slide1
Download
Skip this Video
Download Presentation
Overview

Loading in 2 Seconds...

play fullscreen
1 / 121

Overview - PowerPoint PPT Presentation


  • 158 Views
  • Uploaded on

Florida Division of Workers’ Compensation Claims EDI Release 3 CB Training 2014. 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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Overview' - binah


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Florida Division of Workers’ CompensationClaims EDI Release 3

CB Training

2014

slide2

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
slide4

“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.
event benefits segment rules1
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:

slide6

“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.

slide7

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.

slide8

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

slide9

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

slide10

SROI BenefitsSegment

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

slide11

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).

slide12

“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).

slide13

“EVENT” BENEFITS SEGMENT EXAMPLE

All Benefits data elements are populated. Benefit Payment Issue Date is required for an IP.

slide14

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.

sweep benefits segment rules
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:

sweep benefits segment rules1
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:

mtc s that will not contain any event benefits segment s for fl
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

slide20

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.

sweep benefits segment rules2
“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
slide22

For example:

Changing benefit type from 070 (TP) to 030 (IB).

slide24

Change in Benefit Type

SROI MTC “CB”

See Rule 69L-56.3045(3), F.A.C.

slide25

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.

change in benefit type
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.
slide27

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.

slide28

Change in Benefit Type

However, if any of the following circumstances occur when changing a benefit type, a paper DWC-4 is required…

slide29

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
slide31

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.

slide32

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.)

slide33

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)
slide34

Electronic Notice of Action or Change

SROI MTC CB

Change in Benefits

From 050 (TT) to 070 (TP)

slide35
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
slide37

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.

slide38

Electronic Notice of Action or Change

SROI MTC CB

Change in Benefits

  • Continuing…

From 070 (TP) back to 050 (TT)

slide39
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
slide40

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.

slide41

SROI MTC “CB”Change in Benefit Type from TP to TT

Previous TT Segment:

Current benefit picture:

Cumulative

Current

slide42

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.

slide43

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).

slide44

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

slide45
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)
slide46

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.

slide48

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)
slide49

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.

slide50

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.
slide51

Caveats and Tips for Successful Filing of CB

  • A suspension transaction (S1-7) is only required when ALLindemnity benefits are being suspended.
  • Payment of any ongoing indemnity after a suspension will require an MTC ER or RB (reinstatement).
slide52

Caveats and Tips for Successful Filing of CB

  • When the Change in Benefits also involves a corresponding change in the weekly amount at which the new BTC will be paid, you do not need to file a CA & CB.
  • You can report both changes on a single CB transaction.
slide53

Caveats and Tips for Successful Filing of CB

  • Normally, an MTC CB requires two

“Event” Benefit Segments to report changes to the benefits affected by the MTC CB transaction:

  • The Benefit Type that is ending and
  • The Benefit Type that is beginning.
  • Therefore…
slide54

Caveats and Tips for Successful Filing of CB

An MTC CB should only be present in the 2 Benefit Segments where benefits are being changed.

The Benefit being changed “from” and the Benefit being changed “to.”

slide55

Caveats and Tips for Successful Filing of CB

Errors occur when the MTC is put in the Benefit Segments that are not being affected by the change in benefit type because…

slide56

Caveats and Tips for Successful Filing of CB

…if an MTC is placed in a Benefits Segment, it is edited as an “Event” Benefit Segment, requiring Gross and Net Weekly Amounts and Effective Dates that otherwise would not be required and/or edited.

slide57

Caveats and Tips for Successful Filing of CB

Exceptions: There are two circumstances where an MTC CB will only be present in 1 Benefit Segment.

All benefits are being fully reclassified to a BTC that has not been previously reported.

Reclassifying 030 (IB) to 020 (PT).

slide58

Caveats and Tips for Successful Filing of CB

Exception 1:

In the circumstance where 050 (TT) benefits were initially paid; however, 070 (TP) benefits were actually due instead…

slide59

Caveats and Tips for Successful Filing of CB

An MTC CB should be filed to show the change to 070 (TP) benefits.

The Reduced Benefit Amount Code “R” (Reclassification of Benefits) is required to show that all previously reported 050 (TT) benefits were fully reclassified to 070 (TP) benefits.

(A BTC 050 Benefit Segment will no longer be present).

slide60

Caveats and Tips for Successful Filing of CB

Exception 2:

In the circumstance where 050 (TT) benefits were paid, followed by 030 (IB) benefits, which were later fully reclassified to 020 (PT)…

slide61

Caveats and Tips for Successful Filing of CB

There will be 2 Benefits Segments (050 and 020) but only 1 will be an event Benefit Segment - 020 (PT). This will require an MTC CB to be present in the 020 (PT) Benefit Segment only.

The “disappearance” of 030 (IB) would need to be explained via Reduced Benefit Amount Code “R” (Reclassification of Benefits).

slide63

Common Errors

NO SROI ER OR RB PREVIOUSLY ON FILE

(0002-063)

slide64

Common Errors

NO SROI ER OR RB PREVIOUSLY ON FILE

This error occurs when a CB is received after a suspension (S1-7) and no intervening ER or RB (reinstatement of benefits) is on file with the Division.

(i.e. benefits were never reinstated following the suspension)

slide65

Common Errors

  • NO SROI ER OR RB PREVIOUSLY ON FILE
  • If benefits were reinstated after the last suspension,
  • but no reinstatement has been reported to the Division,
  • an MTC ER or RB will need to be submitted. (Rejected MTC CB should be resubmitted as an MTC ER or RB)

Info is correct…

slide66

Common Errors

  • NO SROI ER OR RB PREVIOUSLY ON FILE
  • Please do not assume you must always send the MTC referenced in the error message.
  • If an ER or RB is sent in response to the error when benefits have not truly been reinstated, you will be unable to file another suspension using the same Suspension Effective Date.
  • Therefore…

2/25/14: This is no longer the case as the claim admin can only report previously paid back benefits on a SROI 02. Slides 66 & 67 can be deleted.

slide67

Common Errors

  • NO SROI ER OR RB PREVIOUSLY ON FILE
  • New process:
  • If a previous suspension (S1-7) was
  • filed in error, an MTC RB will need to be submitted to report payment of additional benefits.
  • The EDI Team will no longer manually remove suspension transactions from the Division’s database.
slide68

Common Errors

INITIAL RTW DATE MUST BE CHANGED VIA AN 02 OR S1

(0068-059)

slide69

Common Errors

INITIAL RTW DATE MUST BE CHANGED VIA AN 02 OR S1

The Initial Return to Work Date (IRTW) must match the IRTW Date that was previously reported unless the IRTW Date is being changed via a FROI 02 or S1.

slide70

Common Errors

INITIAL RTW DATE MUST BE CHANGED VIA AN 02 OR S1

If the IRTW Date was previously reported incorrectly, then a FROI 02 must be sent to change the IRTW Date.

Once the FROI 02 has been accepted, the MTC CB (with the correct IRTW Date) can be resubmitted.

slide71

Common Errors

BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED

(0086-059)

slide72

Common Errors

  • BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED
  • This error occurs when the MTC CB reports a Benefit Type Amount Paid for a particular benefit type that is less than the Benefit Type Amount Paid reported on the last accepted SROI.
slide73

Common Errors

BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED

Check that the Benefit Type Amount Paid sent on the rejected CB is the correct amount.

If Benefit Type Amount Paid is correct and less than previously reported, one of the following situations will apply…

slide74

Common Errors

BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED

1) Ifbenefits were partially reclassified to another benefit type,

Then resubmit the MTC CB with Reduced Benefit Amount Code = “R”.

slide75

Common Errors

BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED

2) Ifbenefits were partially recovered due to an overpayment or voided/returned check,

Then resubmit the MTC CB with recovered monies in the applicable Recovery Code (830 & 880).

slide76

Common Errors

BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED

3) Ifthe Benefit Type Amount Paid was previously reported incorrectly,

Then resubmit the MTC CB with Reduced Benefit Amount Code = “D” (Decrease in Indemnity).

slide77

Common Errors

NON-CONSECUTIVE PERIOD CODE MISSING

(0212-001)

**This code is no longer “Mandatory” ; however, if sent the data will be edited/loaded.

slide78

Common Errors

NON-CONSECUTIVE PERIOD CODE MISSING

This error occurs when the number of calendar weeks represented by the Benefit Period Start Date through the Benefit Period Through Date is greater than the total number of Benefit Type Claim Weeks reported.

slide79

Common Errors

  • NON-CONSECUTIVE PERIOD CODE MISSING
  • Check that the Benefit Type Claim Weeks, Days sent on the rejected CB are correct.
  • If the Benefit Type Claim Weeks, Days are not correct, resubmit the MTC CB with the corrected information.
slide80

Common Errors

  • NON-CONSECUTIVE PERIOD CODE MISSING
  • If Benefit Type Claims Weeks, Days are correct, one of the following situations will apply…

2 + 2 = 4

slide81

Common Errors

NON-CONSECUTIVE PERIOD CODE MISSING

1) Ifthe Waiting Period includes more than one period of disability and the previously reported Non-consecutive Period Code = “W” was dropped from the MTC CB,

Then resubmit the MTC CB with the Non-Consecutive Period Code = “W”.

slide82

Common Errors

NON-CONSECUTIVE PERIOD CODE MISSING

2) If the Benefit Period Start Date through the Benefit Period Through Date do not represent a continuous period of disability,

Then resubmit the MTC CB with the Non-Consecutive Period Code = “B”.

slide83

Common Errors

BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED

(0002-063)

slide84

Common Errors

  • BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED
    • This error occurs when the newly reported benefit type has a Benefit Period Start Date prior to a Benefit Period Start Date on file.
slide85

Common Errors

  • BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED
  • This occurs most often when:
  • Events are reported out of sequence.
  • Attempting to report a different BTC paid for the Waiting Period with a Benefit Period Start Date that is not equal to the Initial Date Disability Began.
slide86

Common Errors

  • BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED
  • Events should not be reported out of sequence.
  • If a Benefit Type Code (BTC) previously reported wasaccidentallyleft off the last accepted transaction, …
slide87

Common Errors

  • BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED
  • … those benefits must be “re-added” by filing a SROI ‘02’ (Change)
  • with an ‘02’ in the Benefits Segment.
slide88

Common Errors

BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED

The Division allows a change in benefit type (MTC CB) to report a different benefit type paid for the Waiting Week provided the Benefit Start Date is the same as the Initial Date Disability Began.

slide89

Common Errors

BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED

The Initial Date Disability Began is always the first day qualifying as a day of disability in the first period of disability.

This will be the first day of the waiting period.

slide90

Common Errors

BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED

1) Ifyou are attempting to add a different BTC paid for the Waiting Week and receive this error,

Thencheck that the Benefit Period Start Date is correct.

slide91

Common Errors

BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED

2) Ifthe Benefit Period Start Date is correct,

Then check that the Initial Date Disability Began is equal to the Start Date.

The Benefit Period Start Date and Initial Date Disability Began must be the same, even if there was a Non-Consecutive Waiting Period.

slide92

Common Errors

BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED

If the Initial Date Disability Began is not equal to the Start Date, then submit a SROI 02 with no MTC 02 in the Benefits Segmentto correct the Initial Date Disability Began.

Once the SROI 02 has been accepted, the MTC CB can be resubmitted.

slide94

Question:

When correcting the Initial Date Disability Began in this circumstance, why should an MTC 02 not be present in the Benefits Segment?

slide95

Answer:

  • Because:
    • a different benefit type has been paid for the waiting week and is present on the transaction
    • and
    • the MTC CB has not yet been accepted to report the different waiting week benefit type.
  • Therefore, the MTC 02 cannot be present in the Benefits Segment so that the system will not evaluate any Benefit Segment to find that a different waiting week benefit type has been introduced.
slide96

Answer:

If an MTC 02 is present in the Benefits Segment and the new waiting week benefit type is present, it will reject for Number of Benefits cannot be > what is on file, because an MTC CB has not yet been accepted to introduce the different waiting week benefit type.

After the MTC 02 has been accepted, resubmit the MTC CB.

slide98

New IAIABC Release 3

Data Elements for 2014

slide99

Employer Paid Salary Prior to Acquisition Code (DN 0203)

A code that indicates Employer Paid Unspecified Benefits, Benefit Type Code (BTC) 240, were the only benefits paid prior to acquisition.

slide100

Employer Paid Salary Prior to Acquisition Code (DN 0203)

Benefit Type Amount Paid cannot be required on BTC 240 because theemployer continued salary in lieu of compensationand the claim administrator does not know the particular benefit amount paid by the employer.

slide101

Employer Paid Salary Prior to Acquisition Code (DN 0203)

Since Benefit Type Amount Paid cannot be required on BTC 240, no dollars can be carried over into OBT 430 (Total Unallocated Prior Indemnity Benefits).

slide102

Employer Paid Salary Prior to Acquisition Code (DN 0203)

The Employer Paid Salary Prior to Acquisition Code “E” was created to explain why OBT 430 is not present on the acquiring transaction.

slide103

Employer Paid Salary Prior to Acquisition Code (DN 0203)

Florida began acceptingthis code on September 25, 2013.

This code is not required; however, it will eliminate arejectionwhen

reporting a claim that has been

acquired and only BTC 240 had

previously been paid.

slide104

Updated IAIABC Release 3

Data Elements for 2014

slide105

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

  • Originally:
    • Current Date Disability Began,
    • Current Date Last Day Worked and
    • Current Return to Work Date
  • were defined to relate to the most recent, subsequent, uninterrupted period of benefit payments (benefit period).
slide106

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

The IAIABC recently changed Current Return to Work DatetoLatest Return to Work Status Date(effective 1/1/2014) because the definition of “current” was widely misunderstood.

slide107

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

Prior to the name and definition change, Current Return to Work Date was intended to represent the date the employee actually returned to work, or was released to return to work, following a subsequent period of disability.

slide108

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

The prior Current Return to Work Date wasnotintended to report the date the Return to Work Type Code and/or Physical Restrictions Indicator changed when there wasnosubsequent period of disability; however, CRTW Date was being used for this purpose.

slide109

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

For example:

The injured worker’s DOA was 6/28/10 and she had surgery on that date, so the Initial Date Disability Beganwas 6/28/10.

On 7/11/10, the claim administrator sent

a00/IPto report the first payment of Temporary Total (050) benefits.

slide110

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

The doctor released the injured worker to light duty on 8/9/10, so the Initial Return to Work Datewas 8/9/10.

The employer could not accommodate the injured worker’s restrictions, so Temporary Partial (070) benefits were paid.

slide111

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

The claim administrator sent an MTC CB (Change in Benefit Type) reporting the change from Temporary Total (050) to Temporary Partial (070) and reported the Initial Return to Work (8/9/10), RTW Type Code & Physical Restrictions Indicator:

Return to Work Type Code = R(Released)

Physical Restrictions Indicator =Y (Yes)

slide112

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

On 9/19/10, the doctor changed the injured worker’s release (to full duty - no restrictions) and the claim administrator suspended all indemnity benefits.

slide113

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

AnMTC S1 (Suspension – RTW) was sent to suspend indemnity, report the date the employee was released to full duty and update the RTW Type Code and Physical Restrictions Indicator:

Return to Work Type Code = A(Actual)

Physical Restrictions Indicator =N (No)

slide114

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

This 9/19/10 date (effective date of the change to Return to Work Type Code and Physical Restrictions Indicator) was reported by some claim administrators as an update to the Initial Return to Work Date and was reported by some as a Current Return to Work Date.

From: Return to Work Type Code = R(Released)

Physical Restrictions Indicator = Y (Yes)

To: Return to Work Type Code = A(Actual)

Physical Restrictions Indicator =N (No)

slide115

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

Reporting this effective date (9/19/10) as a Current Return to Work Datewasnotthe intent of original definition because there wasnota subsequent period of disability followed by a subsequent return to work.

Florida edited for the presence of a subsequent period of disability and this caused confusion and rejections.

slide116

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

The data element name and definition were changed to Latest Return to Work Status Date, which nowrepresentseitherthe most recent date the employee returned to work after the Initial Return to Work Date (and is no longer tied to a subsequent period of disability) OR…

slide117

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

… the “effective date”of the most recent change to the Return to Work Type Code and/or Physical Restrictions Indicator.

Therefore, the 9/19/10 date will now be the appropriate Latest Return to Work Status Date.

slide118

Latest Return to Work Status Date - DN 0072

(formerly Current Return to Work Date)

Florida implemented this change for all transactions received by the Division on or after January 1, 2014, pursuant to the current IAIABC Supplement.

slide119

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.

ad