Florida Division of Workers’ Compensation

Claims EDI Release 3 Training April 27 & 28, 2010

1

Presenter:

Linda Yon

Sr. Management Analyst Supv.

Bureau of Data Quality and Collection Division of Workers’ Compensation (DWC) 2

Additional DWC Staff:

 Tonya Granger – Administrator, Claims & POC EDI Team  Kim Wiley – Claims EDI Project Manager  Karen Kubie –Claims EDI Operations Review Specialist 3

Additional DWC Staff

 Margaret Forsman – Lead Claims EDI Business Analyst  Laura Cotner - Claims EDI & POC Specialist  Debra Lee – Claims EDI Specialist 4

Additional DWC Staff

 Vickie Fields Claims EDI Analyst  Amanda Love Claims EDI Analyst  Janice Youngblood – Claims EDI and POC Consultant/Programmer 5

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. 6

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 errors we are seeing on a consistent basis.

7

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.

8

Training will also include:  Emphasis on Ensuring Data Quality;   Review of some Basic EDI Training information; V arious EDI scenarios and interactive ‘training exercises’; 9

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.

10

This training also includes:  and How to investigate errors and utilize EDI resources (e.g., Edit Matrix, Element Req. Table) in order to understand errors and make necessary corrections;  Review of NEW features in the Claims EDI Data Warehouse.

11

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.

12

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 very distracting to others. 13

We encourage you to raise your hand and ask lots of questions. 14

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. 15

So Let’s Get It Started…

16

The Most Important Component of Claims EDI is…

17

Data Quality

18

Data quality is essential

and has become more significant and necessary with EDI reporting.

19

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. 20

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).

21

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”.) 22

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.

23

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 (8 th Knowledge of Lost Time (8 th day) & day) Claim Type  Empr Paid Salary Ind./Salary Through Date 24

How to Improve Data Quality

25

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.) 26

 The Warehouse filings / transactions received by DWC and their associated Claims EDI Warehouse Claims EDI Data contains all of the processing outcomes (TA, TR, TA-FL).

27

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.) 28

 Errors cannot 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.

29

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.

30

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.

31

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 … 32

… Additionally, this practice will negatively impact your Report Card by over-inflating your counts and percentage of rejected filings.

33

Do not alter any factual data or Benefit/Payment information in an attempt to pass an edit. 34

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.

35

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.

36

Communicate filing issues with your IT staff or vendor so they can address potential programming issues and implement solutions quickly. 37

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.

38

 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.

39

 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.

40

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 .

41

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

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 conditions under which they are expected to be sent (FROI, SROI, & Benefits ‘Conditions’ tabs).

43

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.

44

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… 45

… 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.

46

 I f 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)…, 47

… 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. 48

 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 … 49

… 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 protected]

50

The EDI Team will answer all questions via an email so that both parties have a copy of the response for future reference... 51

…By emailing your question, the EDI Team has the opportunity to research the specific details of the problem thoroughly. Phone calls do not allow adequate time for this research. We appreciate your understanding.

52

Priority attention is given to emails re: TR’s, so been closed TA-FL errors that you responded to may not have (manual process.) You should continue to file the appropriate MTC to fix the TA-FL, and please be patient - the Team will eventually close the TA-FL’s.

53

 Also monitor errors to determine if there are consistent filing issues that could be prevented through training or enhanced system editing. See Your Report Card posted in the Data Warehouse for your ‘Top 5 Reject Errors’ and ‘Top 5 TA-FL Errors’.

54

Note:  There is a new report feature available via the Data Warehouse where you can generate a listing of all TA-FL errors and the specific claims that received those errors.

We will demonstrate this feature later in the training.

55

More detailed information regarding the

Claims EDI

Data Warehouse and troubleshooting errors will Claims EDI Warehouse also be provided later in the training.

56

A separate PowerPoint presentation on the use of the Data Warehouse is posted on the Claims EDI web page.

57

Review from Basic EDI Training

58

Typical Claim Event Flow in FL 1. Establish Claim with 2. Initial Payment or Equivalent

Anytime after First Report and before Final Report

9. Lump Sum Payment(s) 3. Changes to Benefits/Amnts 4. Suspension of all Benefits Benefits 10. Periodic Reports 11. Changes (Non-Indemnity) 12. Cancel 8. Claim Closure 59

Review From Basic EDI Training:

POP QUIZ:

Which two formats comprise the IAIABC standard for reporting workers’ compensation data?

60

Review From Basic EDI Training: ANSWER:

FROI and SROI

61

Review From Basic EDI Training:

Another Pop Quiz:

What code is sent on the FROI or SROI to identify the specific purpose of each transaction being transmitted?

62

Review From Basic EDI Training: ANSWER: MTC

Maintenance Type Code

63

Review From Basic EDI Training: The FROI/SROI formats and specific MTC with DWC per reported on the FROI and/or SROI determine the electronic form equivalent required to be filed Rule 69L-56 .

64

Review From Basic EDI Training: Most MTC combinations equate to a specific DWC Form that is no longer required to be filed with DWC. Remember, the DWC Form may still be required to be sent to other parties, including the EE and Employer ...

65

Review From Basic EDI Training: … Refer to the Claims EDI Rule 69L-56, F.A.C., for direction as to which parties are to receive a hardcopy equivalent. The Event Table and ‘MTC Filing Instructions’ document also ‘Note’ this information.

66

Review From Basic EDI Training: In addition to the Rule 69L-56, which sets out the various electronic form equivalents, the “MTC to Form Crosswalk” provides a one-page summary of MTC(s) that replaced each DWC Form formerly mailed to the Division.

67

If you have to determine which MTC to send for a particular filing purpose/claim event because EDI filings are not ‘auto-triggered’ in your system, if it helps you to think of how you formerly reported via paper, refer to the ‘MTC to Form Crosswalk ’ document for guidance.

68

‘MTC to Form Crosswalk’ identifies what MTC’s equate to which DWC forms.

69

MTC to DWC Form

70

MTC to DWC Form

71

MTC to DWC Form

72

MTC to DWC Form

73

Review From Basic EDI Training: Remember not all MTC’s required to be filed with DWC have a corresponding DWC Form (e.g., EP only), so you should familiarize yourself with the filing requirements in the rule itself.

74

FYI: We plan to workshop a revised version of the rule in the upcoming year.

An e-Alert will be sent to announce the exact date and location, and we would appreciate your participation or written comments at that time.

75

Proper Filing of MTC’s Occurring in the ‘Life of a Claim ’

76

We will now address electronic filings/MTC’s that typically occur in the life of a claim, starting with the Electronic First Report of Injury or Illness (EDI DWC-1 form equivalents).

Frequent filing issues will be identified, including sequencing problems related to filing downstream SROI MTC’s.

77

Most of today’s training will focus on issues related to SROI MTC’s, since most errors occur on SROI filings, either in combination with the FROI, or standalone. 78

Caveats will be provided for avoiding errors, as well as tips to promote successful filing.

79

Note: In developing EDI edits and requirements, particularly in relation to SROI MTC’s, DWC went to great lengths to ensure that exceptions were created for R3 edits/requirements that did not exist for paper or R1 (legacy claims.) 80

For purposes of editing, ‘ legacy claims’ are those where the ‘Date Claim Admin. Had Knowledge of the Injury’ was prior to the Trading Partner’s R3 ‘go live’ date. 81