Florida Division of Workers’ Compensation Claims EDI MTC’s, Codes, FROI 00, SROI IP Overview 2013 WELCOME

Presenter: Tonya Granger Administrator, Claims & POC EDI Team Bureau of Data Quality and Collection FL Division of Workers’ Compensation

In R3 EDI, all WC data is sent electronically via a FROI or SROI transaction.

What Is A ? FROI

First Report of Injury (FROI)

Release 3 FROI Transaction Originally, the EDI First Report of Injury Record was identified by a single record with a Transaction Set ID of '148'.  In Release 3, the 148 record must be paired with a companion record - R21, FROI Companion Record to complete the First Report of Injury transaction.

Release 3 FROI Transaction This means the Release 3 FROI transaction requires 2 records to communicate the First Report event, the “148” & “R21” records.

First Report of Injury FROI =148 + R21

The FROI Flat File

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

FROI Flat File (148) Record Layout Data Elements Filler

FROI Companion Flat File (R21) Record Layout Data Elements Filler

FROI R21 Variable Segments

What Is A ? SROI

Subsequent Report of Injury (SROI)

Release 3 SROI Transaction Originally, the EDI Subsequent Report of Injury Record was identified by a single record Transaction Set ID of ‘A49’. In Release 3, the A49 must be paired with a companion record - R22, SROI Companion Record, to complete the SROI transaction.

Release 3 SROI Transaction This means the Release 3 SROI transaction requires 2 records to communicate the Subsequent Report event, the “A49” & “R22” records.

Subsequent Report of Injury SROI = A49+R22

The SROI Flat File

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

SROI Flat File (A49) Record Layout Data Elements Filler

SROI A49 Variable Segments

SROI Companion Flat File (R22) Record Layout Data Elements Filler

SROI R22 Variable Segment Counters

SROI R22 Benefit (BEN) Segment

SROI R22 Payment/OBT Segments

SROI R22 Adjustment/Credit/Redistribution Segments

SROI R22 Recoveries/Reduced Earnings/Segments **Reduced Earnings are not reported in FL.

SROI R22 Concurrent Employer Segment

SROI R22 Denial Reasons/Suspension Variable Segments

EDI Terminology

Let’s Review Important Codes Common To EDI Transactions

Important Codes R3 Quick Code Reference Guide (see FL Claims EDI webpage) Maintenance Type Codes Benefit Type Codes Other Benefit Type Codes

R3 Quick Code Reference One Stop Shopping for most codes Found on FL Claims EDI webpage One Stop Shopping for most codes

What Is An ? MTC MTC

Maintenance Type Code

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

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

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

Maintenance Type Code When an MTC is required to be sent at the ‘Benefits level’ on the SROI (i.e., in the benefits segment itself), the same MTC must be sent at the ‘Claim level’ on the SROI.

First Report of Injury MTC’s

FL FROI MTC’s Include : 00 – Original 04 – Total Denial 01 – Cancel (Claim Filed in Error) AQ – Acquired Claim AU – Acquired First Report

FL FROI MTC’s: Changes 02 – Change

Subsequent Report MTC’s

Initial Payment Equivalents: EP – Employer Paid Salary in Lieu of Comp FL SROI MTC’s: Initial Payment Equivalents: IP - Initial Payment PY – Payment EP – Employer Paid Salary in Lieu of Comp AP - Acquired First Payment

FL SROI MTC’s: Initial Payment Equivalents (cont’d): CD – Compensable Death-No Known Dependents/Payees VE - Volunteer

Denials: FL SROI Report MTC’s: 04 – Full Denial PD – Partial Denial (Indemnity Only & other required partial denials).

Additions/Changes FL SROI MTC’s: AB – Add Concurrent Benefit CA – Change in Benefit Amount CB – Change in Benefit Type

Reinstatements FL SROI MTC’s: ER – Employer Reinstatement RB – Reinstatement of Benefits ER – Employer Reinstatement

Full Suspensions (of all Indemnity) FL SROI MTC’s: Full Suspensions (of all Indemnity) S1 – RTW or Released to RTW S2 - Medical Non-Compliance S3 – Administrative Non-Compliance

Full Suspensions (of all Indemnity) FL SROI MTC’s: Full Suspensions (of all Indemnity) S4 – Claimant Death S5 - Incarceration S6 – Claimant’s Whereabouts Unknown

Full Suspensions (of all Indemnity) FL SROI MTC’s: Full Suspensions (of all Indemnity) S7 – Benefits Exhausted S8 – Jurisdiction Change You should recognize these from the DWC-4 Form

Partial Suspension (of a concurrent benefit) FL SROI MTC’s: Partial Suspension (of a concurrent benefit) P7 – Benefits Exhausted FL’s only concurrent benefit type is PT and PT Supplemental Benefits. If one benefit is suspended but the other benefit continues, a Partial Suspension is filed.

Periodic Reports FL SROI MTC’s: SA – Sub Annual For EDI R3, the Annual Claim Cost Report has been replaced with a Sub Annual report, due every 6 months from the Date of Injury until the claim is closed.

FL SROI MTC’s: Periodic Reports (cont’d)… FN – Final

FL SROI MTC’s: Changes 02 – Changes EDI

FL requires both the FROI and SROI combination filing to constitute the electronic form equivalent of a DWC-1 reporting initial payment or ‘equivalent’ information.

Claims EDI R3 Required MTC’s SROI Maintenance Type Codes (MTC’s) required by FL to be filed with a FROI MTC (00 or AU) to report the initial payment or equivalent are: IP, EP, PY, PD, CD, VE, & AP

Benefit Type Codes (BTC) ? What are Benefit Type Codes (BTC) ?

codes that identify the type of indemnity benefits being paid. TT - 050 TP - 070 IB - 030 BTC’s are codes that identify the type of indemnity benefits being paid.

Benefit Type Codes 010 – Fatal/Death 020 – Permanent Total 021 – Permanent Total Supplemental 030 – Perm Partial Scheduled (Impairment Income) 040 – Perm Partial Unscheduled (Supplemental Income) 050 – Temporary Total

Benefit Type Codes 051 – Temporary Total Catastrophic 070 – Temporary Partial 090 – Permanent Partial Disfigurement 410 – Voc Rehab Maintenance 500 – Unspecified Lump Sum Pmt/Settlement 5XX – Specific Lump Sum Pmt/Settlement per Benefit Type Code (e.g., 510, 550, etc.)

Benefit Type Codes 210 – Employer Paid Fatal (Death) 230 – Employer Paid Perm Partial (IB’s) 240 - Employer Paid Unspecified 242 – Employer Paid Voc Rehab Maintenance 250 – Employer Paid Temporary Total 251 – Employer Paid Temporary Total Catastrophic 270 – Employer Paid Temporary Partial

What are “Other Benefit Type” Codes (OBT’s)?

codes that represent the type of non-indemnity benefits being paid. 311 321 370 OBT’s are codes that represent the type of non-indemnity benefits being paid.

Other Benefit Type Codes (required by FL) 300 – Total Funeral Expenses 310 – Total Penalties 311 – Total Employee Penalties 320 – Total Interest 321 – Total Employee Interest 370 – Total Other Medical

Other Benefit Type Codes (required by FL) 380 – Total Voc Rehab Evaluation 390 – Total Voc Rehab Education 400 – Total Other Voc Rehab 430 – Total Unallocated Prior Indemnity Benefits (acquired claims) 475 – Total Medical Travel Expenses

300 400 475 FL has reduced the amount of OBT Codes required to be reported for R3, because the majority of medical information is already being reported to the Division via another electronic format.

Hot Topic

Other Benefit Type Codes (not required by FL) FL no longer requires the reporting of: Physician (Medical) Hospital, or Pharmacy/Durable Medical Paid To Date on the EDI Claim Cost “Periodic” report.

If you are currently reporting this information under OBT 370, it should be corrected using one of the following: SROI 02 SA (amended) FN (amended)

FL BUSINESS SCENARIOS

FL SCENARIO ASSUMPTIONS

FL SCENARIO ASSUMPTIONS General scenario assumptions are included in the scenarios to assist in understanding the sample data that is presented.

FL SCENARIO ASSUMPTIONS The FL Scenarios were enhanced from the IAIABC scenarios in the R3 Implementation Guide. All the 2001 dates were moved forward to 2007 (the next year where all dates fell on the same day of the week).

FL SCENARIO ASSUMPTIONS Calculated Weekly Compensation Amount is the Comp. Rate, and is 66 2/3% of the Average Wage. The statutory comp rate max is not accurate per FL law.

FL SCENARIO ASSUMPTIONS Scenarios are presented in uppercase text. However, data may be sent to FL in mixed case format (except between FROI/SROI combos for match data.) Payment of indemnity benefits is based upon a 5 day work week. The Industry Code must be a 2002 or 2007 NAICS code.

FL SCENARIO ASSUMPTIONS FL Scenarios contain required sample data elements pertinent to the scenario. These data are identified as “M” (Mandatory) or “MC” (Mandatory/Conditional) on the FL Element Requirement Table.

FL SCENARIO ASSUMPTIONS Additional data elements may be present in the scenario if they are identified as “IA” (If Applicable/Available) on the Element Requirement Table (e.g., Middle Initial and Suffix).

FL SCENARIO ASSUMPTIONS Although Claim Administrators may send additional data elements marked “NA” (Not Applicable), such data will not be edited or loaded by FL, and therefore not presented in the scenarios.

Note: Do not use the FL Business Scenarios to determine if a data element is required for a particular MTC. The Element Requirement Table is the official source of FL’s data element requirements per MTC and the conditions under which the data must be present.

FL SCENARIO PROFILES

FL Scenario Profiles Unless otherwise noted in the scenario narrative, the basic scenario profile information for all scenarios will be as follows….

FL Scenario Profiles Description Data Name: John James Smith, Jr. Injured Employee Description Data Name: John James Smith, Jr. SSN: 324-55-6745 DOI: June 15, 2007 DOB: May 1, 1953 Empmnt Status: Full Time

FL Scenario Profiles Description Data Class Code: 2802 (Carpenter) Injured Employee Description Data Class Code: 2802 (Carpenter) Days Worked/Week: 5 Wage: $15.00 Wage Period: Hourly (FROI)

FL Scenario Profiles Employer/Insured Description Data Employer: Acme Construction Inc. FEIN: 74-6994235 Physical Location: 32 Meadowbrook Lane Anytown, FL 32399 Industry (NAICS): 236116

Insurer/Claim Administrator FL Scenario Profiles Insurer/Claim Administrator Description Data Insurer: Old Reliable Ins. Co. FEIN: 78-5902378 Average Wage: $600.00 Wage Period: Weekly (SROI)

FL SCENARIOS A FROI MUST be paired with the applicable SROI that is reporting the initial payment or equivalent, unless the FROI is reporting a Full Denial (MTC 04), Cancel (MTC 01), Change (MTC 02) or Acquired Claim (MTC AQ).

Complete Scenario for FROI/SROI Combo MTC “00” with “IP” Disability Immediate & Continuous Rule 69L-56.301(1)(a)1., F.A.C.

Indemnity Benefits other than TP or IB or settlement will be paid, an NEW CLAIM: Lost Time Case Where Disability is Immediate and Continuous If the Initial Payment of Indemnity Benefits will be made by the Claim Administrator, and Indemnity Benefits other than TP or IB or settlement will be paid, an Electronic First Report of Injury or Illness is due.

NEW CLAIM: Lost Time Case Where Disability is Immediate and Continuous Again, the specific timeframes for the timely submission of this and other required electronic filings are set out in Rule 69L-56, F.A.C., the Event Table, and the MTC Filing Instructions document (all available on the Claims EDI web page.)

To avoid late filing penalties for an Electronic First Report of Injury or Illness, the EDI DWC-1 should be triggered immediately upon the CA’s disposition of the claim (payment or denial), to allow time for correction of potential errors and resubmission and subsequent receipt/acceptance by the Division within the filing due dates specified in Rule 69L-56, F.A.C.

FROI “00” Scenario Narrative Employee fell from ladder at employer’s warehouse on 6/15/07. Employee broke his leg. Foreman witnessed the accident. Employee treated and released from the Emergency Room.

FROI “00” Scenario Narrative Employee earned $15.00 an hour working 40 hours a week. Employer reported injury to insurer on 6/17/07.

FROI MTC “00” SCENARIO Claim Administrator reported the loss to DWC on 6/29/07.

FROI MTC “00” SCENARIO Insurer is identified. Claim Administrator details are provided (remainder are on R21).

FROI MTC “00” SCENARIO Employer/Insured information is reported. The Employer’s name is on the R21 The rest of the Employer’s address is on the R21 NAICS Code

FROI MTC “00” SCENARIO If applicable, Policy Number should be reported, but Effective Date & Expiration Date are not required.

FROI MTC “00” SCENARIO Details of the accident are included. Employee broke leg falling from a ladder.

FROI MTC “00” SCENARIO Employer reported injury to Claim Administrator on 6/17/07.

FROI MTC “00” SCENARIO Details about injured employee are sent. The rest of the Employee’s name and address is on the R21

FROI MTC “00” SCENARIO Date the initial disability began & other FROI fields must be reported on the SROI. Manual “Risk” Class Code is only on the FROI.

FROI MTC “00” SCENARIO Employee earned $15.00 an hour and worked 5 days a week. Employee has not returned to work.

FROI MTC “00” SCENARIO FROI Companion Record - R21

FROI MTC “00” SCENARIO Claim Administrator Claim Number is repeated in the R21. It links the R21 companion to the related 148.

FROI MTC “00” SCENARIO Claim Administrator FEIN is sent. Claim Administrator Name is sent, & rest of the Claim Admin. Address. 456 Main St

FROI MTC “00” SCENARIO ID qualifier = S. Positions 232 to 246 contain a Social Security Number.

FROI MTC “00” SCENARIO Remainder of Employee name, address fields and phone are here in the R21 record.

FROI MTC “00” SCENARIO Type of Loss Code is reported on the SROI. Employee has not returned to work.

FROI MTC “00” SCENARIO Insured FEIN and Insured Name are reported.

FROI MTC “00” SCENARIO Insurer Name and Insurer Type Code are reported.

FROI MTC “00” SCENARIO Details of accident site:

FROI MTC “00” SCENARIO Employer Name, Physical address and contact information.

FROI MTC “00” SCENARIO Employer Mailing Address information is not required.

FROI MTC “00” SCENARIO Claim Type Code and EP Salary Indicator are to be reported on the SROI.

FROI MTC “00” SCENARIO Variable Segment Counters include: Two Accident/Injury Narratives, and One Witness segment.

FROI MTC “00” SCENARIO Accident description exceeds 50 characters; two segments are needed to send entire narrative description.

Variable Segment Population Rules for FROI ACCIDENT/INJURY DESCRIPTION NARRATIVES SEGMENT: No more than 10 (50 byte narrative text) segments per claim, and the number of segments sent must equal the “Number” of Accident/Injury Description Narratives segment counter.

FROI MTC “00” SCENARIO Foreman Jones was the only witness.

Variable Segment Population Rules for FROI WITNESSES SEGMENT: No more than 5 witnesses per claim, and the number of segments sent must equal the “Number” of Witnesses segment counter.

Corresponding SROI MTC “IP”

MTC “IP” (Initial Payment) The Claim Administrator has issued its first payment of indemnity benefits (not a lump sum payment/settlement.) The Initial Payment transaction implies that indemnity benefits are ongoing until suspended.

SROI IP Scenario Narrative On 6/29/07, the Claim Administrator issued the first indemnity check. Check covered TTD benefits from 6/23/07 through 6/29/07 (Day 8-14).

SROI MTC “IP” SCENARIO Initial Payment transaction is sent to the Division on 6/29/07.

SROI MTC “IP” SCENARIO Initial Date Disability Began is the day after DOI because Employer paid for DOI. Employee was a 5 day per week worker.

SROI MTC “IP” SCENARIO Claim Admin. Claim Number must be sent on every record.

SROI MTC “IP” SCENARIO No Jurisdiction Claim number required because IP SROI is filed with 00 FROI.

SROI MTC “IP” SCENARIO Claim Type indicates Lost Time case.

SROI MTC “IP” SCENARIO No variable segments; A49 ends at position 208.

SROI MTC “IP” SCENARIO Claim Administrator Claim Number is repeated in R22. It links the R22 companion to the related A49.

SROI MTC “IP” SCENARIO Claim Administrator information:

SROI MTC “IP” SCENARIO R22 includes additional employee information.

SROI MTC “IP” SCENARIO These fields are either not required, or they are reported on the FROI.

SROI MTC “IP” SCENARIO These fields are not applicable to this claim, except the Initial Date Last Day Worked.

SROI MTC “IP” SCENARIO Current Date Disability Began should NOT be defaulted to the same as the Initial Date Dis Began. Only populated if there is a 2nd period of disability.

SROI MTC “IP” SCENARIO Weekly Compensation Rate is $400 based on Average Wage of $600 effective the Date of Injury.

SROI MTC “IP” SCENARIO Type of Loss Code and Employment Status Code are reported on the SROI.

SROI MTC “IP” SCENARIO Additional wage information:

SROI MTC “IP” SCENARIO One Benefits segment and one Payment segment are required on this claim.

SROI MTC “IP” SCENARIO Temporary Total was the only benefit paid. MTC is also in Ben segment for IP.

SROI MTC “IP” SCENARIO Gross & Net Weekly Amount = $400/week (comp rate), effective on the DOI.

SROI MTC “IP” SCENARIO The Gross Weekly Amount is the weekly payment rate for the Benefit Type reported.

SROI MTC “IP” SCENARIO

SROI MTC “IP” SCENARIO Initial payment reflected benefits paid from June 23 thru June 29, 2007 (Day 8-14) for 1 week in the amount of $400.

SROI MTC “IP” SCENARIO Ben Payment Issue Date is the date payment left the CA’s control, e.g., mailed (6-28-07), not necessarily the system check issue date.

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

Benefit Payment Issue Date (DN 0192) and Payment Issue Date (DN 0195) Due to the advancement of technology, Payment Issue Date & Benefit Payment Issue Date were recently updated and added to the current IAIABC Supplement to include electronic fund transfer (EFT) payments made by the claim administrator to an injured employee.

Benefit Payment Issue Date (DN 0192) and Payment Issue Date (DN 0195) The update to the definitions of Payment Issue Date and Benefit Payment Issue Date will be in the 2014 IAIABC Implementation Guide (Data Dictionary).

Benefit Payment Issue Date (DN 0192) and Payment Issue Date (DN 0195) For Maintenance Type Codes: IP - Initial Payment, AP - Acquired/Payment, PY - Payment Report, and RB - Reinstatement of Benefits, the Benefit Payment Issue Date and Payment Issue Date is…

Benefit Payment Issue Date (DN 0192) and Payment Issue Date (DN 0195) …the date when the check that initiated the Maintenance Type Code is officially surrendered during business hours to a letter delivery organization, is available for pickup per agreement with the employee, or…

Benefit Payment Issue Date (DN 0192) and Payment Issue Date (DN 0195) … the date the funds are available to the employee, if the payment is made by Electronic Funds Transfer (EFT).

Electronic Fund Transfer (EFT) Payments If a claim administrator opts to pay an injured employee via EFT, it is the claim administrator’s responsibility to be familiar with the bank’s process to ensure Payment Issue Date is reported accurately.

Electronic Fund Transfer (EFT) Payments Florida Statute 440.20(1)(a) states: “Compensation by direct deposit or through the use of a prepaid card is considered paid on the date the funds become available for withdrawal by the employee.”

Back to the SROI MTC “IP” SCENARIO

SROI MTC “IP” SCENARIO FL requires the reporting of the exact amount of the Claim Administrator’s initial payment of indemnity benefits on MTC IP; therefore, the Payment segment must also be sent on the SROI, in accordance with the Element Requirement table.

SROI MTC “IP” SCENARIO If filing late, or re-sending an 00/IP that previously rejected, AND another indemnity check has been issued since the first installment, the Benefit Type Amount Paid should reflect the total amount and ALL benefits paid to date at the time of filing, not just the amount of the initial indemnity (IP) check.

SROI MTC “IP” SCENARIO However, the Payment Segment should only reflect the initial payment information, not subsequent payment information. This is the segment from which DWC loads the ‘Date First Payment Mailed’, to its claims system utilized by CPS.

SROI MTC “IP” SCENARIO MTC IP requires a Payments segment. Payment Reason Code = Benefit Type Code.

SROI MTC “IP” SCENARIO Payment information related to the Initial Payment is captured in the Payments segment.

SROI MTC “IP” SCENARIO Payment Issue Date = Benefit Payment Issue Date in Benefits Segment.

Hot Topic

Claim Administrator Claim Number (DN 0015)

Claim Administrator Claim Number DN 0015 The current IAIABC Supplement was recently updated to clarify that a Claim Administrator Claim Number should be unique for each claim in the claim administrator’s system.

Claim Administrator Claim Number DN 0015 This means that a claim administrator should not report more than one claim with the same claim number.

Claim Administrator Claim Number DN 0015 Additionally, the Data Processing Rule for this definition was updated to ensure that the Employee SSN is not reported as or embedded in the claim number to prevent confidentiality or redaction issues for states that must produce public records.

Claim Administrator Claim Number DN 0015 Due to Florida’s broad public records law, which requires the release of a claim number on a public records request, in April 2013, the Division implemented edits to prevent the reporting of Employee SSN in the Claim Administrator Claim Number field.

Claim Administrator Claim Number DN 0015 These changes were necessary to avoid the accidental release of the employee’s SSN when a claim number is provided as part of a public records request.

After you get back to the office, ALL Questions, either Business or Technical, should be sent via email to claims.edi@myfloridacfo.com This email address is copied to all members of the EDI team. It is the quickest and most efficient way for us to respond to your concerns.

Questions?