Florida Division of Workers’ Compensation Claims EDI Requirements Table Training 2013 WELCOME
Presenter: Tonya Granger Administrator, Claims & POC EDI Team Bureau of Data Quality and Collection FL Division of Workers’ Compensation
FL Trading Partner TablesRequirements and Resource documents
FL EDI Reporting requirements are defined in the Trading Partner Tables: • Required • Report(s) • Data needed on the Report(s) • Applied • Editing
The tables are part of the rule and Trading Partners are responsible for the requirements in those tables. Event Table: When each transaction is due.
Element Requirement Table: Data Elements required for each transaction (MTC), and under what conditions the data elements are required.
Edit Matrix: • Edits that are applied to the incoming transactions and will reject the record or require follow up with an EDI Team Member. This table includes population restrictions edits, sequencing, duplicate processing and money calculations.
Important! These very important requirements documents can be found on the Claims EDI webpage, and are your resource for determining when a transaction should be filed and why it may have errored.
http://www.myfloridacfo.com/wc/edi_clms.html These are the Requirement Tables
Bookmark the FL Claims EDI Webpage and Check It For New or Updated Information http://www.myfloridacfo.com/wc/edi_clms.html
An Event is a business circumstance that occurs in the life of a WC Claim which requires the reporting of EDI information to DWC. These circumstances reflect FL’s requirements, including: • First Report of Injury events • Subsequent Report events • Periodic events
1. Establish Claim 2. Initial Payment or Equivalent 7. Suspend 3. Changes to Benefits/Amnts 5. Reinstate 6. Change Claim Business Events Claim Event Flow in FL with 9. Lump Sum Payment(s) 10. Periodic Reports 11. Changes (Non-Indemnity) Benefits 4. Suspension of all Benefits 12. Cancel 8. Claim Closure
FL identifies all of the transactions (MTC’s) that are required for reporting business events on the Event Table
Due to the national standard format and sequencing requirements, FL requires the reporting of more business events (MTC’s) than were required via paper forms.
Event Table FL Event Table Example Florida’s Event Table describes what and when each MTC is due based on claim events.
In addition to reporting “typical” business claim Events, FL requires the claim administrator to report the “cost status” of the claim via Periodic (Claim Cost) Reports.
Event Table • FLPeriodicReports • SA Sub-Annual – Submitted every 6 months after the DOI, as defined on FL’s Event Table. • FN Final – Submitted when Claim Administrator determines no further benefits will be paid.
In addition to the Event Table, FL describes its business events in the ‘MTC Filing Instructions’. This document is a quick reference tool displaying what MTC’s to use in reporting required business events to FL. Event Table MTC Filing Instructions
FL Trading Partner Tables Data needed on the Report(s)
Element Requirements The FL Element Requirement Table describes the data elements required for each electronic event (MTC) documented on the Event Table.
Element Requirements Data Element requirements are defined for each transaction (FROI or SROI) at the Maintenance Type Code (MTC) level.
Element Requirements Requirement Codes express FL’s requirement severity by data element and report type (FROI or SROI). The following slides define FL’s requirement codes.
Element Requirements The Element Requirement Table contains 6 worksheets: • FROI Element Requirements • FROI Conditions (for MC’s) • SROI Element Requirements • SROI Conditions (for MC’s) • Benefit Segment Requirements • Benefit Conditions(for MC’s)
Element Requirements Fatal. The data element is essential to process the transmission/transaction. F =
Element Requirements Exclude. The data element is not applicable to the standard requirements for the MTC and may or may not be sent. X = Edits will NOT be applied, nor will the data be loaded for FL.
Element Requirements M = Mandatory. The data element must be present and must pass all edits (documented in the Edit Matrix) or the transaction will be rejected.
Element Requirements MC = Mandatory/Conditional. The data element becomes mandatory under conditions documented on the applicable “Conditional Requirements” worksheets. If the defined condition exists, the data element becomes mandatory and mandatory rules apply.
Element Requirements Data Elements defined as M or MC (and the condition applies) are required fields. If they are not present on the transaction, the transaction will receive a Mandatory Field Not Present error (Error # 001).
Element Requirements If Applicable/Available. Data should be sent if available or applicable to the claim. IA = If present, data will be edited for valid value and/or format. If the data passes the edits, the data will be loaded. If the data does not pass the edit, the data will not be loaded, and no error will be returned by FL.
Element Requirements NA = Not Applicable. The data element is not applicable to FL’s requirements for the MTC, and may or may not be sent. FL will not be editing or loading these data elements for this MTC.
Element Requirements For DN’s that are on both the FROI and SROI, FL has identified which transaction (FROI Or SROI, or Both) from which it will edit/load data, and from which the data will be ignored (N/A).
Element Requirements Interpreting Requirement Tables FL’s Claim Number is not required on a FROI 00, 04, AQ or AU, but is Mandatory on a FROI 01 or 02.
Element Requirements FL Conditional Requirements Table • Conditional Requirement Code • Data Element Number and Name • Business Conditions
Element Requirements Additional requirement codes were developed for the MTC 02 (Change) transaction.
Element Requirements A Benefitssegment is expected when indemnity benefits have been paid on the claim, for each applicable Benefit Type Code value indicated in the Edit Matrix. Only one Benefits segment can be sent for each Benefit Type Code.
Element Requirements “Event” Benefits Requirements are described on the Event Benefits Segment Requirement Table.
Element Requirements R = Restricted. The data element value will not be accepted by FL. For example, FL does not accept Benefit Type Code 090 (PI) (Permanent Partial Disfigurement) for DOI’s < 08/01/79 or > 12/31/93
Element Requirements Restricted Benefit Types for FL
Element Requirements DN’s in the Benefits segment are required based on the MTC as well as the Benefit Type Code being paid. Net Weekly Amount
Element Requirements Data defined as N/A on the Element Requirement Table, or was not required by the “Condition” will not be edited, processed or loaded to DWC’s system if sent for that MTC. This is commonly misunderstood.
Element Requirements Example: Gross/Net Amounts are not required for MTC SA or FN. If these data elements are sent incorrectly, they will NOT be errored. However, if Gross/Net Amounts are sent wrong on the next Event where they ARE required (CA, CB, etc.) they WILL be errored.
Element Requirements Although the same data element may be on both the FROI and SROI, the Element Requirement Table will depict on which transaction the data is required. The other transaction will list the requirement as N/A, which means it will not be edited, processed or loaded to DWC’s system if sent for that MTC.
Element Requirements Example: Claim Type is not looked at on the FROI 00, but is required on the corresponding SROI IP. If it is only sent on the FROI and not the SROI, they will both reject.
FL Trading Partner Tables Applied Editing
Edit Matrix The Edit Matrix details the edits applied by FL.