Florida Division of Workers’ CompensationClaims EDI Release 3 Training April 27 & 28,2010
Presenter: Linda Yon Sr. Management Analyst Supv. Bureau of Data Quality and Collection Division of Workers’ Compensation (DWC)
Additional DWC Staff: • Tonya Granger – Administrator, Claims & POC EDI Team • Kim Wiley – Claims EDI Project Manager • Karen Kubie –Claims EDI Operations Review Specialist
Additional DWC Staff • Margaret Forsman – Lead Claims EDI Business Analyst • Laura Cotner - Claims EDI & POC Specialist • Debra Lee – Claims EDI Specialist
Additional DWC Staff • Vickie Fields - Claims EDI Analyst • Amanda Love - Claims EDI Analyst • Janice Youngblood – Claims EDI and POC Consultant/Programmer
This training is new and assumes you have received prior instruction on the basics of the Clams EDI R3 process, and have a familiarity with the various IAIABC transactions (MTC’s) and FL’s requirements tables.
We will be highlighting transactions (MTC’s) that typically occur in the life of a claim, with more in depth discussion geared towards helping you avoid various filing errorswe are seeing on a consistent basis.
HELPFUL HINTS, Caveats and Tips for Successful Filing will be interspersed throughout the presentation, as well as many other reminders and “Lessons Learned”. Please feel free to share your own experiences and lessons learned if we do not address them first.
Training will also include: • Emphasis on Ensuring Data Quality; • Review of some Basic EDI Training information; • Various EDI scenarios and interactive ‘training exercises’;
We recognize that your company’s system or your vendor’s software application may use different data element names and look significantly different compared to the sample record layouts/scenarios we will be using during the training.
This training also includes: • How to investigate errors and utilize EDI resources (e.g., Edit Matrix, Element Req. Table) in order to understand errors and make necessary corrections; and • Review of NEW features in the Claims EDI Data Warehouse.
Towards the end of training and time permitting (after break tomorrow afternoon), we will address: • Acquired Claims and • Testing requirements for those who may not yet be in production status.
Please turn all cells and pagers to vibrate and step outside if you must take a call. Please refrain from engaging in sidebar conversations with other members of your group as it can be verydistracting to others.
We encourage you to raise your hand and ask lots of questions.
If you prefer, you can write your question on an index card and drop it in the basket at break, lunch or end of the day. Please be as specific as possible. We will try to read and answer as many questions as we can. Question?
Data quality is essentialand has become more significant and necessary with EDI reporting.
Incoming data will undergo rigorous edits as documented in our Edit Matrix! Pay close attention to the accuracy of your data. Research and resolve errors timely.
Claims Managers & Supervisors - Ensure there is sufficient staff dedicated to reviewing the results of each day’s transmissions and immediately resolve issues with any transactions that reject (TR).
DWC will be conducting on-going data quality reviews to identify ‘suspect’ data elements, which appear to be inaccurate and are not currently being edited by the R3 Claims EDI program edits. (e.g., Nmbr Days Worked/Wk sent as “7”.)
DWC Auditors will also be conducting data validation reviews to confirm the data submitted via EDI is accurate and consistent based on information in the Claim Administrator’s file.
Examples of EDI data reviewed on audit for accuracy include: • Date Reported to Employer/Claim Admin. • Initial Date Disability Began • Initial Date of Lost Time (8th day) & Knowledge of Lost Time (8th day) • Claim Type • Empr Paid Salary Ind./Salary Through Date
To improve data quality: • An ‘external’ Claims EDI Data Warehouse was created to help our trading partners review and resolve errors faster(including filing issues impacting CPS.)
The Claims EDI Data Warehouse contains all of the filings / transactions received by DWCand their associated processing outcomes (TA, TR, TA-FL). Claims EDI Warehouse
For Clarification on All Filing Errors: PLEASE refer to the Claims EDI Data Warehouse, which usually contains an error message that is much easier to understand than what you might see in your system (also data element in question is highlighted.)
Errorscannot be corrected via the Data Warehouse. You still have to correct and re-send the necessary transaction to resolve a rejection. Unless the Division processed a filing improperly, the filing outcomes and statistics presented in the warehouse will not be changed.
Claims Managers & Supervisors - • Ensure that all staff handling EDI and emailing the Claims EDI Team has access and familiarity with the Claims EDI Data Warehouse. This is the first place the EDI Team will go to help you with your filing issues.
HELPFUL HINT Monitor filing outcomes via the Claims EDI Data Warehouse by 9:00 a.m. the following morning to correct and quickly re-file any rejected transactions.
HELPFUL HINT Do not continue to resend a rejected transaction if you have not changed any data…it will only reject again, and cost your company money if you pay by the transaction…
… Additionally, this practice will negatively impact your Report Card by over-inflating your counts and percentage of rejected filings.
HELPFUL HINT Do notalter any factual data or Benefit/Payment information in an attempt to pass an edit.
Reminder from Basic EDI Training: • If a transaction is improperly rejected by DWC, the entire batch will be re-processed and re-acknowledged using the ‘ARC’ Acknowledgement format. • See the ‘Technical Training’ PowerPoint slides for more details on the Acknowledgement Process.
Reminder from Basic EDI Training: • If the Division re-processes (re-loads) an electronic filing/MTC, you will receive credit for the date the filing/MTC was originally received by the Division.
HELPFUL HINT Communicate filing issues with your IT staff or vendor so they can address potential programming issues and implement solutions quickly.
More Improvements: • FL has made many corrections and adjustments to its Claims EDI program to accommodate filing situations we did not initially anticipate. Revised documentation of edits changes, etc. were last posted to DWC’s web site on 3/8/2010.
FL may potentially enhance its Claims EDI program every two weeks as needed (e.g., to relax an edit). However, if a new filing requirement will result in a rejection, we typically allow a 3 month implementation period before enforcing a new edit.
Monthly advisory email notifications are sent re: changes to edits or data elements or filing requirements. If you are not already a recipient of these emails, a revised EDI-1 should be filed to add you as a Business Contact.
For Additional Clarification on Filing Errors: PLEASE also utilize the resources available on the DWC’s Claims EDI Web site for assistance in understanding errors, including the Edits Matrix and Element Requirement Table.
Reminder from Basic EDI Training: The various tabs in the Edits Matrix explain errors. For example: The ‘Populations Restrictions’tab sets out the criteria against which the data is compared; and The ‘Sequencing’ tab reveals the MTC/information that must be on file before another MTC can be accepted.
Reminder from Basic EDI Training: The Element Requirements Table (ERT) sets out: The data elements required to be reported on the FROI and SROI formats (M, MC, IA, F, FY); and The conditionsunder which they are expected to be sent (FROI, SROI, & Benefits ‘Conditions’ tabs).
Reminder from Basic EDI Training: If a data element is not required for a particular FROI MTC or SROI MTC, it will be denoted as ‘NA’ in the ERT; If sent, it will not be edited or loaded to DWC’s database.
Reminder from Basic EDI Training: File updated Trading Partner paperwork asap when there is a change in your profile-related data, including address changes, additional client insurers, etc., since…
… the FEIN/Zip sent in the file header for the Sender ID, and in the transaction detail (claim level) for the Insurer and Claim Admin. must match a FEIN/Zip reported on your EDI Trading Partner paperwork.
If a data element was sent on a prior filing, and it was not required, and there was an error on the data element, it would not have caused a rejection (e.g. Net Weekly Amount on a sweep or legacy)…, HELPFUL HINT
… but if the data element is required for the MTC that is currently being sent, that same data element will now be edited and cause the current MTC to reject.
Thoroughly research all problems and either correct the inaccurate data before re-sending, or email the EDI team if you suspect our program/edit may be at fault … HELPFUL HINT
… After you have thoroughly investigated the error (using DWC resource documents covered in the Basic EDI training) and you still do not understand it, please send an email to the Claims EDI Team at email@example.com