Electronic First Reports of Injury or Illness (EDI DWC-1 Equivalent)

1. Electronic First Reports of Injury or Illness (EDI DWC-1 Equivalent)

2. Electronic First Report of Injury or Illness • (EDI DWC-1 Equivalent) • The most typical EDI DWC-1 filing is: • FROI 00 + SROI IP • Required to be filed with DWC per Rule 69L-56.301, F.A.C.

3. Electronic First Report of Injury or Illness • A SROI IP sent in combination with a FROI 00 reports the Claim Administrator’s initial payment on a lost time claim.

4. Electronic First Report of Injury or Illness • Electronic First Reports of Injury or Illness are also represented by the following other EDI DWC-1 equivalent MTC’s to report lost time claims and are also required to be filed with DWC:

5. Electronic First Report of Injury or Illness Other SROI’s Sent with FROI 00: • CD – Compensable Death with no Known Dependents/Payees • EP – Employer Paid • PD – Partial Denial • PY – Lump Sum Payment/Settlement • VE – Volunteer (covered under FL law) FROI Only • 04 – Full (Total Denial)

6. Electronic First Report of Injury or Illness • Please note that we will be deferring discussion on AU/AP EDI DWC-1 equivalents and other Acquired Claims issues until tomorrow.

7. Pop Quiz:

8. If a Compensable Volunteer also had non-volunteer concurrent employment…

9. …What MTC’s should be sent to report the Electronic First Report of Injury or Illness?

10. Answer: FROI 00 + SROI IP To report payment of indemnity based on wages from concurrent employment.

11. SROI MTCIP (Initial Payment) The SROI MTC IP (Initial Payment) transaction implies that indemnity benefits are on-going until suspended.

12. POP QUIZ: Conversely, what transaction/MTC is used when the first payment on the claim is for a one-time lump sum payment or settlement?

13. ANSWER: MTC 00/PY

14. Lump sum payments / settlements will be discussed in more detail during tomorrow’s training.

15. Another POP Quiz: When is the 00/IP considered timely filed with the Division?

16. Electronic First Report of Injury or Illness • Answer: It depends – • For initial payments other than TP, IB or settlement,if LT is immediate and continuous, 00/IP is timely filed when it is received by DWC and assigned ‘TA’ on or before 21 days after Claim Admin.’s knowledge of the injury.

17. Electronic First Report of Injury or Illness Answer (cont’d): • If LT is delayed or non-consecutive, 00/IP is timely filed with DWC when it is received by DWC and assigned ‘TA’ on or before 13 days after the Claim Admin.’s knowledge of the 8th day of disability (a/k/a Initial Date of Lost Time.)

18. To avoid late filing penalties, the EDI First Report of Injury or Illness (00/IP or equivalent) should be triggered immediately upon the Claim Admin.’s disposition of the claim (payment or denial.) HELPFUL HINT

19. This will allow time for correction of potential errors and subsequent resubmission with eventual receipt/acceptance by DWC within the filing due dates specified in Rule 69L-56, F.A.C. HELPFUL HINT

20. Electronic First Report of Injury or Illness • The specific timeframes for the timely submission of the 00/IP 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.)

21. Electronic First Report of Injury or Illness • For FROI 00 with SROI IP combos (or equivalent), the FROI Date and Time Transmission Sent on the Batch Header must be PRIOR to the SROI Date/Time Transmission Sent. If the SROI is received and processed ahead of the FROI, both will reject.

22. Electronic First Report of Injury or Illness • Also, for processing FROI 00/SROI IP combos (or equivalent), the Match Data in the FROI to SROI column of the Edit Matrix Match Data Tab, must match exactly from FROI to SROI.

23. Electronic First Report of Injury or Illness • If the FROI 00 and SROI IP (or equivalent) do not combine as required in the previous 2 slides, the error messages in this case will be confusing…

24. Electronic First Report of Injury or Illness … because if they do not ‘combo’, they are processed separately as individual FROI & SROI filings, which have different requirements/errors. Example Error: “JCN Missing” - Even though JCN is not required for an 00/IP, it IS required for a standalone SROI IP.

25. Now let’s take a detailed look at the BenefitsSegment on the SROI

26. The Benefits segment on the SROI consists of the following data elements (DN’s):

27. Although you may not see this exact layout of data elements on your own system/screen, your company’s program or vendor software should adhere to the submission requirements covered in the next several slides.

28. SROI BENEFITSSegment The Benefits segment of the SROI transaction is used to report indemnitybenefits that are currently being paid or have been paid by the current Claim Administrator.

29. SROI BENEFITSSegment If you have paid indemnity, a BenefitsSegment for EVERY indemnity Benefit Type paid should be included on EVERY SROI transaction.

30. SROI BENEFITSSegment Exception:A Benefit Type Code (or Other Benefit Type Code) previously reported may be left off the current transaction if its disappearance is ‘explained’ by the presence of certain other codes: • Reduced Benefit Amount Code, • Recovery Code(will discuss in detail later.)

31. SROI BENEFITSSegment • Correspondingly, the Benefit Type Amount(and Other Benefit Type Amount) reported on the current transaction must not be less than the $ previously reported unless a Reduced Benefit Amount CodeorRecovery Code is reported.

32. All Data elements contained in the SROI BENEFITSSegment(e.g., Gross/Net Weekly Amounts, Start Date)are defined in theData Dictionary, Section 6 of IAIABC R3 Implementation Guide.

33. The most current version of the IAIABC R3 Implementation Guide is located at IAIABC.org. The Guide is available for download FREE of charge to any employee of an IAIABC EDI Member. If you are not an EDI Member, you can purchase the Guide for $95. 

34. When and how data should be populated in the SROI Benefits segment is in the Variable Segment Population Rules, Section 4 of the IAIABC R3 Guide.

35. Variable Segment Population Rules for the SROI Benefits Segment

36. SROI BENEFITSSegment Only oneBenefits segment per BenefitType Code (BTC) is allowed. The applicable BTC must be included when a Benefits segment is present in the transaction.

37. SROI BENEFITSSegment The Benefitssegment is populated with the current values at the time of transmission, based upon the Benefit Type Codes paid on the claim (snapshot).

38. SROI BENEFITSSegment Exception:Benefit Payment Issue Date. If the 00/IP is filed late and multiple payments have been issued, the Benefit Payment Issue Date for the IP should correspond to the initial payment, not the current payment.

39. SROI BENEFITSSegment • 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. SROI BENEFITSSegment Example: IP sent with 050 followed by 02 to change something in the 050 Benefits segment – Do not leave MTC IP in 050 Benefits segment on the 02. The MTC in the Benefits segment must match the MTC on the transaction.

41. SROI BENEFITSSegment • 0 (zero) Benefits Segments are allowed for the following SROI MTC’s: • CD - Compensable Death with No Dependents; • VE- Volunteers; • PD - Indemnity Only (Partial) Denials.

42. SROI BENEFITSSegment • 0 (zero) Benefits Segments are also allowed if Reduced Benefit Amount Codeis reported as: • S(Settlement on Another DOI) or • N (No Money Settlement).

43. SROI BENEFITSSegment • Reduced Benefit Amount Code “N” was recently appropriated by the IAIABC for reporting settlements with no dollars paid, such as those due to waiver of a lien.

44. SROI BENEFITSSegment • Where Reduced Benefit Amount Code “N” is reported, a Benefits segment will only be present on the transaction if indemnity benefits had been paid for the DOI prior to the settlement.

45. SROI BENEFITSSegment • 0 (zero) Benefits Segments are also allowed if OBT 430 (Unallocated Indemnity) is reported and the acquiring Claim Admin. has not yet issued its initial payment at the time of filing (e.g., SA.)

46. “Event” Benefits Segments EVENT

47. Sweep DN’s Event DN’s

48. “EVENT”BENEFITS SEGMENT RULES A Claim Administrator must be prepared to send all data elements in the BenefitsSegment as required per the “Benefits Segment Req” worksheet of FL’s Element Requirement Table.

49. “EVENT”BENEFITS SEGMENT RULES Exception:If the ‘Date Claim Admin. Had Knowledge of the Injury’ preceded its R3 “go live” date, Gross and Net Amounts and Effective Dates, and Benefit Period Start and Through Dates are NOT required (nor edited), even for Event Benefits Segments. (Since these data elements were not previously required on legacy paper or R1 filings)

50. “EVENT”BENEFITS SEGMENT RULES • Note (exception to the exception): • Benefit Period Start Date is required for BTC 020 & BTC 240, and • Benefit Period Through Date is required for BTC 240 • …even if the ‘Date Claim Admin. Had Knowledge of the Injury’ preceded its R3 “go live” date.