Florida Division of Workers’ Compensation Claims EDI Release 3 Training February 12, 2014 Day 2

 2014 Error Resolution Expectations  MTC CA (Change in Benefit Amount) with A/C/R Segments (Adjustment, Credit, Redistribution)  Proper Reporting and Calculation of Gross and Net Weekly Amounts  Lump Sum Payment & Settlements (cont’d…) (cont’d…) Discussion Topics 2

 Recent Law Update and Court Case Decision  Updated IAIABC Data Elements  Acquired Claims  New IAIABC Data Element Employer Paid Salary Prior to Acquisition Code ‘E’ Discussion Topics 3

2014 Error Resolution Expectations 4

Error Resolution Expectations In the past, the EDI Team has conducted webinars, teleconferences and on-site visits at the Division in an effort to assist Trading Partners with submitting claims successfully. 5

Error Resolution Expectations This year, the EDI Team will take a more active approach to our Triage Assistance to reduce the overall error rejection percentages. 6

The EDI Team will be contacting entities with high rejection rates and entities with multiple rejections and/or a high volume of Missing Sub-Annuals (SA). 7

If we identify your company as falling into either of these categories, the EDI Team will be contacting you to schedule a teleconference with your EDI staff, your vendor (if applicable) and me (Linda Yon). 8

We will develop an action plan with timelines to reduce errors and/or the repetitious filing of transactions (where the error itself has not been addressed). 9

If you or your company would like help with reducing the rate of rejections and the EDI Team has yet to reach out to you, we encourage you to contact us to set up a personalized session(s) for more direct assistance. 10

EDI Triage Assistance could include review of:  Basic EDI training  FROI/SROI combo filings  Claims EDI Warehouse navigation  Specific Maintenance Type Codes  Event vs. Sweep Benefit Segments  Gross Weekly Amount calculations or  Direct explanation of rejected filings, etc… 11

If you would like to schedule a conference or webinar session with the team, you may do so by submitting an to: and a member of the team will contact you. 12

MTC CA (Change in Amount) 13

MTC CA (Change in Amount) If the Net Weekly Amount increases or decreases due to:  A change to the Average Weekly Wage which affected the Compensation Rate which affected the Compensation Rate  The recalculation of the Gross Weekly Amount, or Amount, or  The application of adjustments or credits, an MTC CA transaction should be sent to the Division. 14

MTC CA is sent when:  Indemnity benefits are currently being paid and the Net Weekly Amount changes due to a re-calculation of the Gross Weekly Amount or an application of adjustments and/or credits… OR… 15

MTC CA is also sent when: The Net Weekly Amount changes after a suspension and an adjustment check is issued for the same previously paid period of indemnity. 16

MTC CA is also sent when:  The Net Weekly Amount changes due to the change in a Benefit Adjustment or Credit Weekly Amount OR  Due to the ending of an adjustment or credit. 17

MTC CA should not be sent when:  The Average Weekly Wage (AWW) or Concurrent Employer Wage changes but the Net Weekly Amount does not change (i.e. Comp Rate is at the max for the current year). In this case, an MTC ‘02’ should be filed instead. 18

MTC CA is not required to be sent when:  The Net Weekly Amount payable for BTC 070 (Temporary Partial) fluctuates due to variations in the employee’s weekly earnings.  The Net Weekly Amount payable for BTC 030 (Impairment Income Benefits) changes due to the employee’s weekly work status/income. 19

POP QUIZ: What MTC is filed when you need to report a change in AWW/CR, but the Gross/Net Weekly Amount is not changed? 20

ANSWER: SROI 02 21

Questions Regarding MTC CA 22

Adjustments, Credits and Redistributions (A/C/R Segments) 23

An Adjustment/Credit/Redistribution (A/C/R) Segment should always and only be included on each SROI transaction when:  The A/C/R is currently being applied to the Benefits Segment that is being reported OR OR  The A/C/R is ending 24

A/C/R Segments are also reported on Sub-Annuals (MTC SA) when still being applied to a BTC that is currently being paid. 25

A/C/R Segments are not required to be reported on subsequent transactions if the A/C/R has already ended at the time of the current filing event. 26

A Benefit A/C/R End Date is only sent when an adjustment, credit or redistribution has ended or benefits are suspended (MTC S1-7). 27

However, if A/C/R Segments have not ended at the time of the current filing, A/C/R information must continue to be reported on all SROIs until the A/C/R has ended. An A/C/R end date is not required if the claim has been subsequently denied/settled. 28

Benefit Adjustments 29

Benefit Adjustment Code The Benefit Adjustment Code is a code identifying reductions or increases applied to the Gross Weekly Amount resulting in a new Net Weekly Amount for the specific benefit type noted. Format: 4 A/N (BNNN) B = Benefit Adjustment Code NNN = Benefit Type Code (e.g. V050) (e.g. V050) 30

Benefit Adjustment Code Some commonly used Benefit Adjustment Codes include:  S = Social Security Disability  V = Safety Violation  E = Employer Provided Pension (Grice) 31

The Benefit Adjustment Start Date is the first date of the uninterrupted period in which the current Benefit Adjustment Weekly Amount was applied to the Benefit Type Code. Benefit Adjustment Start Date 32

The Benefit Adjustment End Date is the last date through which the benefit adjustment was applied to the Benefit Type Code. If the Benefit Adjustment is ongoing, the Benefit Adjustment End Date is left blank. Benefit Adjustment End Date 33

Benefit Adjustment Weekly Amount The Benefit Adjustment Weekly Amount is the weekly amount of the benefit adjustment corresponding to the Benefit Adjustment Code. 34

Let’s take a look at a claim scenario where there is an adjustment for a Safety Violation. A Safety Violation adjustment is for the life of the claim, so the claim administrator continued to report the A/C/R Segment without a Benefit Adjustment End Date. 35

 Average Wage (AWW) = $600  Calculated Weekly Compensation Amount (Comp Rate) = $400 (Comp Rate) = $400  Gross Weekly Amount for TTD Benefits = $400  Safety Violation (V050) Benefits reduced by 25% per week ($100) Example with Safety Violation Adjustment 36

The injured worker was employed by the City of DQC as a chemist and burned her hands while mixing chemicals. 37

The injured worker failed to wear protective gloves as required when mixing chemicals; therefore, the safety violation was applied to the weekly benefits. Date of Injury = 5/18/12 Initial Date Disability Began = 5/19/12 38

BTCBenefit TypeMTC Gross Weekly Amt. Gross Eff. Date Net Weekly Amt. Net Eff. Date Start Date Through Date WeeksDaysAmt. Paid Payment Issue Date 050 TEMPORARY TOTAL IP /19/ /19/125/26/126/1/ /1/12 00/IP: Seg #ACR CodeACR Description Ben Type Code Start DateEnd DateWeekly Amount 1VSafety Violation0505/26/12$ Number of Benefit A/C/R Segments: 001 On 6/1/12, the claim administrator filed the 00/IP reporting the initial payment of TT (050) and the Benefit Adjustment Code for the safety violation (V050). 39

The Benefit Adjustment has not yet ended so the claim administrator must report the A/C/R Segment without the Benefit Adjustment End Date. Seg #ACR CodeACR Description Ben Type Code Start DateEnd DateWeekly Amount 1VSafety Violation0505/26/12$

POP QUIZ: By what percentage are indemnity benefits reduced if the injured worker violates a safety regulation? 41

ANSWER:25% 42

Let’s take a look at the same claim with the next event – Change in Benefit Type. 43

On 6/29/12, the claim admin filed an MTC CB reporting the change in benefits from TT (050) to TP (070) … BTCBenefit TypeMTC Gross Weekly Amt. Gross Eff. Date Net Weekly Amt. Net Eff. Date Start Date Through Date WeeksDaysAmt. Paid Payment Issue Date 050 TEMPORARY TOTAL CB /19/ /19/12 6/15/ TEMPORARY PARTIAL CB /16/ /16/12 6/29/ MTC CB: 44

ending the Benefit Adjustment Segment for TT (V050) and beginning the Benefit Adjustment Segment for TP (V070). On 6/29/12, the claim administrator filed an MTC CB reporting the change in benefits from TT (050) to TP (070), BTCBenefit TypeMTC Gross Weekly Amt. Gross Eff. Date Net Weekly Amt. Net Eff. Date Start Date Through Date WeeksDaysAmt. Paid Payment Issue Date 050 TEMPORARY TOTAL CB /19/ /19/12 6/15/ TEMPORARY PARTIAL CB /16/ /16/12 6/29/ MTC CB: Seg #ACR CodeACR Description Ben Type Code Start DateEnd DateWeekly Amount 1VSafety Violation0505/19/126/15/12$ VSafety Violation0706/16/12$96.00 Number of Benefit A/C/R Segments:

Questions Regarding Adjustments 46

Benefit Credits 47

Benefit Credit Code The Benefit Credit Code identifies a reduction that is applied to the Gross Weekly Amount to yield a new Net Weekly Amount, to recoup monies previously paid. Values: C = Overpayment P = Advance 48

Benefit Credit Start Date The Benefit Credit Start Date is the first date of the uninterrupted period in which the current Benefit Credit Weekly Amount was applied to the Benefit Type Code. 49

Benefit Credit End Date The Benefit Credit End Date is the last date through which the benefit credit was applied to the Benefit Type Code. If the Benefit Credit is ongoing, the Benefit Credit End Date is left blank. 50

Benefit Credit Weekly Amount The Benefit Credit Weekly Amount is the weekly amount of the benefit credit corresponding to the Benefit Credit Code. 51

Let’s take a look at a Benefit Credit scenario with an overpayment (Benefit Credit Code-C). The credit ended during the second event (after the 00/IP), so the claim administrator reported the A/C/R Segment with the Benefit Credit End Date. 52

Benefit Credit Example: DOI = 5/18/12 IDDB = 5/19/12 Average Wage (AWW) = $325 (estimated wages) Calculated Weekly Compensation Amount (Comp Rate) = $ Gross Weekly Amount = $ (TT rate) Payment Amount = $ The 00/IP was filed paying day 8-14 (1 wk) with a Payment Amount of $

Benefit Credit Example: On 6/30/12, the claim administrator received the injured worker’s actual wages from the employer reflecting an AWW of $300 and Comp Rate of $200. By the time the actual wages were received, the injured worker had been overpaid by $ (6 weeks). 54

Benefit Credit Example: Benefits can be reduced by no more than 20%* per week to recoup an overpayment. ($40 in this example) *F.S (12) - Repayment 55

Benefit Credit Example: On 7/13/12, the claim administrator filed an MTC CA reflecting:  New AWW  Calculated Weekly Comp Amount  Gross Weekly Amount  Net Weekly Amount  Payment for weeks 1 through 8 AND  Benefit Credit Code ‘C’ (Overpayment), recouping 20% ($40) of the weekly recouping 20% ($40) of the weekly indemnity benefits for the overpayment. indemnity benefits for the overpayment. 56

First Event:  The MTC CA is sent to report the recoupment of the overpayment ($100.08)  Dates of service overpaid 5/19/12 - 6/29/12 (6 wks) 5/19/12 - 6/29/12 (6 wks) 57

Second Event: Another MTC CA is sent reporting the end of the recoupment, and changing the Net Weekly Amount due to a new Credit Weekly Amount. The Net Weekly Amount for the last week was reduced by $20.08 (not $40) as this was the balance of the overpayment… 58

…The Benefit Credit End Date is reported since the overpayment was recouped in full. 59

Third Event: Another MTC CA is sent to report: The new Net Weekly Amount New Net Effective Date and the advancement of the Benefit Period Through Date for TT benefits. Through Date for TT benefits. The A/C/R Segment is no longer required to be reported as the overpayment credit ended on the previous transaction. 60

If an ACR Segment ends, an MTC CA must be sent to:  Report the end date of the adjustment or credit and credit and  Update the Net Weekly Amount and Net Weekly Amount Effective Date Net Weekly Amount Effective Date 61

POP QUIZ: True or False If an injured worker is overpaid indemnity benefits, payment of the total amount overpaid may not exceed 20% of the injured worker’s biweekly payment. 62

ANSWER:TRUE F.S (12) - Repayment 63

Questions Regarding Credits 64

Redistributions 65

Benefit Redistribution Code The Benefit Redistribution Code identifies that a portion of the Net Weekly Amount is being directed to another party on behalf of the employee or beneficiary, but which does not reduce the Gross Weekly Amount or affect the Net Weekly Amount. 66

The Benefit Redistribution Code used in FL is:  H = Court Ordered Lien 67

Benefit Redistribution Code ‘H’ is applicable where a portion of the injured employee’s payment is reduced/re-directed for payment of child support. This code is also applicable for payment to a nursing home or assisted living facility on behalf of the injured worker, per a legal agreement. 68

Benefit Redistribution Start Date The Benefit Redistribution Start Date is the first date of the uninterrupted period in which the current Benefit Redistribution Weekly Amount was applied to the Benefit Type Code. 69

Benefit Redistribution End Date The Benefit Redistribution End Date is the last date through which the benefit redistribution was applied to the Benefit Type Code. If the Benefit Redistribution is ongoing, the Benefit Redistribution End Date is left blank. 70

Benefit Redistribution Weekly Amount The Benefit Redistribution Weekly Amount is the weekly amount of benefit redistribution corresponding to the Benefit Redistribution Code. 71

Let’s take a look at a claim scenario where the Benefit Redistribution Code ‘H’ (Court Ordered Lien) was reported. The redistribution did not end so the claim administrator continued to report the A/C/R Segment without a Benefit Redistribution End Date. 72

Benefit Redistribution Example: Average Wage (AWW) = $600 Calculated Weekly Compensation Amount (Comp Rate) = $400 Gross & Net Weekly Amount for TTD Benefits = $400 Due to a court order, benefits were reduced by 50% for payment of child support. ($200) 73

Example with Redistribution: Gross Weekly Amt for TTD Benefits = $400 Net Weekly Amt for TTD Benefits = $400 Net Weekly Amt is NOT reduced to $200 because the same weekly amount is being paid by the claim administrator; however, a portion ($200) of the Net Weekly Amount ($400) is being redistributed to another party. Benefit Redistribution Amount = $200 74

BTCBenefit TypeMTC Gross Weekly Amt. Gross Eff. Date Net Weekly Amt. Net Eff. Date Start Date Through Date WeeksDaysAmt. Paid Payment Issue Date 050 TEMPORARY TOTAL CA /19/ /19/13 6/29/1360$ Seg #ACR CodeACR Description Ben Type Code Start DateEnd DateWeekly Amount 1HCourt Ordered Lien0506/16/13$ Number of Benefit A/C/R Segments: 001 MTC CA: On 6/29/13, the claim admin filed an MTC CA with the Benefit Redistribution Code ‘H’ (Court Ordered Lien) reporting that effective 6/16/13, a portion of the injured worker’s check was being sent to the appropriate entity for payment of child support. 75

In this scenario, the redistribution has not ended so the claim administrator must continue to report the A/C/R Segment without the Benefit Redistribution End Date. 76

Questions Regarding Redistributions 77

Top Errors Affecting Claim Administrators Continued… 78

Error #5: GROSS WEEKLY AMOUNT IS > $.05 UNDER CALC GROSS WEEKLY AMOUNT ( ) 79

This error most commonly occurs when the Gross Weekly Amount for IB (030) benefits is reported as greater than $0.05 under the jurisdiction calculated Gross Weekly Amount. Common Errors Received By Claim Administrators: GROSS WEEKLY AMOUNT IS > $.05 UNDER CALC GROSS WEEKLY AMOUNT ( ) 80

FL Claims R3 Edit Matrix FL Calculation (Proprietary Tab) 81

This is a screenshot of the Errors Tab displayed in the Claims EDI Warehouse. 82

The following scenario is an example of when this Gross Weekly Amount error occurs…  Date of accident = 7/24/11  AWW = $  C/R = $  IRTW = 7/25/11 (Actual) (Day after acc)  IDDB = 8/5/11 (out of work for surgery)  00/IP sent on 8/18/11 reporting the initial payment of TT (050) benefits. payment of TT (050) benefits. 83

The injured worker was “released” to Return To Work again on 9/2/11 and he earned pre-injury wages. This should be reported as the Latest RTW Status Date This Latest RTW Status Date was not reported on a SROI 02 prior to the next event - MTC CB. 84

The injured worker reached MMI on 9/28/11 (with 3% PIR). The claim administrator filed an MTC CB on 10/12/11. The Latest RTW Status Date of 9/2/11 was not sent on the CB. 85

The CB reported the change from TT (050) to IB (030) benefits with the Gross and Net Weekly Amounts as $ (which is 50% of 75% of the Comp Rate – or 37.5%). 86

The MTC CB rejected with the error “Gross Weekly Amount is > $.05 Under Calc Gross Weekly Amount”. In this scenario, our program is expecting BTC 030 to be paid at the higher rate ($ which is 75% of the CR) because it appears the injured worker is still out of work as the Latest RTW Status Date information was not reported. 87

The claim administrator will need to report the Latest RTW Status Date and corresponding RTW fields on the MTC CB transaction, along with the MMI & PI information. 88

This same Gross Weekly Amount error also occurs when a Current Date Disability Began is sent in conjunction with the initiation of IB (030) benefits. Common Errors Received By Claim Administrators: GROSS WEEKLY AMOUNT IS > $.05 UNDER CALC GROSS WEEKLY AMOUNT ( ) 89

FL has submitted a request to the IAIABC to modify the definition of Current Date Disability Began in order to clarify that it is not used solely to report the initiation or change to Impairment Income Benefits (030). Common Errors Received By Claim Administrators: GROSS WEEKLY AMOUNT IS > $.05 UNDER CALC GROSS WEEKLY AMOUNT ( ) 90

POP QUIZ: What EDI document contains information regarding the jurisdiction calculated Gross Weekly Amount? 91

ANSWER: The Edit Matrix The Jurisdiction Calculated Weekly Amount can be found on the FL Calculation (Proprietary) Tab. FL Calculation (Proprietary) Tab. This document is located on the Division’s website: 92

Questions Regarding Error #5: GROSS WEEKLY AMOUNT IS > $.05 UNDER CALC GROSS WEEKLY AMOUNT 93

Error #6: GROSS WEEKLY AMOUNT IS > $.05 OVER CALC GROSS WEEKLY AMOUNT ( ) 94

This error most commonly occurs when the Gross Weekly Amount for IB (030) benefits is reported as greater than $0.05 over the jurisdiction calculated Gross Weekly Amount. Common Errors Received By Claim Administrators GROSS WEEKLY AMOUNT IS > $.05 OVER CALC GROSS WEEKLY AMOUNT ( ) 95

This error most often occurs when the Gross Weekly Amount for IB (030) benefits is reported as the Comp Rate. Effective 10/1/2013, an edit was added to Gross Weekly Amount. If the Gross Weekly Amount was reported the same as the Comp Rate, the transaction will reject. Keep in mind, the Gross (and Net) Weekly Amounts should never be reported as the Comp Rate for IB (030) benefits. 96

POP QUIZ: True or False Gross and Net Weekly Amounts are calculated at the same rate for BTC 050 (TT) and BTC 030 (IB). 97

ANSWER:FALSE TT (050) benefits = 66 2/3% of AWW IB (030) benefits = 75% or 37.5% of C/R 98

Questions Regarding Error #6 GROSS WEEKLY AMOUNT IS > $.05 OVER CALC GROSS WEEKLY AMOUNT 99

Error #7: NET WEEKLY AMOUNT MUST CHANGE VIA CA, CB, RB or AP ( ) 100

This error commonly occurs when the Net Weekly Amount reported on a Suspension (Sx) or Sub-Annual (SA) transaction has been changed and does not match the value previously reported. Common Errors Received By Claim Administrators: NET WEEKLY AMOUNT MUST CHANGE VIA CA, CB, RB or AP ( ) 101

The Net Weekly Amount is not required to be reported on a Sub-Annual (SA) or Final (FN) transaction; however, if the MTC SA or FN is present in the Benefit Segment, it will be treated as an “Event” Benefit Segment and both the Gross and Net Weekly Amounts will be edited. 102

The Net Weekly Amount should be changed on a MTC CA – Change in Benefit Amount. The Net Weekly Amount can change on one of the following MTCs if in conjunction with another applicable event:  CB- Change in Benefit Type,  RB- Reinstatement of Benefits,  AP- Acquired/Payment… 103

In the past, trading partners were allowed to change the Net Weekly Amount on a SROI ‘02’ (Change) if they were not approved to send “secondary” MTCs. At this time, all trading partners in production are approved to send “primary and secondary” MTCs; therefore, trading partners are no longer permitted to change the Net Weekly Amount on a SROI

All references to the FL “primary and secondary” implementations in the FL Claims EDI R3 Edit Matrix will be removed in the next Rule revision. 105

POP QUIZ: What MTC should be sent to report a change in benefit amount? 106

ANSWER: MTC CA 107

Questions Regarding Error #7 NET WEEKLY AMOUNT MUST CHANGE VIA CA, CB, RB or AP 108

MTC Review 109

Handouts will be passed out for this portion of the training… 110

Lump Sum Payments/Settlements 111

Lump Sum Payment/Settlement Codes There are two types of Lump Sum Payment/Settlement Codes; Lump Sum Payments (which do not limit future liability) and Settlements (that do limit future liability). 112

NS AS AW AD Lump Sum Payment Codes AgreementStipulated Award Advance Non-SpecifiedPayment 113

A lump sum payment that is not being fully advanced, stipulated, awarded or settled, and does not apply to another LSP/S Code. NS Non-Specified Lump Sum Payment This does not limit future liability. 114 Lump Sum Payment Code ‘NS’

A Lump Sum Payment for Impairment Income Benefits (BTC 030), would be an example of a Non-Specified Lump Sum Payment (NS). 115

A Lump Sum Payment /Settlement Code is currently not required to be reported with a lump sum payment of IB’s; however, effective September 1, 2014, the Lump Sum Payment /Settlement Code NS will be required on the MTC PY for the reporting of 030 benefits in a lump sum. 116

A lump sum payment agreed upon by the parties of one or more benefit types for a disputed period of disability. AS Agreement Stipulated This does not limit future liability. 117 Lump Sum Payment Code ‘AS’

An adjudicated lump sum payment of one or more benefit types for a disputed period of disability. AW Award This does not limit future liability. 118 Lump Sum Payment Code ‘AW’

AD A lump sum payment of benefits in advance of when it is due. This may be recouped as a weekly credit against future benefits not to exceed 20%. Advance 119 Lump Sum Payment Code ‘AD’

If a rate and time period are specified for the lump sum payment, the Benefit Type Code/Payment Reason Code 0xx (vs. 5xx) series would be used. If a rate and time period are not specified, the Benefit Type Code/Payment Reason Code 5xx series will be used. 120

SF SP Settlement Full (washout) (washout) SettlementPartial Settlement Codes 121

A settlement agreed upon by all parties parties to end past, present and future liability of all benefits. SF  No future indemnity or medical benefits are due. benefits are due. Settlement Full (washout)  BTC 500 is required. Settlement Code ‘SF’ 122

A settlement agreed upon by all parties to:  Settle all indemnity benefit type codes, but not medical. codes, but not medical.  Settle all medical, but not indemnity. indemnity. Settlement Partial SP 123 Settlement Code ‘SP’

If all indemnity was previously settled and medical is now being settled, this should be reported as a Settlement Full (SF) rather than Settlement Partial (SP) because the claim is now fully settled. 124 Settlement Codes

Lump sum payments/settlements must be reported using the MTC Code “PY”. Lump sum payment/settlement transactions must have a Payments segment and a Benefits segment, unless Reduced Benefit Amt Code = S or N. 125

When the Lump Sum Payment/Settlement Code = SP or SF, Payment Reason Code must = 500, 524 or 501 for the most recent Payment Issue Date. When the Lump Sum Payment/Settlement Code = SF, Payment Reason Code must = 500 or 524 or 500/524 is previously on file. 126

For FL, a Payments segment is always sent on an MTC ‘IP’ or a ‘PY’, unless Reduced Benefit Amount Code = S or N. 127

The indemnity benefits represented by the Payment Reason Code in the Payments segment are also included in the Benefits segment with the corresponding Benefit Type Code. BTCBenefit TypeMTC Gross Weekly Amt. Gross Eff. Date Net Weekly Amt. Net Eff. Date Start Date Through Date WeeksDaysAmt. Paid Ben Payment Issue Date 500 UNSPEC LUMP SUM PAY PY 5/26/ /26/12 Seg # Pymnt Reason Code PayeeAmountStart DateThrough DatePayment Issue Date 1500Andrew Attorney & Associates5005/26/12 128

Lump Sum Payment/Settlement Codes An Award/Order Date is required for all Lump Sum Payment/Settlements unless the Lump Sum Payment/Settlement code equals:  AD (Advance < $2,000), or  NS (Non-specified Payment) or  BTC = 030 (IB) or  BTC = 530 (Settlement of IB) 129

If indemnity benefits are ongoing following the Payment transaction, the next applicable transaction should then be filed (e.g., IP, AP, RB), to ensure their isn’t a sequencing problem. Lump Sum Payment/Settlement Codes 130

For example: An IP must follow a PY if the claim administrator has paid the lump sum amount (e.g. Award) and is now making an initial payment of ongoing indemnity benefits. IP after PY 131

Lump Sum Payment followed by a later Settlement for the same Benefit Type Code (PY after PY) 132

Lump Sum Payments followed by a Settlement of same Benefit Type Code When an Advance, Award or Stipulated Agreement was previously reported with Benefit Type Code 500 AND a Full or Partial Settlement with Benefit Type Code 500 is now being reported… 133

… the Benefit Type Amount Paid for the 5xx BTC will include the Award or Stipulated Agreement amount as well as the new Settlement amount. The Payment Amount in the Payments segment will only be the amount of the most recent Settlement Amount. 134

Lump Sum Payments/Settlements Covering More Than 1 DOI 135

Settlements covering more than one Date of Injury A Full Settlement may involve more than one date of injury, but the settlement amount (Payment Amount) will only be reported on one PY transaction. 136

If one or more claims (including Medical Only claims) were settled as part of another date of injury, a PY, with the Reduced Benefit Amount Code ‘S’, is required to be sent for each claim, to report the settlement of that injury. 137

Only 1 claim will have the Settlement amount, and all others are reported with RBAC ‘S’. Note: A FROI 00 will have to be sent with any DOI not previously reported to the Division. Note: A FROI 00 will have to be sent with any DOI not previously reported to the Division. Settlements covering more than one Date of Injury 138

Reduced Benefit Amount Code ‘S’ (Claim Settled Under Another DOI) 139

PROPER USE OF REDUCED BENEFIT AMOUNT CODE ‘S’ (CLAIM SETTLED UNDER ANOTHER DOI) PROPER USE OF REDUCED BENEFIT AMOUNT CODE ‘S’ (CLAIM SETTLED UNDER ANOTHER DOI) The Reduced Benefit Amount Code ‘S’ should be reported via an MTC PY if a claim is settled and the settlement dollars for this claim are paid and reported under another date of injury. 140

The presence of RBAC Code ‘S’ means that a ‘Payment’ segment will not be present on the transaction and a ‘Benefits’ segment will only be present on the transaction if indemnity benefits had been paid for this date of injury prior to the settlement… 141

… The Award/Order Dates and Lump Sum Payment/Settlement Code (SF – Settlement Full) would be the same for all files. 142

Reduced Benefit Amount Code ‘N’ (No Money Settlement) 143

PROPER USE OF REDUCED BENEFIT AMOUNT CODE ‘N’ (NO MONEY SETTLEMENT) The Reduced Benefit Amount Code “N” should be reported via an MTC PY if a claim was part of a ‘No Money Settlement’. An example of a “No Money Settlement” includes a settlement with no dollars being paid, due to a waiver of a lien or forgiveness of an overpayment. 144

The presence of RBAC Code ‘N’ means a ‘Payment’ segment will not be present on the transaction and a ‘Benefits’ segment will only be present on the transaction if indemnity benefits had been paid for this date of injury prior to the settlement… 145

… The Award/Order Date and Lump Sum Payment/Settlement Code (SF – Settlement Full) should be reported. 146

Questions? 147

Recent Law Change 148

Temporary Total Catastrophic benefits are paid to injured employees who have:  Sustained loss of arm, leg, hand or foot  Been rendered a paraplegic, paraparetic, quadriplegic or quadriparetic or quadriplegic or quadriparetic or  Lost sight in both eyes Temporary Total Catastrophic (TTC) 149

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

Effective July 1, 2013, the $700 max Comp Rate cap was removed. Temporary Total Catastrophic benefits are now to be paid at 80% of the injured worker’s Average Weekly Wage, and are no longer subject to a maximum Comp Rate. 151

Court Case Decision Escambia County School Board v. Tina Vickery-Orso 152

Comp Rate Calculation The DCA decision in the case of Escambia County School Board v. Tina Vickery-Orso (1 st DCA Case No ) clarified the manner in which an injured worker’s comp rate is to be calculated. 153

 Previous calculation method: AWW x.6667 (66 2/3%)  New calculation method: (AWW x 2)/3 154

There have not been any changes made to the Edit Matrix involving the new calculation of the Comp Rate. Our edits have been relaxed to allow for the minor difference between both calculation methods. 155

A claim administrator can elect to continue using the previous calculation method (AWW x.6667) or use the new method (AWW x 2)/3). The Division will accept either method submitted. 156

2014 Updated IAIABC Release 3 Data Elements 157

Claim Administrator Claim Number (DN 0015) 158

Claim Administrator Claim Number (DN 0015) The definition of Claim Administrator Claim Number was updated to clarify that this number should be unique for each claim in the claim administrator’s system. Therefore, a claim administrator should not report more than one claim with the same claim number. 159

The Data Processing (DP) Rule for this definition was also updated to ensure that the Employee SSN is not reported as, or embedded in, the claim number. This prevents confidentiality or redaction issues for states that must produce public records. 160

In April 2013, the Division implemented edits to prevent the reporting of an Employee’s SSN in the Claim Administrator Claim Number field. The Division must take every precaution to avoid the accidental release of the employee’s SSN when a claim number is provided as part of a public records request. 161

Benefit Payment Issue Date (DN 0192) & Payment Issue Date (DN 0195) 162

Benefit Payment Issue Date (DN 0192) and Payment Issue Date (DN 0195) The definitions for Benefit Payment Issue Date & Payment Issue Date were updated to include Electronic Fund Transfer (EFT) payments made by the claim administrator to an injured employee. 163

The new definition for Benefit Payment Issue Date and Payment Issue Date is… 164

…the date when the check that initiated the Maintenance Type Code (MTC) is officially surrendered during business hours to a letter delivery organization, is available for pickup per agreement with the employee or the date the funds are available to the employee, if the payment is made by Electronic Funds Transfer (EFT). 165

Benefit Payment Issue Date and Payment Issue Date are applicable to the following Maintenance Type Codes (MTCs):  IP- Initial Payment  PY- Payment Report  AP- Acquired/Payment and  RB- Reinstatement of Benefits 166

If the claim administrator is opting to pay an injured employee via EFT, the claim administrator should be familiar with the bank’s process to ensure that the Payment Issue Date is reported accurately (the date the funds are available to the employee). 167

Questions 168

Open Discussion Questions/Issues 169

Acquired Claims 170

An acquired claim is any existing claim (open or closed) that was transferred to a new claim administrator. Acquired Claims 171

Acquired Claims Keep in mind that any new claim occurring after the date of the acquisition is not considered acquired; therefore, the Division would expect the applicable First Report of Injury or Illness to be filed. 172

To report an acquired claim, the new claim administrator is required to file an MTC AQ transaction for the following:  All open lost time claims  Any lost time claim closed within five years prior to the date of acquisition. 173

If the new claim administrator files an MTC AQ and the transaction rejects because the First Report of Injury or Illness (paper or EDI) has not been filed with the Division, the new claim administrator must file a FROI AU with SROI (AP or other applicable SROI). 174

Reminder: Even if the prior claim administrator did not file the First Report of Injury or Illness (paper or EDI) with the Division, the new claim administrator is still required to file the FROI because the insurer is ultimately responsible for the claim. 175

Once the FROI MTC AQ accepts and an initial payment is made by the new claim administrator, a SROI AP (as opposed to a SROI IP) should be filed. 176

All prior indemnity benefits paid by the previous claim administrator must be reported under Other Benefit Type (OBT) Code 430 (Total Unallocated Prior Indemnity Benefits). 177

Florida does not require the acquiring claim administrator to report OBT Code 440 (Total Unallocated Prior Medical), as those costs are collected via the Division’s Medical EDI program. 178

If the claim was closed at the time of acquisition and the acquiring claim administrator does not intend to make any future payments to the injured worker, once the FROI MTC AQ is accepted, no additional transactions will be due and the claim will remain closed in the Division’s database. 179

If a new claim administrator acquires a claim, and the administration of that claim remains in the same claim system (e.g. merger), the new claim administrator can send a FROI 02 (as opposed to an MTC AQ) to update the claim administrator information. 180

The claim administrator will need to coordinate this with the EDI team prior to submitting the FROI 02 transactions. 181

In this FROI 02 situation, any additional benefits reported on a future SROI would still be sent in the Benefit Segment and no OBT 430 (Total Unallocated Prior Indemnity Benefits) would be present because the claim administrator is using the same system that was used prior to the acquisition. 182

POP QUIZ: True or False Once the FROI AQ accepts and an initial payment is made by the new claim administrator, a SROI IP should be filed. 183

ANSWER:FALSE MTC AP (Acquired/Payment) should be filed because this is the first payment made by the acquiring claim administrator. 184

New 2014 IAIABC Release 3 Data Element 185

This is a code that indicates that Employer Paid ‘Unspecified’ Benefits, (Benefit Type Code (BTC) 240), were the only benefits paid prior to an acquisition. Employer Paid Salary Prior to Acquisition Code ‘E’ (DN 0203) 186

Why is this code needed? Benefit Type Amount Paid (total money paid to date for a Benefit Type) cannot be required for Benefit Type Code 240 in accordance with the IAIABC standard; Therefore, there are no monies to carry over into OBT 430 (Total Unallocated Prior Indemnity Benefits). 187

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

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

In the past, the IAIABC standard indicated that the OBT Code and Amount for 430 should be present on an AP, and had not taken into account the instance where only BTC 240 was reported prior to an acquisition, and no dollars would be reportable to reallocate into OBT 430. This was causing rejections… 190

The Employer Paid Salary Prior to Acquisition Code ‘E’ was created to address this issue and explain why OBT 430 is not present on the acquiring payment transaction. 191

Florida began accepting the Employer Paid Salary Prior to Acquisition Code ‘E’ on September 25, Even though this code is not required, the use of it will eliminate a rejection when reporting a claim that has been acquired and only BTC 240 had previously been reported. 192

If you are a claim administrator that does not acquire claims or salary in lieu of comp claims, you do not need to worry about this new data element. 193

Questions Thank You 194