1. 1 SROI MTC 04 Full Denial after Payment Electronic Notice of Denial EDI DWC-12 Equivalent required to be filed with the Division per Rule 69L-56.3012(1), F.A.C.

2. 2 SROI 04 - Full Denial after Payment EDI DWC-12 Equivalent  A SROI 04 should be filed if no further indemnity or medical benefits will be paid, and/or the entire compensability of the claim is denied following the Initial Payment (or equivalent).

3. 3 SROI 04 - Full Denial after Payment EDI DWC-12 Equivalent  You would not send a SROI PD with a new PD Code in this situation. The current status of the denial is required to be reported; thus, if no further indemnity and medical will be paid, this is a Total Denial, not a Partial Denial.

4. 4  A SROI 04 acts like a suspension when benefit(s) are being terminated at the time of the denial. Therefore, an Sx is not required after the 04 before filing an FN.Therefore, an Sx is not required after the 04 before filing an FN. SROI 04 DENIAL RULES

5. 5  In general, a SROI 04 is expected to report all of the previously reported BTC’s and at least the same amount of $ previously reported … SROI 04 DENIAL RULES

6. 6 … However, we were made aware of a filing situation where this did not hold true, and therefore submitted an IRR to solicit a change to the standard… SROI 04 DENIAL RULES

7. 7 Scenario: After having filed an AQ, the acquiring Claim Admin decided to deny payment of all further indemnity and medical benefits and filed a SROI 04… Pending IRR

8. 8 … But the SROI 04 rejected because our program edits expected to see the same BTC’s previously reported. The prior BTC’s were correctly reported under OBT 430, but because OBT’s are “X” on the ERT for SROI 04… Pending IRR

9. 9 … our program did not take these benefits into account. We have therefore requested that the ERT be changed to allow OBT’s to be evaluated on a SROI 04. Note: U ntil then, we will apply special processing if this situation occurs. Pending IRR

10. 10 SROI MTC PD Partial Denial after Payment EDI DWC-12 Equivalent required to be filed with DWC per Rule 69L-56.3012(2), F.A.C. EDI DWC-12 Equivalent required to be filed with DWC per Rule 69L-56.3012(2), F.A.C.

11. 11 SROI PD - Partial Denial after Payment Electronic DWC-12 Equivalent  A ‘standalone’ SROI PD should be filed if indemnity benefits are denied (in whole or part) following the report of Initial Payment.

12. 12 SROI PD - Partial Denial after Payment Electronic DWC-12 Equivalent  The SROI PD must include: Partial Denial Code A, B, E, or G, and Partial Denial Code A, B, E, or G, and Denial Reason Narrative. Denial Reason Narrative.

13. 13 POP QUIZ: If a Full (Total Denial) or Indemnity Only Denied First Report of Injury or Illness was filed, and you subsequently rescind the denial, what MTC is used to report the Electronic Notice of Denial Rescission?

14. 14 ANSWER: To report a rescission of a previous denial of indemnity:  SROI IP, EP, ER, RB, AP, or  PD, or  02 with ‘Denial Rescission Date’

15. 15 Electronic Denial Rescission EDI DWC-12 Equivalent  A SROI PY will also rescind a denial if Denial Rescission Date is sent, but Denial Rescission Dateis not required on a PY with Lump Sum Payment/Settlement Code SF or SP (full settlements)… Denial Rescission Date is not required on a PY with Lump Sum Payment/Settlement Code SF or SP (full settlements)…

16. 16 Electronic Denial Rescission EDI DWC-12 Equivalent … But if the PY reports, for example, an Advance, Denial Rescission Dateshould be included, and an IP would also be required to report ongoing payment of indemnity. … But if the PY reports, for example, an Advance, Denial Rescission Date should be included, and an IP would also be required to report ongoing payment of indemnity.

17. 17 Payment After D enial (Electronic Notice of Denial Rescission) EDI DWC-12 Equivalent required to be filed with the Division per Rule 69L-56.3012(6), F.A.C.

18. 18  A SROI IP (or equivalent), RB, PD, AP, or 02 should be filed if you are rescinding a Full Denial. Note: SROI 02 is used to rescind if no indemnity is payable at the time of rescission. Payment After Denial (Denial Rescission)

19. 19 Payment After Denial (Denial Rescission)  A SROI IP, RB, or 02 should be filed if you are rescinding a Partial Denial (where some or all indemnity benefits previously denied will now be paid). Again, SROI 02 is used to rescind if no indemnity is payable at the time of rescission.Again, SROI 02 is used to rescind if no indemnity is payable at the time of rescission.

20. 20  Whichever MTC is used to rescind, the Denial Rescission Date must be included. Recap: The Denial Rescission Date equates to the date you took the action to rescind the denial, NOT the effective date from which benefits will be paid. Payment After Denial (Denial Rescission)

21. 21  If a denial notice is not ‘on file’ (e.g., PD rejected), you will not be able to file a denial rescission transaction (e.g., IP). Payment After Denial (Denial Rescission)

22. 22  DWC edits do not allow an IP to rescind the denial if the Denial Rescission Date on the IP is prior to the ‘effective date’, a/k/a MTC Date of the PD. Payment After Denial (Denial Rescission)

23. 23  This may become an issue since the R3 transaction does not have an actual date field that identifies when the Partial Denial was ‘effective’ - FL uses the MTC Date of the PD for this purpose. The PD MTC Date may be later than the date you initially took action to partially deny if the PD rejected multiple times... Payment After Denial (Denial Rescission)

24. 24 For example:  PD sent with MTC Date of 12/17/09; PD rejected;  IP sent on 12/18/09 with Denial Rescission Date of 12/17/09; IP rejected … Payment After Denial (Denial Rescission)

25. 25 …  PD re-sent with MTC Date of 12/30/09; PD accepted.  IP re-sent with Denial Rescission Date of 12/17/09; IP rejects since Denial Rescission Date is prior to the effective date of the PD (MTC Date of 12/30/09.) Therefore, the IP must be re-sent with Denial Rescission Date on or after 12/30/09. Payment After Denial (Denial Rescission)

26. 26 This issue will be forwarded to the IAIABC for resolution, e.g., changing ‘Full Denial Effective Date’ to ‘Denial Effective Date’ so there will be one (unchanging) date to compare to Denial Rescission Date. Payment After Denial (Denial Rescission)

27. 27 Questions?

28. 28 Change in Benefit Amount

29. 29 SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent  A SROI CA, EDI DWC-4 Equivalent, is required to be filed with DWC if the Net Weekly Amount increases or decreases due to the recalculation of the Gross Weekly Amount, or due to the application of adjustments or credits. See Rule 69L-56.3045(2), F.A.C..

30. 30 SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent  If you receive a wage statement (after the 00/IP) that either raises or lowers the AWW/CR and therefore changes the Gross/Net Weekly Amounts, if not also changing benefits, you would file a CA.

31. 31 SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent  MTC “CA” is typically used when: Indemnity benefits are currently being paid,Indemnity benefits are currently being paid, The Net Weekly Amount changes due to re-calculation of the Gross Weekly Amount or application of adjustments and/or credits, …The Net Weekly Amount changes due to re-calculation of the Gross Weekly Amount or application of adjustments and/or credits, …

32. 32 SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent  … Additionally, you would also file a CA in relation to non-current benefits where a suspension (Sx) was previously filed, after which the Net Weekly Amount changed. Additional adjustment check to EE must be for the same period of indemnity previously paid (i.e., end dates cannot advance.)Additional adjustment check to EE must be for the same period of indemnity previously paid (i.e., end dates cannot advance.)

33. 33 SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent  MTC “CA” is NOT used when: The Average Wage or Concurrent Employer Wage changes, but the Net Weekly Amount does not change. (Comp Rate at max)The Average Wage or Concurrent Employer Wage changes, but the Net Weekly Amount does not change. (Comp Rate at max) MTC “02” should be filed instead.MTC “02” should be filed instead.

34. 34 SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent  Also, FL does not require MTC CA to be filed each time the payment rate for TP (070) changes due to fluctuations in the EE’s earnings.

35. 35 SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent  However, Rule 69L-56 will be amended to require SROI CA to report a change in Net Weekly Amount for IB (030) when IB payment rate changes due to wage fluctuations (per court case discussed earlier.)

36. 36 Caveats and Tips for Successfully Filing SROI MTC CA

37. 37  If you are trying to file a CA, but a Suspension transaction (Sx) was filed in error: Do not file an RB to get around the edit that indicates an RB should have been filed after the Sx… Do not file an RB to get around the edit that indicates an RB should have been filed after the Sx… Caveats and Tips for Successful Filing of CA

38. 38 … Instead, contact the EDI Team for special processing assistance. … Instead, contact the EDI Team for special processing assistance. We will manually remove the suspension status from DWC’s database and re- process the CA. We will manually remove the suspension status from DWC’s database and re- process the CA. Caveats and Tips for Successful Filing of CA

39. 39 Caveats and Tips for Successful Filing of CA  One error we are seeing a lot for SROI CA filings is: NBR OF BENEFITS SHOULD NOT BE > WHAT IS ON FILE

40. 40 Caveats and Tips for Successful Filing of CA This means the CA contained a BTC(s) that was not previously reported. This means the CA contained a BTC(s) that was not previously reported. A CB will need to be filed to ‘introduce’ the new BTC. A CB will need to be filed to ‘introduce’ the new BTC.

41. 41  Conversely, the error.. BEN TYPE CODE PREVIOUSLY REPORTED NOT SENT ON SROI … is occurring where a BTC(s) ‘on file’ is missing from the CA. Caveats and Tips for Successful Filing of CA

42. 42 Caveats and Tips for Successful Filing of CA  If the wrong BTC was previously reported and never actually paid, you will need to file an 02 with the “R” code to reclassify those benefits. In this case a CA is not needed because you are totally replacing the prior benefit with a new BTC and new Net. In this case a CA is not needed because you are totally replacing the prior benefit with a new BTC and new Net.

43. 43 BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED Caveats and Tips for Successful Filing of CA  Another error occurring frequently for SROI CA filings is:

44. 44 Caveats and Tips for Successful Filing of CA  A reduction in either the number of BTC’s or the amount paid for a BTC must be ‘explained’ by reporting: Reduced Benefit Amount Code ‘R’ (Reclassification), or Reduced Benefit Amount Code ‘R’ (Reclassification), or Recovery Code, or Recovery Code, or Adjustment, or Adjustment, or Credit information. Credit information.

45. 45 Questions?

46. 46 Let’s now discuss Adjustments, Credits & Redistributions (A/C/R’s)

47. 47 NET < FL CALC GROSS AMT MINUS ADJ/CREDIT AMTS and NET $.05 OVER FL CALC GROSS MINUS ADJ/CREDIT AMTS  The below errors (addressed earlier) also occur when the Gross Weekly Amount (computed by DWC) minus the Adj or Credit Amount sent does not equal the Net Weekly Amount reported:

48. 48 If Net Weekly Amt is different from the Gross Weekly Amount, the applicable Adjustment or Credit information must be sent. If Net Weekly Amt is different from the Gross Weekly Amount, the applicable Adjustment or Credit information must be sent. Net Weekly Amount  The Net Weekly Amount equals the Gross Weekly Amount minus any applicable adjustments or credits for the corresponding benefit type.

49. 49 Benefit Adjustment Codes Definition: A code that identifies reductions applied to the Gross Weekly Amount resulting in a new Net Weekly Amount for a specific benefit type. Format: 4 A/N (BNNN) B = Benefit Adjustment Code NNN = Benefit Type Codes

50. 50 Definition: 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

51. 51  Definition: 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 blank. If the Benefit Adjustment is ongoing, the Benefit Adjustment End Date is blank. Benefit Adjustment End Date

52. 52 Definition: The weekly amount of benefit adjustment corresponding to the Benefit Adjustment Code. Benefit Adjustment Weekly Amount

53. 53 Benefit Adjustment Example (Scenario 6-B-4 on web): Benefit Adjustment Example (Scenario 6-B-4 on web): Average Wage (AWW) = $600 Calculated Weekly Compensation Amount (Comp Rate) = $400 Gross Weekly Amount for TTD Benefits = $400 Social Security Offset - Benefits reduced by $100 per week

54. 54 Example with Social Security Offset: Gross Weekly Amt for PT Benefits = $400 Net Weekly Amt for PT Benefits = $300 Benefit Adjustment Weekly Amt = $100

55. 55 Benefits Segment for BTC (020) affected by change (other BTC’s are ‘sweeps’):

56. 56 A/C/R Segment of Transaction

57. 57 Benefit Credit Codes Definition: A code identifying 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

58. 58 Benefit Credit Example: Average Wage (AWW) = $600 Calculated Weekly Compensation Amount (Comp Rate) = $400 Gross Amount for TTD Benefits = $400 Overpayment occurred – Benefits reduced by $80 per week to recoup overpayment.

59. 59 Example with Credit Adjustment: Gross Weekly Amt for TTD = $400 Net Weekly Amt for TTD = $320 Benefit Credit Amount = $80

60. 60 Benefit Redistribution Code  Definition: A code identifying 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.  Values: ‘H’ = Court Ordered Lien (e.g., child support) ‘H’ = Court Ordered Lien (e.g., child support)

61. 61 Benefit Redistribution Code  ‘H’ is also applicable where a portion of the EE’s payment (e.g. PT ) is reduced/re-directed to a nursing home, assisted living facility, per a legal agreement.

62. 62 Benefit Redistribution Example: Average Wage (AWW) = $600 Calculated Weekly Compensation Amount (Comp Rate) = $400 Gross & Net Weekly Amount for TTD Benefits = $400 Court ordered benefits to be reduced by 50% to pay for assisted living costs per legal agreement.

63. 63 Example with Redistribution: Gross Weekly Amt for TTD Benefits = $400 Net Weekly Amt for TTD Benefits = $400 (NOT reduced to $200 because the same weekly amount is being paid; a portion of the Net $400 is just being redistributed to another party.) Benefit Redistribution Amount = $200.

64. 64 A/C/R Segments  A/C/R segment should always and only be included in each SROI transaction when: ACR is currently being applied to theBenefits segment that is being reported; or ACR is currently being applied to theBenefits segment that is being reported; or ACR is ending.ACR is ending.

65. 65 A/C/R Segments  ACR’s are also reported on Periodics (SA, FN) when still being applied to a BTC that is currently being paid.

66. 66 A/C/R Segments A/C/R Segments  ACR’s previously reported (via paper or EDI) and ended before you moved to R3 or are now ended at the time of the current filing (i.e., where ACR End Date was previously sent) are not required to be reported on subsequent transactions (e.g., Periodics.)

67. 67 A/C/R Segments  However, if A/C/R Segment data continues to be applied after you move to R3 and is continuing at the time of the current filing, A/C/R information must continue to be reported on SROI’s until the A/C/R is ended or the claim is denied/settled.

68. 68 A/C/R Segments  Types of ACR’s to be reported are identified in the Value Table worksheet of FL’s Edit Matrix.

69. 69 A/C/R Segments  The Benefit ACR End Date is only populated when the adjustment, credit or redistribution has ended or benefits are suspended (Sx).

70. 70 SCENARIO: SROI MTC CA Change in Amount With Benefit Adjustment and Overpayment Credit

71. 71 SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P (Scenario 6-B-2 on web)  00/IP filed reporting payment of TT (050) benefits.  Further investigation revealed EE did not use a safety device required by the employer.

72. 72 SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P  Net Weekly Amount was reduced to $300 (25% of $400 = $100) due to the application of a Benefit Adjustment for a Safety Violation, and  The Net Weekly Amount was further reduced to $250 due to the application of a $50/wk overpayment credit.

73. 73  These changes reduced the Net Weekly Amount from $400 to $300, resulting in an overpayment of $100.  The claim administrator will take a credit of $50 for each of the next two weeks, thus further reducing the Net to $250. SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

74. 74  On 7/13/07, the Claim Admin. issues a check for the 2nd installment of TT benefits (waiting wk + weeks 3 & 4), and and  Reports the change in the weekly TT payment rate to DWC by sending SROI MTC “CA”. SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

75. 75 Claim Admin. Sends SROI “CA” on 7/13/07 to report the change in Net/Gross Amounts. Partial Display of SROI Record Layout – (only pertinent DN’s displayed) SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

76. 76 Comp Rate remains at $400.00 (two thirds of Average Wage) SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

77. 77 SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

78. 78 Effective Date of Credit (beginning of TT week 3) SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

79. 79 SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

80. 80 SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

81. 81  When the next check is issued, the Claim Admin. will need to send another “CA” transaction to the Division to report a new Net Weekly Amount of $300 effective 7-14-07, due to the ending of the OP Credit. SROI MTC CA Scenario Change in Amount w/Benefit Adj. and O/P

82. 82 QUESTIONS?

83. 83 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?

84. 84 Answer: SROI MTC 02

85. 85  MTC 02 (as opposed to a CA) is required to report changes to a DN in the Benefit or ACR segment, when the benefit will continue to be paid at the same statutory maximum weekly rate. This is because there is NO CHANGE TO THE NET WEEKLY AMOUNT. MTC 02 Change

86. 86  An 02 is also required to be filed with the Division if: A DN designated as “Y”, “YC”, “Y 1 ”, “Y 2 ”, “Y 3 ”, “Y 4 ”, “fy” or “FY” in the FROI/SROI 02 columns of the FL Element Requirement Table (ERT) changes. A DN designated as “Y”, “YC”, “Y 1 ”, “Y 2 ”, “Y 3 ”, “Y 4 ”, “fy” or “FY” in the FROI/SROI 02 columns of the FL Element Requirement Table (ERT) changes. See Rules 69L-56.304, & 69L-56.3045, F.A.C. MTC 02 Change

87. 87  This equates to many more electronic notices of change than were formerly required to be reported to DWC via the paper Form DWC-4. Only the 02’s required in Rule 69L-56.304, F.A.C. represent EDI DWC-4 equivalents. Only the 02’s required in Rule 69L-56.304, F.A.C. represent EDI DWC-4 equivalents. MTC 02 Change

88. 88  If your system is not set up to auto-trigger MTC 02 filings on the basis of a change to all of the designated DN’s, you should review the Element Requirement Table to determine which 02 changes are required to be reported. MTC 02 Change

89. 89 MTC 02 Change Processing Rules

90. 90 Change Processing Rules Transaction Usage  MTC 02 (Change) transaction is intended to: Allow Claim Administrators to correct data previously reported erroneously and/or,Allow Claim Administrators to correct data previously reported erroneously and/or, Allow Claim Administrators to update previously reported data.Allow Claim Administrators to update previously reported data.

91. 91 02 Change Processing Rules Transaction Usage MTC “02” should not be used to report a change in data where other transactions are intended to serve that purpose. CACB ABRB P7

92. 92 Change Processing Rules Transaction Usage  If a data element designated as FY, fy, Y, Y 1, Y 2, Y 3, Y 4 or YC in the MTC 02 column of the ERT is changed, the Claim Administrator must trigger an “02” (Change) transaction, unless another MTC applies.

93. 93 Change Processing Rules Transaction Usage  If a DN designated as N 1 in the 02 column of the ERT is changed, you can send an 02 (Change) unless another MTC applies; However, an “02” is not required every time the value in this field changes … However, an “02” is not required every time the value in this field changes …

94. 94 Change Processing Rules Transaction Usage Example:  Benefit Type Amount Paid is designated as N 1 : If you have reported it incorrectly, you should file an MTC 02 ; If you have reported it incorrectly, you should file an MTC 02 ; However, if the Benefit Type Amount Paid changes/increases because you paid another bi-weekly check, we do not need or want an MTC 02. However, if the Benefit Type Amount Paid changes/increases because you paid another bi-weekly check, we do not need or want an MTC 02.

95. 95 Change Processing Rules Florida has expanded on the ERT standard Requirement Codes for MTC 02. See sample of MTC 02 legend at bottom of SROI ERT.

96. 96 Caveats and Tips for Successfully Filing SROI MTC 02

97. 97  Send MTC “02” (Change) transactions at the appropriate time to avoid transactions rejecting, i.e.... Caveats and Tips for Successful Filing of 02

98. 98 … changes to certain DN’s can’t just ‘show up’ on any MTC - the change must be purposely changed first via MTC 02. For example, changes to RTW- related data must be reported via MTC 02 (or other appropriate MTC) before sending an MTC SA transaction containing the new RTW data. For example, changes to RTW- related data must be reported via MTC 02 (or other appropriate MTC) before sending an MTC SA transaction containing the new RTW data. Caveats and Tips for Successful Filing of 02

99. 99  Analyze Florida’s Element Requirement Table and Edit Matrix to learn how data element(s) will be processed on MTC 02 Change transactions. Caveats and Tips for Successful Filing of 02

100. 100  Important: The JCN sent on the SROI MTC 02 must match the JCN ‘on file’ for the existing SSN/DOI. Caveats and Tips for Successful Filing of 02

101. 101  One of the most frequently occurring errors we are seeing for both FROI and SROI 02 filings is where the JCN is not even sent. JCN is always required for an 02 filing.JCN is always required for an 02 filing. You may want to review your system to ensure it enforces the JCN for MTC 02 filings.You may want to review your system to ensure it enforces the JCN for MTC 02 filings. Caveats and Tips for Successful Filing of 02

102. 102  If a data element has a “Y x ” on both the FROI and SROI, an “02” can be sent on either the FROI or SROI. Caveats and Tips for Successful Filing of 02

103. 103  The MTC 02 must be included in the Benefit segment in order for the DWC’s program to process any changes to the Benefits, OBT, Payments, or ACR segments sent on the 02. Caveats and Tips for Successful Filing of 02

104. 104  Changes to data elements report designated as “N”, “NA” or “X” on FL’s Element Requirement Table reported via MTC 02 will not be edited/loaded to DWC’s database. Caveats and Tips for Successful Filing of 02

105. 105  Also, invalid data sent on an MTC 02 will not overlay existing ‘good’ data on DWC’s database. Caveats and Tips for Successful Filing of 02

106. 106  Data previously required or reported on another transaction will be expected to be included on the MTC 02 transaction. Caveats and Tips for Successful Filing of 02

107. 107 Caveats and Tips for Successful Filing of 02  Exception: If you previously reported the wrong BTC, you can file an 02 to show a total reclassification of one BTC to another BTC e.g., correcting TT (050) to TP (070). If you previously reported the wrong BTC, you can file an 02 to show a total reclassification of one BTC to another BTC e.g., correcting TT (050) to TP (070). RBAC “R” must be included. RBAC “R” must be included.

108. 108  When sending an 02 to report a correction, be sure to update the MTC Date. MTC Date should not be older than 7 days from the date the transaction is being sent (any MTC) – this will reject. MTC Date should not be older than 7 days from the date the transaction is being sent (any MTC) – this will reject. Caveats and Tips for Successful Filing of 02

109. 109  DWC compares the current transaction to the ‘current’ filing on its system: If DWC processes/accepts a current transaction with an older MTC Date (within the 7 days leeway allowed), that filing would be compared to the filing that preceded it … If DWC processes/accepts a current transaction with an older MTC Date (within the 7 days leeway allowed), that filing would be compared to the filing that preceded it … Caveats and Tips for Successful Filing of 02

110. 110 … based on the MTC date and not the date the transaction was actually sent to / received by DWC. This may result in filing errors. For example … This may result in filing errors. For example … Caveats and Tips for Successful Filing of 02

111. 111 SROI 02-Recvd 7/11/2008-MTC Date 7/11/08 (Contained 1 BTC) SROI PY-Recvd 7/12/2008-MTC Date 7/10/08 (Contained 2 BTC’s) (Contained 2 BTC’s) SROI FN-Recvd 7/12/2008-MTC Date 7/12/08 (Contained 2 BTC’s) (Contained 2 BTC’s) The FN rejected because the “current” benefit form being compared to the FN is the SROI 02 (most recent MTC Date prior to FN) which only had 1 BTC segment. MTC FN can not introduce a new BTC.

112. 112  Florida will not be setting data to spaces based on MTC 02 (absence of/removing data).  If a data element was reported in error and needs to be removed (vs. changed), contact the Claims EDI Team for special handling. Caveats and Tips for Successful Filing of 02

113. 113  If a data element is changed and not required (NA), per FL’s Element Requirement Table for the particular MTC being reported, but is sent on that MTC, that data element will not be edited/loaded to the Division’s database because it is not required (e.g., Nmbr Days Worked/Week sent on MTC SA). Caveats and Tips for Successful Filing of 02

114. 114 Caveats and Tips for Successful Filing of 02 To change these data elements, you must send an MTC 02.

115. 115  Also, a particular MTC/filing may have been accepted (TA’d) even where a “non-required” data element was sent invalid or in error. In this case, if a subsequent MTC 02 is filed and contains… In this case, if a subsequent MTC 02 is filed and contains… Caveats and Tips for Successful Filing of 02

116. 116 … the same invalid data from the previous MTC that TA’d, the 02 may now reject or receive an error… Caveats and Tips for Successful Filing of 02

117. 117 This is because a jurisdiction can not tell what is changing on an 02, and can not identify on the 02 what data elements are required for the circumstances of that claim; Therefore EVERY field on an 02 must be edited. Caveats and Tips for Successful Filing of 02

118. 118  Also, if an 02 TA’d, but a subsequent MTC/filing TR’d for ‘Mandatory Field Not Present’ error (001), you may wonder why the earlier 02 did not reject for this same error… Caveats and Tips for Successful Filing of 02

119. 119 (cont’d…) Again, because we can not designate which fields are “required” on an 02, we can not run all of the presence edits (- 001) on MTC 02. Again, because we can not designate which fields are “required” on an 02, we can not run all of the presence edits (- 001) on MTC 02. Caveats and Tips for Successful Filing of 02

120. 120 Recap:  MTC 02 must be included in the Benefits segment (therefore making it an “Event” Benefits segment ) in order for DWC’s program to process any changes to the Benefit, Payment, OBT or A/C/R segments data reported on the 02. Caveats and Tips for Successful Filing of 02

121. 121  If you are filing an MTC 02 to change the date the first payment was mailed, you must include a Payment segment and report the revised “Payment Issue Date” (vs. Benefit Payment issue Date”. ) Caveats and Tips for Successful Filing of 02

122. 122 SUS EFF DATE CANT BE REPTD UNLESS MTC = S1-S8 P7, and SUS EFF DT ON MTC 02 BUT NO S1-S8 OR P7 PREV FILED, and NUMBER OF SUSPENSION NARRATIVES MUST NOT BE > 0 Caveats and Tips for Successful Filing of 02  Most errors occurring on SROI 02 filings are:

123. 123 Caveats and Tips for Successful Filing of 02 These errors basically indicate that there is no prior suspension notice (paper or EDI) on file with DWC, so we cannot process an 02 that is reporting a Suspension Effective Date for the first time. These errors basically indicate that there is no prior suspension notice (paper or EDI) on file with DWC, so we cannot process an 02 that is reporting a Suspension Effective Date for the first time.

124. 124  We are also seeing errors for: RED BEN AMT CODE R IS NOT APPLICABLE Caveats and Tips for Successful Filing of 02

125. 125 Reduced Benefit Amount Code ‘R’ can not be initially reported on a SROI 02 if MTC 02 is not at the Benefit Level. Reduced Benefit Amount Code ‘R’ can not be initially reported on a SROI 02 if MTC 02 is not at the Benefit Level. Caveats and Tips for Successful Filing of 02

126. 126 SROI MTC “02” Reporting a Benefit Redistribution for Child Support (after Initial Payment)

127. 127 Benefit Redistribution for Child Support  A SROI 02 is filed if a portion of the Net Weekly Amount is being directed to another party due to a court ordered lien, such as for child support. See Rule 69L-56.3045(1)(b), F.A.C. See Rule 69L-56.3045(1)(b), F.A.C.

128. 128  MTC CA does not apply in this situation because the Net Weekly Amount is unchanged. Benefit Redistribution for Child Support

129. 129 SCENARIO: SROI MTC 02 Reporting a Benefit Redistribution for Child Support (after Initial Payment)

130. 130 Reporting a Benefit Redistribution for Child Support  Court-ordered child support in the amount of $50/week has been assessed against the employee’s WC benefits. Amount is to be paid directly to employee’s ex-wife.

131. 131 Reporting a Benefit Redistribution for Child Support If time permits, we will fill out the Benefit and ACR segment live. The following slide is the IP transaction that immediately preceded the Benefit Redistribution.

132. 132 Benefit Segment last reported to DWC for IP: IP 2007071313, 0004 160000$1,600.00 20070629 June 29, 2007

133. 133 Reporting a Benefit Redistribution for Child Support The Benefit Redistribution is now to be reported at the time the next bi-weekly payment is sent. Please complete the Benefit and ACR segment to report this event.

134. 134 Now lets build the Benefit and ACR Segments for a Redistribution of Benefits

135. 135 Variable Segment Counters 0288Number of Benefits01 0283Number of Payments00 0282 Number of Other Benefits00 0289Nmbr of Benefit ACR001 0284Number of Recoveries00 0285 Number of Reduced Earnings00

136. 136 0275 Number of Concurrent Employers 00 0277 Number of Full Denial Reason Code00 0276 Number of Denial Reason Narratives00 0287 Number of Suspension Narratives00

137. 137 Benefits 1 Occ 0085Benefit Type Code050Temporary Total 0002 Maintenance Type Code02Change 0174Gross Weekly Amt00000040000$400.00 0175 Gross Weekly Amount Eff. Date20070615 June 15, 2007 0087Net Weekly Amount00000040000$400.00 0211 Net Weekly Amount Effective Date20070615 June 15, 2007 0088 Benefit Period Start Date20070616 June 16, 2007

138. 138 0089 Benefit Period Through Date 20070727 July 27, 2007 0090 Benefit Type Claim Weeks0006 0091 Benefit Type Claim Days0 0086 Benefit Type Amount Paid00000240000$2,400.00 0192 Benefit Payment Issue DateN/A

139. 139 Benefit ACR 1 Occurrence 0130 Benefit Redistribution CodeH050 Court Ordered Lien 0131 Benefit Redistribution Start Date20070714 July 14, 2007 0132Benefit Redistribution End Date Blank because redistribution is continuing 0133 Benefit Redistribution Weekly Amount 00000005000$50.00

140. 140 Reporting Benefit Redistribution for Child Support (after initial payment):  If the lien for Child Support ends and indemnity is ongoing, MTC 02 should be sent with a Benefit Redistribution segment reflecting an End Date.  If all indemnity is being suspended, the Benefit Redistribution segment reflecting an End Date can be sent on the Sx.

141. 141 An MTC 02 with Benefit Redistribution Code H (Court Ordered Lien) would also be sent if the courts determined that the claim administrator should redirect a portion of the claimant’s benefits to pay for assisted living costs, etc.

142. 142 Questions?

143. 143 What MTC should be filed when you are changing from TT to TP benefits and … Pop Quiz:

144. 144 … there is a retroactive change in AWW/CR that affected what you paid in TT? Pop Quiz:

145. 145 Answer: “CB” Both the change in amount and change in benefit type can be accomplished on the CB alone.

146. 146 SROI MTC CB - Change in Benefit Type Electronic Notice of Action/Change Electronic DWC-4 Equivalent Required to be filed with DWC per Rule 69L-56.3045(3), F.A.C.

147. 147 Change in Benefit Type EDI DWC-4 Equivalent  SROI CB should be filed if indemnity benefits are continuing without interruption, but the Benefit Type being paid changes to a different Benefit Type.

148. 148 POP QUIZ: What is the due date for filing a SROI CB with the Division?

149. 149 SROI CB should be received/accepted by DWC on or before 14 days after the date payment (for the new Benefit Type) was mailed by the Claim Administrator. ANSWER:

150. 150 Change in Benefit Type EDI DWC-4 Equivalent  Changed from 14 days from ‘knowledge of change in benefits’ to ‘14 days after payment mailed’ because some Clm Admin.’s systems would not auto-trigger a new report / MTC until pymnt was actually issued. Rule will be revised to reflect change. Rule will be revised to reflect change.

151. 151 Change in Benefit Type EDI DWC-4 Equivalent  Because the requirement to report a change in benefits did not previously exist for paper, a DWC FORM DWC-4 is not required to be provided to the employee or employer.

152. 152 Change in Benefit Type EDI DWC-4 Equivalent SROI CB is typically used when:  Indemnity benefits are currently being paid,  A new Benefit Type Code begins,  The previous Benefit Type Code ends or is reclassified,  There is no break in benefit periods.

153. SROI CB - Change in Benefit Type EDI DWC-4 Equivalent For Example:

154. 154 SROI CB - Change in Benefit Type EDI DWC-4 Equivalent  Reminder: Since CB is an “Event” Benefits segment, if there have been multiple benefit periods for the BTC that benefits are being changed ‘to’, the Start Date is the first date of the uninterrupted period of payments for that BTC …

155. 155 SROI CB - Change in Benefit Type EDI DWC-4 Equivalent If that same BTC was paid for a prior disability period, the Start Date should not be reported as the initial date of the first payment period for that BTC. If that same BTC was paid for a prior disability period, the Start Date should not be reported as the initial date of the first payment period for that BTC.

156. 156 SROI CB - Change in Benefit Type EDI DWC-4 Equivalent The Benefit Period Start Date of the BTC that benefits are changing ‘from’ should be reported as the latest Start Date where there are multiple payment periods. It is an Event Benefits segment. The Benefit Period Start Date of the BTC that benefits are changing ‘from’ should be reported as the latest Start Date where there are multiple payment periods. It is an Event Benefits segment.

157. 157 SROI CB - Change in Benefit Type EDI DWC-4 Equivalent  Normally, MTC “CB” requires two “Event Benefit” segments to report changes in data to the two benefits affected by the MTC “CB” transaction: The Benefit Type that is ending, and The Benefit Type that is ending, and The Benefit Type that is beginning. The Benefit Type that is beginning.Therefore…

158. 158 … unless your system does it for you automatically, you need to include MTC CB in only the two Benefits Segments where you are changing benefits ‘from’ and ‘to’. Errors occur when the MTC is put on the wrong BTC.

159. 159 SROI CB - Change in Benefit Type EDI DWC-4 Equivalent  Exception: There will only be one Event Benefit Segment on the CB if: BTC is ‘exchanged’ for another BTC ( e.g., reclassify all IB’s previously paid to PT), or BTC is ‘exchanged’ for another BTC ( e.g., reclassify all IB’s previously paid to PT), or BTC is changed to a different BTC (e.g., correcting all TT to TP) … BTC is changed to a different BTC (e.g., correcting all TT to TP) …

160. 160 SROI CB - Change in Benefit Type EDI DWC-4 Equivalent … In this case, the ‘disappearance’ of the previously reported BTC that was entirely converted/reclassified would need to be explained via the Reduced Benefit Amount Code “R” (Reclassification of Benefits.)

161. 161 This is a good juncture to go into more detail about Reduced Benefit Amount Code “R”.

162. 162  Reduced Benefit Amount Code “R” should only be sent when: All or part of a BTC previously reported was actually reclassified to another BTC, orAll or part of a BTC previously reported was actually reclassified to another BTC, or The wrong BTC was previously reported and needs to be corrected to a different BTC. The wrong BTC was previously reported and needs to be corrected to a different BTC.

163. 163  Reduced Benefit Amount Code “R” will explain why there are fewer or different BTC’s on the current transaction than were previously reported.

164. 164  Once reported, Reduced Benefit Amount Code “R” (or any RBAC) must be sent on all subsequent transactions.

165. 165  If Reduced Benefit Amount Code “R” (Reclassification) was reported in error, DWC can remove the code from its system upon request (email claims.edi@myfloridacfo.com)

166. 166  To minimize these requests, DWC instituted edits to preclude the acceptance of Reduced Benefit Amount Code “R” under certain circumstances, including: 00/IP’s (can’t reclassify benefits not previously sent), and 00/IP’s (can’t reclassify benefits not previously sent), and Where BTC’s are unchanged from BTC’s previously reported. Where BTC’s are unchanged from BTC’s previously reported.

167. 167 If the current transaction TA’s and includes Reduced Benefit Amount Code “R” (Reclassification), but one or more BTC’s were inadvertently left off the transaction… If the current transaction TA’s and includes Reduced Benefit Amount Code “R” (Reclassification), but one or more BTC’s were inadvertently left off the transaction…

168. 168 … only the BTC’s reported on the current transaction will be used by DWC’s program when processing/comparing BTC’s on future transactions. … only the BTC’s reported on the current transaction will be used by DWC’s program when processing/comparing BTC’s on future transactions.

169. 169 This means that due to the presence of the “R” code, DWC’s program did not question the ‘disappearance’ of a BTC(s). If the ‘missing” BTC(s) shows up on a future transaction…

170. 170 … that transaction will reject, and the ‘missing’ BTC(s) will have to be re-introduced / re-reported via one or more CB’s.

171. 171  If you receive the error message, Reduced Benefit Amount Code Missing; this does not always mean that the code is applicable and should be sent …

172. 172 … In some cases, this error is generated because one or more BTC’s previously reported were accidentally left off the current transaction (as we just mentioned) …

173. 173 … in which case you will need to add the missing BTC and re-send the transaction. Here, you would not report the Reduced Benefit Amount Code, even though the error message implies it is missing. Here, you would not report the Reduced Benefit Amount Code, even though the error message implies it is missing.

174. 174  You should only re-file and include a ‘missing’ Reduced Benefit Amount Code “R” only if the lower $ amount or # of BTC’s reported was correct.

175. 175 Example:  MTC SA reported BTC 050 (TT) and 070 (TP);  Subsequent MTC CA was filed to report a change in the Net Wkly Amount for 050 but 070 was left off the CA …

176. 176 Example (continued):  MTC CA rejected for the errors: “Nbr of Benefits < Previous”, and “Nbr of Benefits < Previous”, and “Reduced Benefit Amount Code Missing” … “Reduced Benefit Amount Code Missing” …

177. 177  … If all prior BTC 070 had been reclassified to BTC 050, then the ‘R’ code would be applicable to ‘fix’ the CA.  But if BTC 070 was accidentally left off, the CA would need to be re-sent with both 070 and 050, in which case you do not include the ‘missing’ R code.

178. 178  Sending the Reduced Benefit Amount Code when not appropriate causes edit errors downstream, since the presence of this code allows BTC’s to drop off and resets the benefit picture on DWC’s database. For example... For example...

179. 179 … When SA becomes due and correctly reports all BTC’s paid to date, the SA will reject for the error: Nbr of Benefits should not be > what it on file. This may require multiple subsequent transactions to fix the benefit picture.

180. 180  We continue to see the “R” code used when it is absolutely inappropriate (i.e., where there has been no change in benefit types and amounts). DWC will be adding more edits to preclude acceptance of a filing when the “R” code is N/A.

181. 181  FL has also requested the appropriation of another Reduced Benefit Amount Code – “E” (Expense Reduction) to explain a ‘less than previous’ Benefit Type Amount Paid $ for the following circumstance: …

182. 182 … Indemnity benefits have been suspended & no further indemnity is expected to be paid; and Claim Admin. has incurred an overpayment and will not be recovering or offsetting against future benefits (e.g., due to late receipt of revised wage information that resulted in a new, lower AWW/CR) …

183. 183 … Since NCCI requires un- recovered overpayments to be classified as an expense vs. a true cost of the claim, some Claim Administrator’s systems (no vendor) therefore …

184. 184 … write the excess amount paid to an expense category for purposes of reporting to NCCI, and only record the amount actually ‘due and owing’ in the Benefit Type Amount Paid field.

185. 185 … Rule 69L-56.3045(2), F.A.C., requires a CA “If the Net Weekly Amount changes from the amount previously reported due to a revised Average Wage (e.g., wage statement, discontinuation of fringe benefits), or due to the application of a Benefit Adjustment Code or Benefit Credit Code…”.

186. 186 So, when the Claim Admin. sends a ‘CA’ to report the revised AWW/CR/Gross/Net Weekly Amounts, the CA rejects because a lower Benefit Type Amount Paid is reported compared to the previous amount (and nothing is present on the transaction to ‘excuse/explain’ the lower amount.)

187. 187  An IRR has been submitted asking for: Guidance on what value should be reported for Benefit Type Amount Paid, i.e., cumulative amount ‘paid’ or ‘due’ based on the current IAIABC definition of this field, and Guidance on what value should be reported for Benefit Type Amount Paid, i.e., cumulative amount ‘paid’ or ‘due’ based on the current IAIABC definition of this field, and The addition of a new RBAC “E” (Expense Reduction”). The addition of a new RBAC “E” (Expense Reduction”).

188. 188 SROI CB - Change in Benefit Type EDI DWC-4 Equivalent  Going back to an earlier example where benefits were changed from TT (050) to IB (030): The CB reporting BTC 030 will also need to include a Permanent Impairments Segment. The CB reporting BTC 030 will also need to include a Permanent Impairments Segment.

189. 189  The Permanent Impairments Segment consists of the following data elements: PI Body Part Code, and PI Body Part Code, and Permanent Impairment Percentage Permanent Impairment Percentage “PERMANENT IMPAIRMENTS” SEGMENT:

190. 190  FL requires that all PI ratings are reported with PI Body Part Code 99. “PERMANENT IMPAIRMENTS” SEGMENT

191. 191 “ PERMANENT IMPAIRMENTS” SEGMENT  The SROI “Permanent Impairment Body Part Code” should not be confused with the FROI Part of Body Code. There are 2 separate tables for these codes; although many of the codes are similar, the SROI PI Body Part Code uses an expanded 3 character format (used by other states) while the FROI Part of Body Code is only 2 characters. There are 2 separate tables for these codes; although many of the codes are similar, the SROI PI Body Part Code uses an expanded 3 character format (used by other states) while the FROI Part of Body Code is only 2 characters.

192. 192  Since only one overall (whole body) Permanent Impairment Body Part Code of ‘99’ is allowed by FL, there will only be one PI Segment (Number of Occurrences = ‘01’) and therefore only one Permanent Impairment Percentage per filing. PERMANENT IMPAIRMENTS SEGMENT

193. 193  If the EE’s doctor initially assigns one PI rating and subsequently assigns additional impairment, the Permanent Impairment Percentage must still report one overall PI rating (not just the additional impairment percentage.) PERMANENT IMPAIRMENTS SEGMENT

194. 194  Permanent Impairment Percentage (including 0%) must be reported if: MMI Date is sent and DOI > 7/1/90, orMMI Date is sent and DOI > 7/1/90, or PI Body Part Code is present.PI Body Part Code is present. “ PERMANENT IMPAIRMENTS” SEGMENT:

195. 195  Basically, MMI and PI % are now both required if one or the other is sent, even if the PI % = 0. We DO want 0% PI ratings reported, although they were not previously required on paper. “PERMANENT IMPAIRMENTS” SEGMENT:

196. 196  Although not part of the Permanent Impairment Segment, Date of Maximum Medical Improvement is required if any of the following are reported: IB’s (030, 230, 530 & DOI > 7/1/90) IB’s (030, 230, 530 & DOI > 7/1/90) SB’s (040 & DOI > 7/1/90) SB’s (040 & DOI > 7/1/90) PI Rating PI Rating Exception: BTC 500 (Final Settlement)

197. 197 Permanent Impairment Minimum Payment Indicator  If the specific MMI date or PI rating is not initially known, you may report the Permanent Impairment Minimum Payment Indicator as “Y” until MTC FN. At FN, MMI/PI rating will only be excused if claim is settled in full (‘washed out’.) At FN, MMI/PI rating will only be excused if claim is settled in full (‘washed out’.)

198. 198 Caveats and Tips for Successfully Filing SROI MTC CB

199. 199 Caveats and Tips for Successful Filing of CB  Recap: FL allows a CB to add a new benefit type that was improperly left off a previously accepted filing (providing that a suspension was not the last reported claim event.

200. 200 Caveats and Tips for Successful Filing of CB  When the Change in Benefits also involves a corresponding change in the weekly amount and a new BTC will be paid, you do not need to file a CA and a CB. You should report both types of changes on the same SROI CB. You should report both types of changes on the same SROI CB.

201. 201 NO SROI ER OR RB PREVIOUSLY ON FILE Caveats and Tips for Successful Filing of CB  We are seeing a lot of CB’s reject for the following error:

202. 202 Caveats and Tips for Successful Filing of CB This error is generated when a CB is sent after a Sx (Suspension) has been filed, but a SROI RB (or ER) has not been filed to report the resumption of benefits following the suspension. This error is generated when a CB is sent after a Sx (Suspension) has been filed, but a SROI RB (or ER) has not been filed to report the resumption of benefits following the suspension.

203. 203 Caveats and Tips for Successful Filing of CB  When changing from TT to IB benefits, you do not need to first file an S1 to report suspension of TT due to RTW. The CB ‘ends’ the TT benefits and ‘begins’ the IB benefits; The CB ‘ends’ the TT benefits and ‘begins’ the IB benefits; RTW info should be included on the CB (vs. filing a separate S1)… RTW info should be included on the CB (vs. filing a separate S1)…

204. 204 Caveats and Tips for Successful Filing of CB... An Sx is not applicable because Suspension transactions are only required when you are suspending ALL indemnity benefits,.

205. 205 Caveats and Tips for Successful Filing of CB  We are also seeing a lot of CB rejections for the error: BTC ENDING MUST HAVE BEEN REPTD BTC ENDING MUST HAVE BEEN REPTD Unless you are adding a new BTC for the waiting week not previously reported, you can’t report a change from a BTC that was not already on file … Unless you are adding a new BTC for the waiting week not previously reported, you can’t report a change from a BTC that was not already on file …

206. 206 Caveats and Tips for Successful Filing of CB … So, you will need to file a CB to introduce the BTC you are trying to change benefits from.

207. 207 Caveats and Tips for Successful Filing of CB If you are sending a CB to report the payment of a different BTC for the waiting week, we are often seeing this same error (BTC ENDING MUST HAVE BEEN REPTD) when either the IDDB is incorrect or the BTC Start Date is incorrect. If you are sending a CB to report the payment of a different BTC for the waiting week, we are often seeing this same error (BTC ENDING MUST HAVE BEEN REPTD) when either the IDDB is incorrect or the BTC Start Date is incorrect.

208. 208 Caveats and Tips for Successful Filing of CB DWC’s program doesn’t allow the reporting of an earlier BTC unless it occurred during the waiting week, in which case, the IDDB should equal the Start Date for the BTC being reported in the earliest segment. DWC’s program doesn’t allow the reporting of an earlier BTC unless it occurred during the waiting week, in which case, the IDDB should equal the Start Date for the BTC being reported in the earliest segment.

209. 209 Caveats and Tips for Successful Filing of CB  Another error frequently occurring for CB’s is: CURRENT DATE DISABILITY BEGAN MISSING

210. 210 Caveats and Tips for Successful Filing of CB A Current Date Disability Began (CDDB) is required for a CB if you are reporting a Current Last Day Worked and starting a type of total disability e.g., DB (010), PT (020), TT (050). A Current Date Disability Began (CDDB) is required for a CB if you are reporting a Current Last Day Worked and starting a type of total disability e.g., DB (010), PT (020), TT (050).

211. 211  But if you are changing to BTC 030 (IB) or reporting ‘IB (030) Only’: “Current Date Disability Began” (CDDB) should not be sent in relation to the start of IB’s if there has been no break in disability periods... “Current Date Disability Began” (CDDB) should not be sent in relation to the start of IB’s if there has been no break in disability periods... Caveats and Tips for Successful Filing of CB

212. 212 … For example, if IB’s immediately follow TP and there is no break in the period of disability benefits being paid (e.g., TP ends 3/3 and IB’s start 3/4), by definition, you would not report CDDB since IB’s are not associated with a ‘subsequent period of disability’… … For example, if IB’s immediately follow TP and there is no break in the period of disability benefits being paid (e.g., TP ends 3/3 and IB’s start 3/4), by definition, you would not report CDDB since IB’s are not associated with a ‘subsequent period of disability’… Caveats and Tips for Successful Filing of CB

213. 213 … If your system requires CDDB even when it is not applicable, you will need to report a RTW => IB Start Date so that DWC can determine the EE is still working (since CDDB implies a change in work status and a later period of disability.) … If your system requires CDDB even when it is not applicable, you will need to report a RTW => IB Start Date so that DWC can determine the EE is still working (since CDDB implies a change in work status and a later period of disability.) Caveats and Tips for Successful Filing of CB

214. 214  Note: IRR was recently submitted requesting the ERT for Current RTW be changed on an RB from “X” to “IA”: DWC needs to apply the correct IB payment rate based on the presence of RTW data. DWC needs to apply the correct IB payment rate based on the presence of RTW data. RB is sent (vs. CB) when there is a break between the end of TT, TP and the resumption of IB after MMI/PI is obtained. RB is sent (vs. CB) when there is a break between the end of TT, TP and the resumption of IB after MMI/PI is obtained.

215. 215 Many CB’s are also rejecting for the error: INITIAL RTW DATE MUST BE CHANGED VIA AN 02 OR S1 If required by MTC, Initial Return to Work Date (IRTW) must match IRTW date previously reported. If required by MTC, Initial Return to Work Date (IRTW) must match IRTW date previously reported. Caveats and Tips for Successful Filing of CB

216. 216 Because there is so much confusion on reporting Initial and Current RTW Dates, this is a good point to discuss all of the Initial and Current date fields, and afterwards complete another SROI scenario...

217. 217 Initial Dates vs. Current Dates

218. 218 Initial Dates vs. Current Dates  The following “Initial” date values should not change unless reported incorrectly (send 02): Initial Date Last Day Worked, Initial Date Last Day Worked, Initial Date Disability Began Initial Date Disability Began

219. 219 Initial Dates vs. Current Dates  “Initial RTW” can change (via 02) if: Reported incorrectly, or Reported incorrectly, or RTW Type Code and/or Physical Restrictions Indicator changes, but a subsequent period of disability has not occurred. RTW Type Code and/or Physical Restrictions Indicator changes, but a subsequent period of disability has not occurred.

220. 220 Initial Dates vs. Current Dates  FL will not be implementing the IAIABC DP Rule that allows the MTC Date on the 02 to be used as an estimate of when the subsequent RTW Type Code and/or Physical Restrictions Indicator took effect if a revised IRTW is not sent on the 02.

221. 221 Initial Dates vs. Current Dates To clarify:  For example, if RTW Type Code “R” and Physical Restrictions “Y” were reported in conjunction with the Initial RTW Date, and you subsequently learn the date the EE actually RTW (although not required to be reported to DWC if payments were not based on this change), or …

222. 222 … the Phys Restrictions changed, the Initial RTW Date, RTW Type Code (Actual), and Physical Restrictions Indicator can be changed on the 02. Do not report this ‘revised Initial RTW as a ‘Current RTW’. Do not report this ‘revised Initial RTW as a ‘Current RTW’. Note: Both the Initial and ‘revised’ Initial RTW dates are stored by DWC.

223. 223 Initial Dates vs. Current Dates Initial Dates vs. Current Dates  If you misreported the Physical Restrictions Indicator, you would not revise the IRTW date: Here, you would only need to change the Physical Restrictions Indicator via MTC 02. Here, you would only need to change the Physical Restrictions Indicator via MTC 02.

224. 224 Initial Dates vs. Current Dates  “Current” date values represent a second period of disability (not reported if disability periods are continuous.) Current Date Last Day Worked, Current Date Last Day Worked, Current Date Disability Began, & Current Date Disability Began, & Current Return To Work Date) Current Return To Work Date)

225. 225 Initial Dates vs. Current Dates  Current RTW - T he first occurrence of CRTW must be associated with a subsequent period of disability; Afterwards, FL will also accept changes to CRTW when there has been a change in RTW Type Code and/or Physical Restrictions Indicator. Afterwards, FL will also accept changes to CRTW when there has been a change in RTW Type Code and/or Physical Restrictions Indicator.

226. 226 Initial Dates vs. Current Dates  “Current” date values should be updated each time a new date is applicable to that field.  Do not populate “Current” date values with “Initial” date values.

227. 227 Questions?

228. 228 Now, we will complete a SROI for Scenario 6-C-4 (New) in your Handouts…

229. 229 Electronic Notice of Action or Change SCENARIO 6-C-4 SROI CB (TT to TP) Change in Benefits TT and TP with Initial and Current Values and Reclassification

230. 230 The following scenario is based on our interpretation of the IAIABC R3 definitions. We believe that there are problems with certain definitions given the actual implementation of EDI R3, when there are multiple periods of disability with different benefit types being paid. We have created this scenario in an effort to explain our interpretation. We DO believe our interpretation (using the actual language of the definitions) may not match the original “intent” of these DN’s.

231. 231 Benefits Segment for CB filed 11/20/09. This is the transaction sent prior to the one you will now fill out.

232. 232 0001Transaction Set ID A49Subsequent Report 0002Maint. Type CodeCBChange in Benefit 0003 Maint. Type Code Date20091202 Dec. 2, 2009 0004Jurisdiction CodeFL 0006Insurer FEIN785902378 0014 Claim Administrator Postal Code379921223 0055 Employee Number of DependentsN/A 0069 Pre-Existing Disability CodeN/A

233. 233 0063Wage Period Code N/A 0064 Number of Days Worked Per WeekN/A Reported on the IP 0056 Initial Date Disability BeganN/A Reported on the IP 0070 Date of Maximum Medical ImprovementN/A 0072 Current Return to Work Date 0057 Employee Date of DeathN/A 20091114 Nov. 14, 2009

234. 234 0031Date of Injury 20090615 June 15, 2009 0015 Claim Administrator Claim NumberWC1256782 0074Claim Type CodeN/A Reported on the IP 0026Insured Report NumberN/A 0005 Jurisdiction Claim Number06152001 0073Claim Status CodeN/A 0075 Agreement To Compensate CodeN/A

235. 235 Variable Segment Counters for A49 0078 Number of Permanent Impairments00 0082 Number of Death Dependent/Payee Relationships00 End A49 Elements 0076 Date Claim Administrator Notified of Employee RepresentationN/A 0077Late Reason CodeN/A

236. 236 R22 Data Elements 0001Transaction Set IDR22 0298Date Claim Administrator Had Knowledge of Lost Time (Clm Admin’s Knowledge of 8 th Day of Dis for FL) 0015 Claim Administrator Claim NumberWC1256782 0295MTC Correction CodeN/A 0296 MTC Correction Code DateN/A 0186Juris Branch Off CodeN/A N/A – Reported on the IP

237. 237 0187 Claim Administrator FEIN 785902378 0188Claim Administrator Name OLD RELIABLE INSURANCE COMPANY 0140Claim Administrator Claim Rep Name Angie,,Adjuster Angie Adjuster 0137Claim Admin. Claim Rep Phone Number 8505551111(850) 555- 1111 0138 Claim Admin. Claim Rep E-mail AddressN/A 0139 Claim Admin. Claim Rep Fax NumberN/A

238. 238 0270Employee ID Type Qualifier SSocial Security Number 0042Employee SSN324556745 0043Employee Last NameSMITH 0044 Employee First Name JOHN 0045 Employee Middle Name/Initial J 0255 Employee Last Name SuffixJR

239. 239 0052 Employee Date of Birth 19530501May 1, 1953 0054 Employee Marital Status CodeN/A 0151 Employee Education LevelN/A 0213 Employee Number of Entitled ExempN/A 0201 Anticipated Wage Loss IndicatorN/A 0202 Reduced Benefit Amount Code R Reclassification

240. 240 0314Insured FEIN N/A Reported on the FROI N/A Reported on the FROI N/A Reported on the FROI 0016Employer FEIN 0023 Employer Physical Postal Code 0158 Employee Tax Filing Status CodeN/A 0146 Death Result Of Injury CodeN/A 0292 Insolvent Insurer FEINN/A

241. 241 0228 Return To Work with Same Employer Ind YYes 0281 Date Employer Had Knowledge of Date of DisabilityN/A 0212 Non-Consecutive Period Code 0172 Estimated Gross Weekly Amount IndN/A 0145 Current Date Last Day Worked 0144 Current Date Disability Began 9/07/09 – Unchanged per IAIABC definition of DN 9/08/09 – Unchanged per IAIABC definition of DN B Benefit Period

242. 242 0065 Initial Date Last Day Worked N/A Reported on FROI 0189 Return To Work Type Code AActual 0224 Physical Restrictions Ind. YYes 0193Suspension Eff DateN/A 0199Full Denial Eff DateN/A 0196 Denial Rescission DateN/A 0294Partial Denial CodeN/A

243. 243 0134 Calculated Weekly Compensation Amount 00000040000$400.00 0256Wage Effective Date20090615 June 15, 2009 0149 Discontinued Fringe BenefitsN/A 0290Type of Loss Code01Trauma 0058 Employment Status Code N/A Rprtd on FROI 0223 Permanent Impairment Minimum Payment IndN/A

244. 244 0068 Initial Return to Work Date 0066Full Wages Paid For Date Of Injury Indicator N/A Reported on FROI 0273Employer Paid Salary in Lieu of Compensation IndicatorNNo 0293 Lump Sum Payment/ Settlement CodeN/A 0286Average Wage00000060000$600.00 N/A – Reported on IP

245. 245 0297 Initial Date of Lost Time (8 th Day of Dis for FL) N/A – Reported on IP 0200 Claim Administrator Alternate Postal Code (Mailing) 993574528 0299Award/Order DateN/A

246. 246 Variable Segment Counters 0288 Number of Benefits 02 2 Occurrences 0283 Number of Payments 00 0282 Number of Other Benefits 00 0289 Number of Benefit ACR 00 0284 Number of Recoveries00

247. 247 0285 Number of Reduced Earnings 00 0275 Number of Concurrent Employers00 0277 Number of Full Denial Reason Code 00 0276 Number of Denial Reason Narratives 00 0287 Number of Suspension Narratives00

248. 248 Variable Segments Benefits2 Occ’s 0085Benefit Type Code050Temporary Total 0002Maint. Type CodeCB Change in Benefit 0174Gross Weekly Amt00000040000$400.00 0175 Gross Weekly Amount Effective Date 20090615 June 15, 2009 0087Net Weekly Amount00000040000$400.00 0211 Net Weekly Amount Effective Date20090615 June 15, 2009

249. 249 0088 Benefit Period Start Date 20091107 Nov. 7, 2009 0089 Benefit Period Through Date20091113 Nov. 13, 2009 0090 Benefit Type Claim Weeks 0010 0091 Benefit Type Claim Days 0 0086 Benefit Type Amount Paid 00000400000$4000.00 0192 Benefit Payment Issue Date N/A

250. 250 Variable Segments (cont’d) 0085Benefit Type Code070 Temporary Partial 0002Maint. Type CodeCB Change in Benefit 0174Gross Weekly AmtN/A 0175 Gross Weekly Amount Effective Date N/A 0087Net Weekly AmountN/A 0211 Net Weekly Amount Effective Date N/A

251. 251 0088 Benefit Period Start Date 20091114 Nov. 14, 2009 0089 Benefit Period Through Date20091204 Dec. 4, 2009 0090 Benefit Type Claim Weeks 0009 0091 Benefit Type Claim Days 4 0086 Benefit Type Amount Paid 00000261120$2,611.20 0192 Benefit Payment Issue Date N/A

252. 252 Initial Dates vs. Current Dates Initial Dates vs. Current Dates  Recap: Current RTW does not require (for FL): Current Date Disability Began, or Current Date Disability Began, or Current Date Last Day Worked (for FL.) Current Date Last Day Worked (for FL.)

253. 253 Initial Dates vs. Current Dates Initial Dates vs. Current Dates  Had the scenario indicated the EE went straight from TP after delayed TT – i.e., where there was no suspension/break in disability – CDDB (or CDLDW) would not apply, even though you would have reported a revised IRTW because Restrictions now apply… CDDB (or CDLDW) would not apply, even though you would have reported a revised IRTW because Restrictions now apply…

254. 254 Initial Dates vs. Current Dates Initial Dates vs. Current Dates … In that case, the IP would have reported Initial RTW as 6/15 (Actual), and… In that case, the IP would have reported Initial RTW as 6/15 (Actual), and The CB (changing from TT to TP) would report a revised IRTW date of 9/8/09 (Released) due to change in RTW Type Code and Physical Restrictions Indicator. The CB (changing from TT to TP) would report a revised IRTW date of 9/8/09 (Released) due to change in RTW Type Code and Physical Restrictions Indicator.

255. 255 Initial Dates vs. Current Dates Initial Dates vs. Current Dates … But CDLDW and CDDB would not have been reported because there was not a subsequent period of disability involved (all disability was continuous in this example.) … But CDLDW and CDDB would not have been reported because there was not a subsequent period of disability involved (all disability was continuous in this example.)

256. 256 In summary:  You can only move from “Initial” to “Current” Date sets with a break in disability periods (not benefit types) i.e., suspension.  For RTW within a ‘set’, the RTW Date (Initial or Current) will change based on changes of Type Code or Physical Restrictions Indicator.  For CDDB and CDLDW, you would only report a new “Current” date if there has been a 2 nd break in disability (suspension). Initial Dates vs. Current Dates

257. 257 Initial Dates vs. Current Dates Initial Dates vs. Current Dates  Also, Initial RTW can be sent without Initial Date Last Day Worked if the EE never stopped working after the DOI: For example - IP reporting TP (070) where EE continued to work immediately after the accident at reduced wages. For example - IP reporting TP (070) where EE continued to work immediately after the accident at reduced wages.

258. 258 More Initial Dates vs. Current Dates Discussion

259. 259 Initial Dates vs. Current Dates Initial Dates vs. Current Dates  If sending an RB to report the resumption of ‘total’ indemnity benefits after ‘IB Only’ (030) was previously paid (e.g., TT after IB), where : EE never stopped working while receiving IB’s, and EE never stopped working while receiving IB’s, and There was a break between the IB and TT periods: … There was a break between the IB and TT periods: …

260. 260 Initial Dates vs. Current Dates Initial Dates vs. Current Dates  You would not report IDDB and CDDB as the same date, even though the EE is now ‘off work’ for the first time …

261. 261 Initial Dates vs. Current Dates Initial Dates vs. Current Dates Although IDDB is not required for the initial ‘IB Only’ filing in FL, the subsequent RB filing requires CDDB when total disability (e.g., TT or PT) is being resumed. Although IDDB is not required for the initial ‘IB Only’ filing in FL, the subsequent RB filing requires CDDB when total disability (e.g., TT or PT) is being resumed. CDDB on the RB should be reported as the Start date of TT… CDDB on the RB should be reported as the Start date of TT…

262. 262 Initial Dates vs. Current Dates Initial Dates vs. Current Dates …The dilemma for FL is that the RB requires CDDB, but the IDDB has never been required. …The dilemma for FL is that the RB requires CDDB, but the IDDB has never been required. If IDDB is voluntarily sent the same as CDDB, either the RB or a future transaction will be rejected since IDDB can not = CDDB. If IDDB is voluntarily sent the same as CDDB, either the RB or a future transaction will be rejected since IDDB can not = CDDB. IDDB if ever sent should be reported as the MMI Date + 1 day… IDDB if ever sent should be reported as the MMI Date + 1 day…

263. 263 Initial Dates vs. Current Dates Initial Dates vs. Current Dates …FL is considering changing its requirements for IDDB to make it mandatory for ‘IB only’ claims, to ensure we capture and load this date for future editing of the proper disability sequence (IDDB must be < CDDB). …FL is considering changing its requirements for IDDB to make it mandatory for ‘IB only’ claims, to ensure we capture and load this date for future editing of the proper disability sequence (IDDB must be < CDDB).

264. 264 Initial Dates vs. Current Dates Rule of Thumb:  Typically, CDLDW and CDDB are not reported unless there has been a suspension.  Nor would a second set of ‘currents’ be reported unless a second suspension had occurred.

265. 265 Questions?