Acquired Claims: Reporting a Change in Claims Administration

1. Acquired Claims:Reporting a Change in Claims Administration Required to be filed with DWC per Rule 69L-56.304(2), F.A.C.

2. Acquired ClaimsSee Processing Rules: Section 4 in the IAIABC EDI Guide

3. Acquired ClaimsChange in Claims Administration • Claims are considered to be “acquired” any time a new Claim Administrator is taking them over from a prior Claim Administrator.

4. Acquired ClaimsChange in Claims Administration • Any existing claims(open or closed) that were transferred to the new Claim Admin. are considered “acquired”.

5. Acquired ClaimsChange in Claims Administration • New reports of injury the acquiring Claim Admin. receives after the takeover effective date are notconsidered acquired claims (would file 00/IP, etc.).

6. Acquired ClaimsChange in Claims Administration • For reporting to DWC, a change in acquisition is required for: • All OPEN lost time claims, and • Any CLOSED lost time claims with a DOI within FIVE years prior to the date of acquisition.

7. Acquired ClaimsChange in Claims Administration • To report an acquired claim, the new Claim Administrator should send: • FROI “AQ” (Acquired Claim) • (EDI equivalent of DWC-49).

8. Acquired Claims Change in Claims Administration • AQ (Acquired Claim): Minimal data is sent to report that a new Claim Admin. has acquired the claim.

9. Acquired Claims Change in Claims Administration • If the AQ rejects because the First Report of Injury or Illness (paper or EDI) is not already ‘on file’ with DWC, the new Claim Admin. must file: • FROI AU with applicable SROI.

10. Acquired ClaimsChange in Claims Administration • If AQ rejects due to match data, email the EDI Team to determine which match data element is different & if your data or DWC’s data is correct. • If DWC’s data is wrong or out of date, we will correct our file and reload your filing.

11. Acquired ClaimsChange in Claims Administration • Subsequent to the acceptance of the AQ, when the new Claim Administrator eventually mails its first payment of indemnity, it should file a SROI‘AP only’(vs. a standalone IP).

12. Acquired ClaimsChange in Claims Administration • If SROI AP does not apply to the particular claim situation, other standalone SROI’s may be sent instead (EP, PY, PD or SROI 04).

13. Acquired Claims • JCNis required for ‘standalone’ SROI AP (or other SROI equivalent). • JCN is provided on the ACK transaction for the previously accepted FROI AQ.

14. Acquired Claims Note:Jurisdiction Claim Number (JCN) never changes. If the former claim administrator provided the JCN, it would still be valid.

15. Change in Claims Administration • SROI AP must only be sent: • With a FROI AU, or • Subsequent to filing a FROI AQ.

16. Change in Claims Administration • If the new Claim Admin. acquires a claim and initiates payment, the new Claim Admin. must file: • FROI AU+ SROI AP(Acquired Payment)

17. Acquired ClaimsChange in Claims Administration • If SROI AP does not apply to the filing situation, other SROI MTC’s may be sent instead…

18. Change in Claims Administration • FROI AU + SROI EP • FROIAU + SROI CD • FROI AU + SROI VE • FROI AU + SROI PY • FROI AU + SROI PD • FROI AU + SROI 04

19. Jurisdiction Claim Number (JCN) is not required for FROI “AQ”, or FROI “AU” + applicable SROI Acquired ClaimsChange in Claims Administration

20. Acquired Claims All prior indemnity paid by the former Claim Administrator(s) must be rolled up and reported on the SROI under: Other Benefit Type 430(Total Unallocated Prior Indemnity Benefits).

21. Acquired Claims • Note:Presence of OBT 430 alone will not prevent the edit, ‘Ben Type Amount Paid < Prev. Reported’ from running. • Total of all Benefit Type Amount Paid (for all BTC’s) plus OBT 430 must be at least equal to all BTC amounts previously reported.

22. Acquired Claims • If the only prior indemnity reported by the former Claim Admin. was 2xx, the current Claim Admin. should report the actual $ under OBT 430 if BTC other than 240 was paid. • If only BTC 240 was paid, FL’s program will accept $0 in the OBT 430 field, however …

23. Acquired Claims … OBT 430 is currently defined as the “sum of prior indemnity benefits ‘paid’ to date by the previous claim administrator(s)”, and BTC 240 Employer Paid benefits are not paid by the Claim Administrator. As a result of this conflict …

24. Acquired Claims … FL submitted an IRR with the IAIABC requesting a standardized approach to this filing dilemma …

25. Acquired Claims • Proposed solutions include: • Appropriation of a new OBT Code, or • Allow OBT 430 to be reported w/ $0, or • Allow BTC 240 to continue to be reported in the Benefits segment (vs. moved to an OBT segment.)

26. FL does notrequire OBT Code 440 (Total Unallocated Prior Medical) to report the amount the prior Claim Admin. paid in medical because those costs are collected via DWC’s Medical EDI program. Acquired Claims

27. The new Claim Admin. must also report certain medical costs paidsince the acquisition of the claim. Report under “Other Benefit Type Codes”, e.g., OBT Code 370 (Total Other Medical), etc. Acquired Claims

28. Acquired Claims • If DWC-1 is not already on file, AU + SROI will: • Establish initial claim record in DWC’s database, and • Be evaluated for timely filing of the initial report of injury to DWC.

29. POP QUIZ: If no indemnity was paid by the former Claim Admin. but the new Claim Admin. is denying the claim in its entirety and there is no DWC-1 on file with DWC, what should be sent?

30. ANSWER: FROI AU + SROI 04

31. FROIAU+ SROI04should be sent rather than a FROI 04 because there is no way to convey an Acquired Denial with a FROI 04. If the denial is rescinded, an AP would reject if there was no prior AQ or AU on file. Acquired Claims

32. Acquired Claims Change in Claims Administration • If the acquiring Claim Admin. sends an AQ that rejects because there is no DWC-1 on file, and if no SROI is applicable to the present filing situation (e.g., you are not making payment or denying) …

33. Acquired Claims • … at the present time, the acquiring Claim Admin. will need to fax a paper DWC-1 (copy of original) to EDI Team at (850) 488-3453. • If you have ‘a lot’ that will fall into this situation, contact the Claims EDI Team before mailing ‘lots’ of paper DWC-1’s.

34. Acquired Claims Note: Even though the former TPA should have filed the First Report of Injury or Illness (paper or EDI) with DWC, the new TPA is still required to file the FROI, because the Insurer is ultimately responsible .

35. Acquired Claims • Corrections of an incorrect Insurer FEIN (reported on a prior paper or EDI filing) to another Insurer FEIN within the same insurer group/relationship, are not considered changes in claims administration and may be changed via MTC 02.

36. Acquired Claims • If 02 is sent to report a change in FEIN and MTC 02 is included in the Ben segment, • All previously reported indemnity will be required on the 02.

37. Acquired Claims • Recap:If AQ or AU/SROI is sent to report an actual change in administration, all indemnity paid by the former Claim Admin. must be rolled up into OBT 430before sending the next SROI event …

38. Acquired Claims … because by definition, “Benefit Period Start Date” is reset and should only represent indemnity paid by the new Claim Admin. Therefore, it is not appropriate to include the prior claim admin payments in the Benefits segment.

39. OBT Code 430 (Total Unallocated Prior Indemnity) must not be reported unless: MTC AQ, AU or AP is on file or being filed, OR Date Claim Admin. Had Knowledge of Injury is prior to the Claim Admin.’s R3 Production Implementation Date. Acquired Claims

40. Acquired Claims • Recap: If there is no actual change, but rather a correction in claims administration, MTC 02 should be sent.

41. Acquired Claims Benefits Segment Definitions

42. BENEFITS Segment - Acquired Claims “Gross Weekly Amount” and“Net Weekly Amount” The Gross and Net Weekly Amounts apply to the Acquiring Claim Administrator’s payment, rather than the previous Claim Administrator’s payments.

43. BENEFITS Segment - Acquired Claims “Gross Weekly Amount Effective Date” “Net Weekly Amount Effective Date” The Gross and Net Weekly Amount Effective Dates are the date the acquiring claim administrator assumed responsibility for handling the claim.

44. BENEFITS Segment - Acquired Claims “Benefit Period Start Date” For MTC “AP” and all subsequent MTC’s filed on acquired claims, the Benefit Period Start Date is the first date of the uninterrupted period of benefit payments by the acquiring Claim Administrator corresponding to a specific Benefit Type Code.

45. BENEFITS Segment - Acquired Claims “Benefit Period Through Date” For all MTC’s that are initiating or reinstating a Benefit Type Code (AB, AP, IP, RB, EP, ER, CB): The Benefit Period Through Date is the latest date of the uninterrupted period of benefit payments that corresponds to the Benefit Type Code.

46. BENEFITS Segment - Acquired Claims “Benefit Type Claim Weeks/Days” For acquired claims, Benefit Type Claim Weeks/Days will be the cumulative number of whole weeks and residual number of days paid for a Benefit Type Code by the acquiring claim administrator.

47. BENEFITS Segment - Acquired Claims “Benefit Type Amount Paid” For acquired claims, the Benefit Type Amount Paid will be the cumulative paid to date amount by the acquiring claim administrator.

48. Questions?