Overview

1. Florida Division of Workers’ CompensationClaims EDI Release 3 CB Training 2014

2. Overview • Review of Event vs. Sweep • Introduction to the SROI MTC CB • Filing Requirements • Timely Filing • Caveats and Tips for filing SROI MTC CB • Common Errors • Scenario TT to TP, TP back to TT, then TT to IB • Hot Topic – New & Updated R3 Data Elements for 2014 • Questions

3. “Event” Benefits Segments “EVENT” BENEFITS SEGMENT RULES EVENT

4. “EVENT” BENEFITS SEGMENT RULES A Claim Administrator must be prepared to send all data elements in the Benefits Segment, • if required, on the “Event Benefits” worksheet of FL’s Element Requirement Table.

5. MTC Gross Weekly Amount Gross Weekly Amount Effective Date Net Weekly Amount Net Weekly Amount Effective Date Benefit Type Code Benefit Period Start Date Benefit Period Through Date Benefit Type Claim Weeks Benefit Type Claim Days Benefit Type Amount Paid Benefit Payment Issue Date (IP, AP, PY with BTC 0xx only) “EVENT” BENEFITS SEGMENT RULES An “Event” Benefits Segment must and will includethe following data elements:

6. “EVENT” BENEFITS SEGMENT RULES When a Benefit Type is affected by the “Event” being reported, the MTC is sent in the Benefits Segment of the Benefit that is being: Started, Changed (to/from), Suspended ~ OR ~ When reporting a lump sum payment with Benefit Type Code 0xx.

7. When a Benefit Type is not affected by the “Event” being reported (older/previously reported benefits), the MTC is not required to be sent in the BenefitsSegment for the older/previously reported benefit type(s). This Benefits Segment is called a “Sweep” Benefits Segment and will be discussed later in this presentation.

8. MTC’s THAT WILL CONTAIN “EVENT” BENEFITS SEGMENT(s) FOR FL AB – Add Concurrent Benefit Type AP – Acquired/Payment CB – Change in Benefit Type EP – Employer Paid ER – Employer Reinstatement IP – Initial Payment RB – Reinstatement of Benefits

9. MTC’s THAT WILL CONTAIN “EVENT” BENEFITS SEGMENT(s) FOR FL PY - Payment Report (BTC 0xx ONLY) (When the lump sum payment specifies a rate and time period). CA - Change in Benefit Amount SROI 02 – Change (if changing data in Benefits Segment) P7 – Partial Suspension, Benefits Exhausted Sx – Suspension

10. SROI BenefitsSegment If a SROI MTC CB is sent, then an MTC CB must be sent in the Benefits Segment of the affected benefits.

11. In FL, when an MTC is placed in a Benefits Segment, it is edited as an “Event” Benefits Segment, requiring Gross and Net Weekly Amounts, Effective Dates and Benefit Payment Issue Date (when required).

12. “EVENT” BENEFITS SEGMENT EXAMPLE MTC is reported in the Benefits Segment when a benefit type is being affected by the “Event” (AB, AP, CB, CA, S1-8, P7, EP, ER, IP, or RB).

13. “EVENT” BENEFITS SEGMENT EXAMPLE All Benefits data elements are populated. Benefit Payment Issue Date is required for an IP.

14. Reminder: A Payment Segment is also required to be sent on a SROI MTC IP. The Payment Issue Date (Payment Segment) is the data element equivalent of FL’s “Date First Payment Mailed” on paper. CPS uses this date to calculate timeliness of the initial payment.

15. Event DN’s

16. “Sweep”Benefits Segments BENEFITS SEGMENT

17. Benefit Type Code Benefit Period Start Date Benefit Period Through Date Benefit Type Claim Weeks Benefit Type Claim Days Benefit Type Amount Paid “SWEEP” BENEFITS SEGMENT RULES A “Sweep” Benefits Segment must and will only includethe following data elements:

18. MTC Gross Weekly Amount Gross Weekly Amount Effective Date Net Weekly Amount Net Weekly Amount Effective Date Benefit Payment Issue Date “SWEEP” BENEFITS SEGMENT RULES A “Sweep” Benefits Segment will NOTinclude the following:

19. MTC’s THAT WILL NOT CONTAIN ANY “EVENT” BENEFITS SEGMENT(s) FOR FL SROI 02 – Change (when no change (“Event”) is occurring in the Benefits Segment) SROI 04 – Denial PD – Partial Denial SA – Sub-Annual FN – Final MTC

20. Reminder: If an MTC is present in the Benefits Segment, that would typically be considered a Sweep Benefits Segment, FL will edit the Benefits Segment as an Event Benefits Segment.

21. “Sweep” Benefit Segment(s) will be sent along with any “Event” Benefit Segment(s) if older/previously reported benefits are not part of the “Event” that is currently being reported. “SWEEP” BENEFITS SEGMENT RULES

22. For example: Changing benefit type from 070 (TP) to 030 (IB).

23. Sweep DN’s

24. Change in Benefit Type SROI MTC “CB” See Rule 69L-56.3045(3), F.A.C.

25. Change in Benefit Type If indemnity benefits are continuing but the Benefit Type being paid changes to a different Benefit Type, an Electronic Notice of Action or Change, SROI CB, is required to be filed with the Division.

26. Change in Benefit Type SROI MTC “CB” is typically used when: • Indemnity benefits are currently being paid, • The Benefit Type Code currently being paid changes (or is reclassified), • Benefits are not currently suspended.

27. Change in Benefit Type A previous requirement to report a change in benefit type did not exist for paper; therefore, a form DWC-4 is not requiredto be provided to the employer or employee.

28. Change in Benefit Type However, if any of the following circumstances occur when changing a benefit type, a paper DWC-4 is required…

29. Change in Benefit Type • Return to Work Date, • RTW Type Code, • Physical Restrictions Indicator, • Date of Maximum Medical Improvement, • Permanent Impairment Rating, • PT Date Accepted/Adjudicated, • Date of Death

30. When is an MTC CB Due?

31. Timely Filing An MTC CB will be considered timely filed with the Division if received and is assigned a Transaction Acknowledgement Code of “TA” on or before 14 days after payment (for a different benefit type) is mailed.

32. Timely Filing Note:The previous filing requirement was to receive a “TA” on or before 14 days after “knowledge of change in benefits.” However, because many automated systems do not trigger an MTC until a payment has been issued, the new requirement is on or before “14 days after payment mailed.” (Rule will be revised to reflect change.)

33. Electronic Notice of Action or Change SCENARIO SROI MTC CB Change in Benefits Initial Payment (IP) was for 050 (TT) benefits MTC CB change from 050 (TT) to 070 (TP) • MTC CB change from 070 (TP) back to 050 (TT) • MTC CB change from 050 (TT) to 030 (IB)

34. Electronic Notice of Action or Change SROI MTC CB Change in Benefits From 050 (TT) to 070 (TP)

35. Change in Benefit Type Example: • 00/IP Reports initial payment of 050 (TT) benefits: • 050 Benefits paid  1/1/12 – 1/28/12 • CB Reports a change from 050 (TT) benefits ending 1/28/12 to 070 (TP) benefits starting 1/29/12: • 070 Benefits paid 1/29/12 - 2/11/12

36. SROI MTC “CB”Change in Benefit Type from TT to TP For Example:

37. An MTC CB is required in the Benefit Segment for both benefit types 050 (TT) and 070 (TP) because two events are occurring: 050 (TT) is ending and 070 (TP) is beginning.

38. Electronic Notice of Action or Change SROI MTC CB Change in Benefits • Continuing… From 070 (TP) back to 050 (TT)

39. Change in Benefit Type Example: New CB reports a change from 070 (TP) benefits ending 2/11/12 going back to 050 (TT) benefits starting 2/12/12: • 050 Benefits paid  2/12/12 – 2/25/12

40. Change in Benefit Type Only one Benefits Segment can be sent per Benefit Type Code; therefore, the Benefit Period Start Date for BTC 050 (on the MTC CB) should be the start of the current period of 050 (TT) benefits.

41. SROI MTC “CB”Change in Benefit Type from TP to TT Previous TT Segment: Current benefit picture: Cumulative Current

42. Change in Benefit Type The Benefit Period Start and Through Dates are for the most recentuninterrupted period of benefits. The Benefit Type Claim Weeks, Days and Benefit Type Amount Paid are cumulative for the life of the claim.

43. An MTC CB is required in the Benefits Segment for both benefit types 050 (TT) and 070 (TP) because two events are occurring: 070 (TP) is ending and 050 (TT) is beginning (subsequent period).

44. Electronic Notice of Action or Change SROI MTC CB Change in Benefits Continuing… From 050 (TT) to 030 (IB) Employee RTW making pre-injury wages

45. Change in Benefit Type Example: • New CB reports a change from 050 (TT) benefits ending 2/25/12 to 030 (IB) benefits starting 2/26/12: • 030 Benefits paid 2/26/12 – 3/10/12 (1st PYMT) • Date of MMI: 2/25/12 • PI Rating: 2% • Actual RTW Date: 2/26/12 (no restrictions)

46. An MTC CB is required in the Benefit Segment for both 050 (TT) and 030 (IB) because two events are occurring: 050 (TT) is ending and 030 (IB) is beginning. An MTC CB is not required in the Benefit Segment for 070 (TP) because it is a sweep segment.

47. Caveats andTips for Successfully Filing SROI MTC CB

48. Caveats and Tips for Successful Filing of CB • The following information can either be reported on a MTC 02* or included on the MTC CB (if further benefits will be paid), whichever event is due first: • Return to Work information* • FROI 02 (Initial RTW) or SROI 02 (Latest RTW Status Date) • Date of MMI* (SROI 02) • PI Rating* (SROI 02)

49. Caveats and Tips for Successful Filing of CB An S1 (Suspension – Return to Work) is not required to report Return to Work information, unless ALL benefits are being suspended.

50. Caveats and Tips for Successful Filing of CB • For example: • If 070 (TP) benefits will be paid in 14 days, the IRTW info can be reported on the MTC CB. • If 070 (TP) benefits are anticipated to be paid, but not necessarily within 14 days, the IRTW info can be reported on a FROI 02.