sroi mtc “ip” scenario

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Florida Division of Workers’
Compensation
Claims EDI
MTC’s, Codes,
FROI 00, SROI IP
Overview 2013
1
Presenter:
Tonya Granger
Administrator, Claims & POC EDI Team
Bureau of Data Quality and Collection
FL Division of Workers’ Compensation
2
In R3 EDI, all WC data
is sent electronically
via a
FROI or SROI
transaction.
3
What Is A
4
First Report
of Injury
(FROI)
5
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.
6
Release 3 FROI Transaction
This means the Release 3 FROI
transaction requires 2 records
to communicate the First Report
event, the “148” & “R21”
records.
7
First Report
of Injury
FROI =148 + R21
8
The FROI
Flat File
9
FROI Flat File Record Layout is
found in Section 2 of the
Implementation Guide
10
FROI Flat File (148) Record Layout
Data Elements
Filler
11
FROI Companion Flat File (R21) Record Layout
Data Elements
Filler
12
FROI R21 Variable Segments
13
What Is A
14
Subsequent
Report of Injury
(SROI)
15
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.
16
Release 3 SROI Transaction
This means the Release 3
SROI transaction requires 2
records to communicate the
Subsequent Report
event, the “A49” &
“R22” records.
17
Subsequent Report
of Injury
SROI = A49+R22
18
The SROI
Flat File
19
SROI Flat File Record Layout is
found in Section 2 of the
Implementation Guide
20
SROI Flat File (A49) Record Layout
Data Elements
Filler
21
SROI A49 Variable Segments
22
SROI Companion Flat File (R22) Record Layout
Data Elements
Filler
23
SROI R22 Variable Segment
Counters
24
SROI R22 Benefit (BEN) Segment
25
SROI R22 Payment/OBT Segments
26
SROI R22 Adjustment/Credit/Redistribution
Segments
27
SROI R22 Recoveries/Reduced
Earnings/Segments
**Reduced Earnings are not reported in FL.
28
SROI R22 Concurrent Employer
Segment
29
SROI R22 Denial
Reasons/Suspension
Variable Segments
30
EDI
Terminology
31
Let’s Review
Important Codes
Common To EDI
Transactions
32
Important Codes
 R3 Quick Code Reference Guide
(see FL Claims EDI webpage)
 Maintenance Type Codes
 Benefit Type Codes
 Other Benefit Type Codes
33
R3 Quick Code Reference
Found on FL
Claims EDI
webpage
One Stop
Shopping for
most codes
34
What Is An
MTC
35
36
A code that defines the
specific purpose of each
transaction being
transmitted.
37
DWC Forms required to
be filed with the Division
are replaced by EDI filings
identified by MTC codes.
38
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).
39
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.
40
First Report
of Injury
MTC’s
41
FL FROI MTC’s Include :
00 – Original
04 – Total Denial
01 – Cancel (Claim Filed in Error)
AQ – Acquired Claim
AU – Acquired First Report
42
FL FROI MTC’s:
Changes
02 – Change
43
Subsequent
Report
MTC’s
44
FL SROI MTC’s:
Initial Payment Equivalents:
IP - Initial Payment
PY – Payment
EP – Employer Paid Salary in
Lieu of Comp
AP - Acquired First Payment
45
FL SROI MTC’s:
Initial Payment Equivalents
(cont’d):
CD – Compensable Death-No
Known Dependents/Payees
VE - Volunteer
46
FL SROI Report MTC’s:
Denials:
04 – Full Denial
PD – Partial Denial
(Indemnity Only & other required
partial denials).
47
FL SROI MTC’s:
Additions/Changes
AB – Add Concurrent Benefit
CA – Change in Benefit Amount
CB – Change in Benefit Type
48
FL SROI MTC’s:
Reinstatements
RB – Reinstatement of Benefits
ER – Employer Reinstatement
49
FL SROI MTC’s:
Full Suspensions
(of all Indemnity)
S1 – RTW or Released to RTW
S2 - Medical Non-Compliance
S3 – Administrative Non-Compliance
50
FL SROI MTC’s:
Full Suspensions
(of all Indemnity)
S4 – Claimant Death
S5 - Incarceration
S6 – Claimant’s Whereabouts
Unknown
51
FL SROI MTC’s:
Full Suspensions
(of all Indemnity)
S7 – Benefits Exhausted
S8 – Jurisdiction Change
You should recognize these from the DWC-4 Form
52
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.
53
FL SROI MTC’s:
Periodic Reports
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.
54
FL SROI MTC’s:
Periodic Reports
(cont’d)…
FN – Final
55
FL SROI MTC’s:
Changes
02 – Changes
EDI
56
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.
57
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
58
What are
Benefit Type Codes
(BTC) ?
59
BTC’s are
codes that identify the
type of indemnity benefits
being paid.
60
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
61
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.)
62
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
63
What are
“Other Benefit Type” Codes
(OBT’s)?
64
OBT’s are
codes that represent the type of
non-indemnity benefits being
paid.
65
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
66
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
67
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.
68
Hot
Topic
69
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.
70
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)
71
FL BUSINESS
SCENARIOS
72
73
FL SCENARIO
ASSUMPTIONS
74
FL SCENARIO ASSUMPTIONS
General scenario
assumptions are included
in the scenarios to assist in
understanding the sample
data that is presented.
75
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).
76
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.
77
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.
78
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.
79
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).
80
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.
81
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.
82
FL SCENARIO
PROFILES
83
FL Scenario Profiles
Unless otherwise noted in the
scenario narrative, the basic
scenario profile information for
all scenarios will be
as follows….
84
FL Scenario Profiles
Injured Employee
Description
Name:
SSN:
DOI:
DOB:
Empmnt Status:
Data
John James Smith, Jr.
324-55-6745
June 15, 2007
May 1, 1953
Full Time
85
FL Scenario Profiles
Injured Employee
Description
Class Code:
Days Worked/Week:
Wage:
Wage Period:
Data
2802 (Carpenter)
5
$15.00
Hourly
(FROI)
86
FL Scenario Profiles
Employer/Insured
Description
Employer:
FEIN:
Physical Location:
Industry (NAICS):
Data
Acme Construction Inc.
74-6994235
32 Meadowbrook Lane
Anytown, FL 32399
236116
87
FL Scenario Profiles
Insurer/Claim Administrator
Description
Insurer:
FEIN:
Average Wage:
Wage Period:
(SROI)
Data
Old Reliable Ins. Co.
78-5902378
$600.00
Weekly
88
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).
89
Complete Scenario for
FROI/SROI Combo
MTC “00” with “IP”
Disability Immediate &
Continuous
Rule 69L56.301(1)(a)1., F.A.C.
90
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.
91
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.)
92
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.
93
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.
94
FROI “00” Scenario Narrative
Employee earned $15.00 an
hour working 40 hours a
week.
Employer reported injury to
insurer on 6/17/07.
95
FROI MTC “00” SCENARIO
Claim Administrator reported the
loss to DWC on 6/29/07.
96
FROI MTC “00” SCENARIO
Insurer is identified.
Claim Administrator details are
provided (remainder are on R21).
97
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
98
FROI MTC “00” SCENARIO
If applicable, Policy Number should
be reported, but Effective Date &
Expiration Date are not required.
99
FROI MTC “00” SCENARIO
Details of the accident are included.
Employee broke leg falling from a ladder.
100
FROI MTC “00” SCENARIO
Employer reported injury to Claim
Administrator on 6/17/07.
101
FROI MTC “00” SCENARIO
Details about injured employee are sent.
The rest of the
Employee’s
name and
address is
on the R21
102
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.
103
FROI MTC “00” SCENARIO
Employee earned $15.00 an hour and
worked 5 days a week.
Employee has not returned to work.
104
FROI MTC “00” SCENARIO
FROI Companion Record - R21
105
FROI MTC “00” SCENARIO
Claim Administrator Claim Number
is repeated in the R21. It links the
R21 companion to the related 148.
106
FROI MTC “00” SCENARIO
Claim Administrator FEIN is sent.
Claim Administrator Name is sent,
& rest of the Claim Admin. Address.
456 Main St
107
FROI MTC “00” SCENARIO
ID qualifier = S.
Positions 232 to 246 contain a
Social Security Number.
108
FROI MTC “00” SCENARIO
Remainder of Employee name,
address fields and phone are here
in the R21 record.
109
FROI MTC “00” SCENARIO
Type of Loss Code is reported on
the SROI.
Employee has not returned to work.
110
FROI MTC “00” SCENARIO
Insured FEIN and Insured Name
are reported.
111
FROI MTC “00” SCENARIO
Insurer Name and Insurer Type Code
are reported.
112
FROI MTC “00” SCENARIO
Details of accident site:
113
FROI MTC “00” SCENARIO
Employer Name, Physical address
and contact information.
114
FROI MTC “00” SCENARIO
Employer Mailing Address
information is not required.
115
FROI MTC “00” SCENARIO
Claim Type Code and EP Salary Indicator
are to be reported on the SROI.
116
FROI MTC “00” SCENARIO
Variable Segment Counters include:
Two Accident/Injury Narratives, and
One Witness segment.
117
FROI MTC “00” SCENARIO
Accident description exceeds 50
characters; two segments are needed
to send entire narrative description.
118
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.
119
FROI MTC “00” SCENARIO
Foreman Jones was the only witness.
120
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.
121
Corresponding
SROI
MTC “IP”
122
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.
123
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).
124
SROI MTC “IP” SCENARIO
Initial Payment transaction is sent
to the Division on 6/29/07.
125
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.
126
SROI MTC “IP” SCENARIO
Claim Admin. Claim Number must
be sent on every record.
127
SROI MTC “IP” SCENARIO
No Jurisdiction Claim number required
because IP SROI is filed with 00 FROI.
128
SROI MTC “IP” SCENARIO
Claim Type indicates Lost Time case.
129
SROI MTC “IP” SCENARIO
No variable segments; A49 ends at
position 208.
130
SROI MTC “IP” SCENARIO
Claim Administrator Claim Number
is repeated in R22. It links the R22
companion to the related A49.
131
SROI MTC “IP” SCENARIO
Claim Administrator information:
132
SROI MTC “IP” SCENARIO
R22 includes additional employee
information.
133
SROI MTC “IP” SCENARIO
These fields are either not required,
or they are reported on the FROI.
134
SROI MTC “IP” SCENARIO
These fields are not applicable to
this claim, except the Initial Date
Last Day Worked.
135
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.
136
SROI MTC “IP” SCENARIO
Weekly Compensation Rate is $400
based on Average Wage of $600
effective the Date of Injury.
137
SROI MTC “IP” SCENARIO
Type of Loss Code and Employment
Status Code are reported on the SROI.
138
SROI MTC “IP” SCENARIO
Additional wage information:
139
SROI MTC “IP” SCENARIO
One Benefits segment and one Payment
segment are required on this claim.
140
SROI MTC “IP” SCENARIO
Temporary Total was the only benefit
paid. MTC is also in Ben segment for IP.
141
SROI MTC “IP” SCENARIO
Gross & Net Weekly Amount = $400/week
(comp rate), effective on the DOI.
142
SROI MTC “IP” SCENARIO
The Gross Weekly Amount is the
weekly payment rate for the Benefit
Type reported.
143
SROI MTC “IP” SCENARIO
144
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.
145
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.
146
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
AP
PY
RB
- Initial Payment,
- Acquired/Payment,
- Payment Report, and
- 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
155
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.
156
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.
157
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.
158
SROI MTC “IP” SCENARIO
MTC IP requires a Payments segment.
Payment Reason Code = Benefit Type
Code.
159
SROI MTC “IP” SCENARIO
Payment information related to the
Initial Payment is captured in the
Payments segment.
160
SROI MTC “IP” SCENARIO
Payment Issue Date = Benefit Payment
Issue Date in Benefits Segment.
161
Hot
Topic
162
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
[email protected]
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.
169
Questions?
170
171
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