Transcript FL Claims EDI Release 3 Training 2007

POP QUIZ:
What MTC is used to
retract an EDI DWC-1
filed in error with
DWC?
1
ANSWER:
FROI MTC 01
2
Cancel /
Jurisdiction
Transfer Rules
See Rule 69L-56.307, F.A.C.
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FROI 01 - Cancel Rules
FROI MTC 01
is required to be filed
with DWC to report the
cancellation of the claim in its
entirety.
• It is not used to cancel an
individual MTC sent in error.
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FROI 01 - Cancel Rules

FROI 01 (Cancel) should be
sent if a First Report of Injury
or Illness has been filed with
DWC (paper or EDI), but the
claim is subsequently
determined to be ‘nonreportable’ because…
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FROI 01 - Cancel Rules
...
the claim is actually a
Medical Only Case.
• In this case, the FROI 01
should report Claim Type
“B” (Became Medical Only).
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FROI 01 - Cancel Rules
 FROI 01 should also be sent if:
• The claim was reported
multiple times under different
SSN’s/DOI’s & the claim filed
with the incorrect SSN/DOI
needs to be cancelled (i.e.,
duplicate submission), in which
case…
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FROI 01 - Cancel Rules
… you will probably want to keep
the one filed with DWC the
earliest & file MTC 02 to correct
SSN/DOI as applicable; then
file the FROI 01 to cancel
the other one.
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FROI 01 - Cancel Rules
 FROI 01 should also be sent
if the claim was transferred to
another jurisdiction and no
indemnity benefits were ever
paid/reported to DWC
because…
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FROI 01 - Cancel Rules
…
Claim was initially denied
(FROI 04, 00/PD), or
• Claim was reported as
compensable death, no
dependents or volunteer
(00/CD, 00/VE).
•
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FROI 01 - Cancel Rules
 Under these circumstances,
SROI S8 (Jurisdiction Change)
is not applicable because there
are no indemnity benefits being
suspended.
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FROI 01 - Cancel Rules
 Per IAIABC standard Cancel
Rules, when FROI 01 is filed, DWC
will flag the associated claim in its
database as “cancelled”.
• This means the claim
is no longer considered
to be “on file” with DWC.
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FROI 01 - Cancel Rules
• As such, the claim will
be removed from DWC’s
online Claims Database
on the web.
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FROI 01 - Cancel Rules
 FROI 01 requires limited data:
• ‘Match Data’ keys (including
JCN) so DWC can locate the
correct claim in its database.
(Designated as “M” – Mandatory on FL’s ERT.)
• Fatal technical data elements
(Designated as “F” - Fatal on FL’s ERT.)
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Caveats
and Tips for
Successfully Filing
FROI 01 – Cancel
Transactions
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Caveats and Tips for Filing FROI 01
 FROI 01 should not be used to cancel
a claim due to a deficiency in a Claim
Admin.’s system that doesn’t allow
changes to key data (e.g., SSN, DOI,
Claim #, etc.), and instead requires the
establishment of another file under the
correct key information.
• MTC 02 should be used to correct keys.
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Caveats and Tips for Filing FROI 01
 FROI 01 should also not be used to
cancel a claim when the wrong MTC was
sent (e.g., 00/PD sent when really a FROI
04 should have been sent or 00/EP was
sent when 00/IP was sent).
• Solution will vary depending on what
MTC was sent incorrectly. Sometimes
EDI Team intervention is required to
“push through” the subsequent MTC.
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Caveats and Tips for Filing FROI 01
 To “un-cancel” a previously
accepted FROI 01, the Claim
Admin. must file a new Electronic
First Report or Injury or Illness via:
• FROI MTC 00 (or AU) + SROI, or
• FROI 04, depending on the situation.
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Caveats and Tips for Filing FROI 01
 After cancellation/re-establishment,
the Claim Admin. will NOT receive
credit for the original filing date for the
claim that was cancelled.
• The new FROI/SROI filing will be
evaluated for timeliness by DWC.
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Caveats and Tips for Filing FROI 01
 If the FROI 01 was filed in error
and the entire claim was never
intended to be cancelled, contact
the Claims EDI Team for
assistance.
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Caveats and Tips for Filing FROI 01
• If the 01 was filed in error and
SROI’s are now rejecting,
depending on the circumstances,
DWC may be able to remove the
‘cancel’ status so SROI’s can be
re-loaded.
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Caveats and Tips for Filing FROI 01
 If a claim is cancelled in
DWC’s system, no further
transactions can be accepted
unless the claim is
re-established with DWC
or “un-cancelled” by DWC.
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Caveats and Tips for Filing FROI 01
 Do not send FROI 01 when:
•All indemnity benefits have been
voided/cancelled/returned
because EE can not be located;
•Instead send MTC “S6”, Suspension
- Claimant’s Whereabouts Unknown.
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Caveats and Tips for Filing FROI 01
 Also, do not send FROI 01
when:
• A claim is transferred from FL
to another jurisdiction after
indemnity payments have
been made on the claim;
• Instead send MTC “S8”, Suspension Jurisdiction Change.
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Cancel/Transfer Rules
If a claim is being transferred
TO FL ….
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Cancel/Transfer Rules
 The FROI/SROI or FROI 04
sent to establish the claim with
FL should include
Late Reason Code "L4"
(Late Notification,
Jurisdiction Transfer).
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Cancel/Transfer Rules
If filing a 00/IP to report the
claim, the Payment Issue Date
in the Payment segment on
the SROI IP should reflect the
date associated with the first
payment in FL.
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SROI MTC “S8”
Suspension, Jurisdiction Change
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SROI MTC “S8”
Suspension, Jurisdiction Change
MTC “S8” is used to report the suspension
of all indemnity benefits when a claim is
transferred to another jurisdiction after
indemnity benefits have been initiated, i.e.,
 Another state’s workers’ comp Act,
Or ,
 U.S. Longshoremen’s and Harbor
Workers’ Compensation Act,
Or ,
SROI MTC “S8”
Suspension, Jurisdiction Change
 Federal Employers’ Liability Act,
Or,
 Federal Employees’ Compensation Act,
Or,
 Jones Act.
SROI MTC “S8”
Suspension, Jurisdiction Change
No further EDI filings
(e.g., SROI MTC FN) are
required to be sent to the
Division after the
acceptance of MTC “S8”.
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Reminder: Jurisdiction Transfer
Claim administrator then sends
the following to the appropriate
state (if applicable):
 FROI
MTC “00”
 SROI MTC “IP”
(or other applicable SROI)
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Reminder: Jurisdiction Transfer
If a claim is transferred TO
FL from another jurisdiction
(i.e., a different state, or
compensation act, etc.)…
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Reminder: Jurisdiction Transfer
The claim administrator should
send FROI 00 and SROI IP (or
other FROI/SROI filing equivalent),
and
 Report Late Reason Code “L4” –
Late Notification, Jurisdiction
Transfer .
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If no indemnity was paid (e.g., 04,
00/PD, 00/CD, or 00/VE on file), or
indemnity was paid but check(s) was
returned/voided/cancelled prior to the
change in jurisdiction, the Claim
Admin. should send:
MTC 01 to Cancel the claim with the
Division (since indemnity is not being
suspended) and not an S8.
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Questions?
36
Other Helpful Hints
and
“Lessons Learned”
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OTHER HELPFUL HINTS
Numeric fields that are not
populated on a transaction,
should be sent as spaces and
not zeros.
• Zero is a valid value for some
numeric fields.
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OTHER HELPFUL HINTS
Upper or Lower Case?
• Data can be sent in mixed case
format; however,
• DWC’s ‘match criteria’ requires
case be the same between FROI &
SROI combos (either all upper case,
or all lower, or identical mixed text.)
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OTHER HELPFUL HINTS
 DWC has a “relational database”
and stores one EE Name, SSN &
DOB. If your system stores multiple
names for different DOI’s, an EDI
filing could reject if the EE Name
does not match name on file an
earlier filing (or from a different claim
admin.)
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OTHER HELPFUL HINTS
 Note: FL Recently relaxed
match data requirements on
Middle Initial/Name (i.e., no
longer required if on file or
previously sent. If middle
Initial/Name is not consistent with
what is on file you will receive a
TA-FL.
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OTHER HELPFUL HINTS
 If
DWC receives a FROI/SROI
from one Claim Admin., and
afterwards a FROI 04 denial from
a different Claim Admin., a new
JCN is NOT established for the
denied claim. However, …
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OTHER HELPFUL HINTS
… if two Claim Admin.’s pay on the
same claim, two different JCN’s
are established.
• If FL’s “relational database”
reflects a different name for the
EE, the EDI team will contact
each of the Claim Admin’s to
reconcile the correct EE name.
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Which MTC’s to
Send When…
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Scenario
MTC
Claim Admin paid disability days
1-7 only in first check.
NONE
EP filed; IP filed; Sx filed; and now
the Employer is paying IB’s.
ER
IP filed; Sx filed; and now the
Employer is paying IB’s.
EP
EP filed; IP filed; and now the
Employer is paying IB’s.
CB
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Scenario
DWC1 filed (paper); CA filed (R3)
with incomplete benefit picture; SA
filed & rejected because “# Benefits
> than what is on file”.
CB rejects because “No SROI ER
or RB on file” (previously filed Sx )
MTC
CB then
re-file SA
(nonstandard)
ER or RB
IP filed with TT; TT ended due to rls 02 to rpt
RTW
to RTW; TP to be determined
Incorrect MTC filed (Do NOT file
FROI 01 Cancel)
CONTACT
EDI Team 46
Scenario
MTC
FROI 04 filed with Denial Narrative
incomplete (per EAO)
IP filed with TT; TT ended & TP
started and new AWW/Comp Rate
which affected TT & TP
02
IP filed with TT; CB filed to change
from TT to TP; Sx filed; MMI
reached & IB benefits to be
commenced weekly.
… (after above situation) IB paid in
full.
RB
CB
S7
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Scenario
MTC
Paying TP; reached MMI and given CB if paying
PI%; actually RTW w/Restrictions; wkly, or PY if
lump sum
need to pay IB
Filed FROI 04; and now realized
PD
should’ve been “indemnity only”
denial.
SA filed; and now realized Weeks
SA
and Benefit Amount reported
incorrectly.
FN filed; SA filed to reopen;
RB
ongoing indemnity benefits to pay.
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Scenario
MTC
IP filed with wrong BTC
MTC 02, or CB
with RBAC ‘R’
will also work
PT awarded during period TT was
already paid, plus JCC revised
AWW/CR.
Benefit Period Start Date of a BTC
was reported in error in the past.
CB with RBAC
‘R’, no CA
needed
MTC 02 (CB or
RB is not
required)
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Scenario
Sx already filed; previously
reported BTC info (type and period
paid) now determined to be
incorrect.
IP reported TT; CB filed to add TP
paid for waiting week. What MTC is
filed to show the continuation of
TT?
MTC
MTC 02, but
can’t add new BTC or
advance Thru Date.
(Do Not Send
RB)
None
TT is
already ‘on
file’.
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