Transcript FL Claims EDI Release 3 Training 2007

Florida Division of
Workers’ Compensation
Claims EDI
Release 3
CB Training
2014
1
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
2
“EVENT” BENEFITS SEGMENT RULES
“Event”
Benefits
Segments
3
“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.
4
“EVENT” BENEFITS SEGMENT RULES
An “Event” Benefits Segment must and will include the
following data elements:
 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)
5
“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.
6
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
Benefits Segment 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.
7
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
8
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
9
SROI Benefits Segment
If a SROI MTC CB is sent, then an MTC CB must be
sent in the Benefits Segment of the affected benefits.
10
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).
11
“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).
12
“EVENT” BENEFITS SEGMENT EXAMPLE
All Benefits data elements are populated.
Benefit Payment Issue Date is required
for an IP.
13
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.
14
Event DN’s
15
BENEFITS SEGMENT
“Sweep” Benefits
Segments
16
“SWEEP” BENEFITS SEGMENT RULES
A “Sweep” Benefits Segment must and will only
include the following data elements:






Benefit Type Code
Benefit Period Start Date
Benefit Period Through Date
Benefit Type Claim Weeks
Benefit Type Claim Days
Benefit Type Amount Paid
17
“SWEEP” BENEFITS SEGMENT RULES
A “Sweep” Benefits Segment will NOT
include the following:






MTC
Gross Weekly Amount
Gross Weekly Amount Effective Date
Net Weekly Amount
Net Weekly Amount Effective Date
Benefit Payment Issue Date
18
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
19
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.
20
“SWEEP” BENEFITS SEGMENT RULES
“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.
21
For example:
Changing benefit type from 070 (TP)
to 030 (IB).
Gross
Gross Eff.
BTC Benefit Type MTC Weekly
Date
Amt.
Net
Net Eff.
Weekly
Date
Amt.
050
TEMPORARY
TOTAL
070
TEMPORARY
CB
PARTIAL
333.57
1/29/12
333.57
030
PERM PART
SCHEDULED
130.30
2/15/12
130.30
CB
Start
Date
Through
Date
Weeks Days Amt. Paid
1/1/12
1/28/12
4
0
1,389.84
1/29/12
1/29/12
2/11/12
2
0
667.14
2/15/12
2/15/12
2/28/12
2
0
260.60
Payment
Issue Date
22
Sweep DN’s
23
Change in Benefit Type
SROI MTC “CB”
See Rule 69L-56.3045(3), F.A.C.
24
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.
25
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.
26
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 required to be
provided to the employer or
employee.
27
Change in Benefit Type
However, if any of the following
circumstances occur when
changing a benefit type, a
paper DWC-4 is required…
28
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
29
When is an MTC CB
Due?
30
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.
31
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.)
32
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)
33
Electronic Notice of Action or Change
SROI MTC CB
Change in Benefits
From 050 (TT) to 070 (TP)
34
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
35
SROI MTC “CB”
Change in Benefit Type from TT to TP
For Example:
Gross
BTC Benefit Type MTC Weekly
Amt.
Gross Eff.
Date
Net
Weekly
Amt.
Net Eff.
Date
Start Date
Through
Date
Benefit
Weeks Days Amt. Paid Payment
Issue Date
050
TEMPORARY
CB
TOTAL
347.46
1/1/12
347.46
1/1/12
1/1/12
1/28/12
4
0
1,389.84
070
TEMPORARY
CB
PARTIAL
333.57
1/29/12
333.57
1/29/12
1/29/12
2/11/12
2
0
667.14
36
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.
Gross
BTC Benefit Type MTC Weekly
Amt.
Gross Eff.
Date
Net
Weekly
Amt.
Net Eff.
Date
Start Date
Through
Date
Benefit
Weeks Days Amt. Paid Payment
Issue Date
050
TEMPORARY
CB
TOTAL
347.46
1/1/12
347.46
1/1/12
1/1/12
1/28/12
4
0
1,389.84
070
TEMPORARY
CB
PARTIAL
333.57
1/29/12
333.57
1/29/12
1/29/12
2/11/12
2
0
667.14
37
Electronic Notice of Action or Change
SROI MTC CB
Change in Benefits
Continuing…
From 070 (TP) back to 050 (TT)
38
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
39
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.
40
SROI MTC “CB”
Change in Benefit Type from TP to TT
Previous TT Segment:
Current benefit picture:
Gross
BTC Benefit Type MTC Weekly
Amt.
Gross Eff.
Date
Net
Weekly
Amt.
Net Eff.
Date
Start Date
Current
Through
Date
Benefit
Weeks Days Amt. Paid Payment
Issue Date
Cumulative
050
TEMPORARY
CB
TOTAL
347.46
1/1/12
347.46
1/1/12
2/12/12
2/25/12
6
0
2084.76
070
TEMPORARY
CB
PARTIAL
333.57
1/29/12
333.57
1/29/12
1/29/12
2/11/12
2
0
667.14
41
Change in Benefit Type
The Benefit Period Start and
Through Dates are for the most
recent uninterrupted period of
benefits.
The Benefit Type Claim Weeks,
Days and Benefit Type Amount
Paid are cumulative for the life of
the claim.
42
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).
Gross
BTC Benefit Type MTC Weekly
Amt.
Gross Eff.
Date
Net
Weekly
Amt.
Net Eff.
Date
Start Date
Through
Date
Benefit
Weeks Days Amt. Paid Payment
Issue Date
050
TEMPORARY
CB
TOTAL
347.46
1/1/12
347.46
1/1/12
2/12/12
2/25/12
6
0
2084.76
070
TEMPORARY
CB
PARTIAL
333.57
1/29/12
333.57
1/29/12
1/29/12
2/11/12
2
0
667.14
43
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
44
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)
45
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.
Gross
BTC Benefit Type MTC Weekly
Amt.
050
TEMPORARY
TOTAL
070
TEMPORARY
PARTIAL
030
PERM PART
SCHEDULED
CB
CB
347.46
130.30
Gross Eff.
Date
Net
Weekly
Amt.
Net Eff.
Date
Start Date
Through
Date
1/1/12
347.46
1/1/12
2/12/12
2/25/12
6
0
2,084.76
1/29/12
2/11/12
2
0
667.14
2/26/12
3/10/12
2
0
260.60
2/26/12
130.30
2/26/12
Benefit
Weeks Days Amt. Paid Payment
Issue Date
46
Caveats and
Tips for
Successfully Filing
SROI MTC CB
47
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)
48
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.
49
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.
50
Caveats and Tips for Successful Filing of CB
A suspension transaction (S1-7) is
only required when ALL indemnity
benefits are being suspended.
Payment of any ongoing
indemnity after a suspension will
require an MTC ER or RB
(reinstatement).
51
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.
52
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…
53
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.”
54
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…
55
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.
56
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.
1. All benefits are being fully reclassified
to a BTC that has not been previously
reported.
2. Reclassifying 030 (IB) to 020 (PT).
57
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…
58
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).
59
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)…
60
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).
61
Common Errors
Encountered With MTC
SROI CB
62
Common Errors
NO SROI ER OR RB
PREVIOUSLY ON FILE
(0002-063)
63
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)
64
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…
65
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. 2/25/14: This is no longer the case as the
Therefore…
claim admin can only report previously paid
back benefits on a SROI 02. Slides 66 & 67
can be deleted.
66
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.
67
Common Errors
INITIAL RTW DATE MUST BE
CHANGED VIA AN 02 OR S1
(0068-059)
68
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.
69
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.
70
Common Errors
BENEFIT TYPE AMOUNT PAID <
PREVIOUSLY REPORTED
(0086-059)
71
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.
72
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…
73
Common Errors
BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED
1) If benefits were partially
reclassified to another benefit
type,
Then resubmit the MTC CB with
Reduced Benefit Amount
Code = “R”.
74
Common Errors
BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED
2) If benefits 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).
75
Common Errors
BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED
3) If the Benefit Type Amount
Paid was previously reported
incorrectly,
Then resubmit the MTC CB with
Reduced Benefit Amount
Code = “D” (Decrease in Indemnity).
76
Common Errors
NON-CONSECUTIVE PERIOD
CODE MISSING
(0212-001)
**This code is no longer “Mandatory” ;
however, if sent the data will be
edited/loaded.
77
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.
78
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.
79
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
80
Common Errors
NON-CONSECUTIVE PERIOD CODE MISSING
1) If the 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”.
81
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”.
82
Common Errors
BTC ENDING MUST HAVE BEEN
PREVIOUSLY REPORTED
(0002-063)
83
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.
84
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.
85
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 was accidentally
left off the last accepted transaction, …
86
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.
87
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.
88
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.
89
Common Errors
BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED
1) If you are attempting to add
a different BTC paid for the
Waiting Week and receive this
error,
Then check that the Benefit
Period Start Date is correct.
90
Common Errors
BTC ENDING MUST HAVE BEEN PREVIOUSLY REPORTED
2) If the 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.
91
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 Segment to correct the Initial
Date Disability Began.
Once the SROI 02 has been accepted,
the MTC CB can be resubmitted.
92
93
Question:
When correcting the Initial Date
Disability Began in this
circumstance, why should an
MTC 02 not be present in the
Benefits Segment?
94
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.
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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.
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Hot
Topic
97
New IAIABC Release 3
Data Elements for 2014
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.
Employer Paid Salary Prior to
Acquisition Code (DN 0203)
Benefit Type Amount Paid cannot be required
on BTC 240 because the employer continued
salary in lieu of compensation and the claim
administrator does not know the particular
benefit amount paid by the employer.
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).
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.
Employer Paid Salary Prior to
Acquisition Code (DN 0203)
Florida began accepting this code on
September 25, 2013.
This code is not required; however, it will
eliminate a rejection when
reporting a claim that has been
acquired and only BTC 240 had
previously been paid.
Updated IAIABC Release 3
Data Elements for 2014
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).
Latest Return to Work Status Date - DN 0072
(formerly Current Return to Work Date)
The IAIABC recently changed Current
Return to Work Date to Latest Return to
Work Status Date (effective 1/1/2014)
because the definition of “current” was
widely misunderstood.
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.
Latest Return to Work Status Date - DN 0072
(formerly Current Return to Work Date)
The prior Current Return to Work Date
was not intended to report the date the
Return to Work Type Code and/or
Physical Restrictions Indicator changed
when there was no subsequent period
of disability; however, CRTW Date was
being used for this purpose.
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 Began was 6/28/10.
On 7/11/10, the claim administrator sent
a 00/IP to report the first payment of
Temporary Total (050) benefits.
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 Date was 8/9/10.
The employer could not accommodate the
injured worker’s restrictions, so Temporary
Partial (070) benefits were paid.
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)
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.
Latest Return to Work Status Date - DN 0072
(formerly Current Return to Work Date)
An MTC 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)
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)
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 Date was not the
intent of original definition because there
was not a 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.
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 now represents either
the 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 …
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.
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.
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.
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Questions?
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