N/A

243

0134

Calculated Weekly Compensation Amount 00000040000 $400.00

0256 Wage Effective Date 20090615June 15,

2009

0149Discontinued Fringe Benefits N/A

0290 Type of Loss Code 01 Trauma

0058Employment Status Code N/A

Rprtd on FROI

0223

Permanent Impairment Minimum Payment Ind N/A

244

0068 Initial Return to Work Date

0066 Full Wages Paid For Date Of Injury Indicator N/A

Reported on FROI

0273 Employer Paid Salary in Lieu of Compensation Indicator N No

0293

Lump Sum Payment/ Settlement Code N/A

0286 Average Wage 00000060000 $600.00

N/A – Reported on IP

245

0297Initial Date of Lost Time (8th Day of Dis for FL) N/A – Reported on IP

0200

Claim Administrator Alternate Postal Code (Mailing) 993574528

0299 Award/Order Date N/A

246

Variable Segment Counters

0288Number of Benefits 02

2 Occurrences

0283Number of Payments

00

0282Number of Other Benefits 00

0289Number of Benefit ACR 00

0284Number of Recoveries 00

247

0285Number of Reduced Earnings 00

0275

Number of Concurrent Employers 00

0277

Number of Full Denial Reason Code 00

0276Number of Denial Reason Narratives 00

0287

Number of Suspension Narratives 00

248

Variable Segments

Benefits 2 Occ’s

0085 Benefit Type Code 050 Temporary Total


0174 Gross Weekly Amt 00000040000 $400.00

0175

Gross Weekly Amount Effective Date 20090615

June 15, 2009

0087 Net Weekly Amount 00000040000 $400.00

0211Net Weekly Amount Effective Date 20090615

June 15, 2009

249


Nov. 7, 2009


Nov. 13, 2009



0086Benefit Type Amount Paid 00000400000 $4000.00

0192Benefit Payment Issue Date

N/A

250

Variable Segments (cont’d)

0085 Benefit Type Code 070 Temporary Partial


0174 Gross Weekly Amt N/A

0175

Gross Weekly Amount Effective Date N/A

0087 Net Weekly Amount N/A

0211Net Weekly Amount Effective Date

N/A

251


Nov. 14, 2009


Dec. 4, 2009



0086Benefit Type Amount Paid 00000261120 $2,611.20

0192Benefit Payment Issue Date N/A

252


Recap:Recap: Current RTW Current RTW does does notnot require (for require (for FL): FL):

• Current Date Current Date Disability Began, or Disability Began, or

• Current Date Last Current Date Last Day Worked (for FL.) Day Worked (for FL.)

253


Had the scenario Had the scenario indicated the EE went indicated the EE went straight from TP after straight from TP after delayed TT – i.e., where delayed TT – i.e., where there was no there was no suspensionsuspension/break in /break in disability –disability –

• CDDB (or CDLDW) CDDB (or CDLDW) would would not not apply, even apply, even though you would have though you would have reported a revised IRTW reported a revised IRTW because Restrictions now because Restrictions now apply…apply…

254


•… … In that case, the In that case, the IP would IP would have reported Initial RTW as have reported Initial RTW as 6/15 (Actual), and 6/15 (Actual), and

• The CB (changing from TT to The CB (changing from TT to TP) would report a TP) would report a revised revised IRTW dateIRTW date of 9/8/09 of 9/8/09 (Released) due to change in (Released) due to change in RTW Type Code and Physical RTW Type Code and Physical Restrictions Indicator. Restrictions Indicator.

255


• … … But CDLDW and CDDB But CDLDW and CDDB would not have been would not have been reported because there reported because there was not a subsequent was not a subsequent period of disability period of disability involved (all disability was involved (all disability was continuous in this continuous in this example.) example.)

256

In summary: In summary:

You can only move from “Initial” You can only move from “Initial” to “Current” Date sets with a break to “Current” Date sets with a break in disability periods (not benefit in disability periods (not benefit types) i.e., suspension.types) i.e., suspension.

For RTW within a ‘set’, the RTW For RTW within a ‘set’, the RTW Date (Initial or Current) will change Date (Initial or Current) will change based on changes of Type Code or based on changes of Type Code or Physical Restrictions Indicator.Physical Restrictions Indicator.

For CDDB and CDLDW, you would For CDDB and CDLDW, you would only report a new “Current” date if only report a new “Current” date if there has been a 2there has been a 2ndnd break in break in disability (suspension).disability (suspension).


257


Also, Initial RTW can be Also, Initial RTW can be sent without Initial Date sent without Initial Date Last Day Worked if the EE Last Day Worked if the EE never stopped working after never stopped working after the DOI:the DOI:

• For example - IP For example - IP reporting TP (070) where reporting TP (070) where EE continued to work EE continued to work immediately after the immediately after the accident at reduced accident at reduced wages. wages.

258

More Initial More Initial Dates Dates vs. vs.

Current Current Dates Dates

DiscussionDiscussion

259


If sending an RB to report If sending an RB to report the resumption of ‘total’ the resumption of ‘total’ indemnity benefits after ‘IB indemnity benefits after ‘IB Only’ (030) was previously Only’ (030) was previously paid (e.g., TT after IB), paid (e.g., TT after IB), where :where :

• EE never stopped working EE never stopped working while receiving IB’s, andwhile receiving IB’s, and

• There was a break There was a break between the IB and TT between the IB and TT periods: …periods: …

260


You would not report You would not report IDDB and CDDB as the IDDB and CDDB as the same date, even though same date, even though the EE is now ‘off work’ for the EE is now ‘off work’ for the first time …the first time …

261

Initial Dates vs. Current Initial Dates vs. Current DatesDates • Although IDDB is not Although IDDB is not

required for the initial ‘IB required for the initial ‘IB Only’ filing in FL, the Only’ filing in FL, the subsequent RB filing subsequent RB filing requires CDDB when total requires CDDB when total disability (e.g., TT or PT) is disability (e.g., TT or PT) is being resumed. being resumed.

• CDDB on the RB should be CDDB on the RB should be reported as the Start date reported as the Start date of TT… of TT…

262

Initial Dates vs. Current Initial Dates vs. Current DatesDates • ……The dilemma for FL is The dilemma for FL is

that the RB requires CDDB, that the RB requires CDDB, but the IDDB has never but the IDDB has never been required. been required.

• If IDDB is voluntarily sent If IDDB is voluntarily sent the same as CDDB, either the same as CDDB, either the RB or a future the RB or a future transaction will be rejected transaction will be rejected since IDDB can not = CDDB. since IDDB can not = CDDB. • IDDB if ever sent should IDDB if ever sent should be reported as the MMI be reported as the MMI Date + 1 day…Date + 1 day…

263

Initial Dates vs. Current Initial Dates vs. Current DatesDates • … …FL is considering FL is considering

changing its requirements changing its requirements for IDDB to make it for IDDB to make it mandatory for ‘IB only’ mandatory for ‘IB only’ claims, to ensure we claims, to ensure we capture and load this date capture and load this date for future editing of the for future editing of the proper disability sequence proper disability sequence (IDDB must be < CDDB).(IDDB must be < CDDB).

264


Rule of Thumb:Rule of Thumb:

Typically, CDLDW and Typically, CDLDW and CDDB are not reported CDDB are not reported unless there has been a unless there has been a suspensionsuspension. .

Nor would a second set Nor would a second set of ‘currents’ be reported of ‘currents’ be reported unless a second unless a second suspension had occurred.suspension had occurred.

265


1 sroi mtc 04 full denial after payment electronic notice of denial edi dwc-12 equivalent required...

Documents