Florida Regulations 69L-3.0091

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§ 69L-3.0091 Notice of Action/Change.

History:



The claims-handling entity shall send Form DFS-F2-DWC-4, as adopted in Rule 69L- 3.025, F.A.C., to the Division as specified in this section for any industrial accident or injury filed for lost time cases as defined in subsection 69L- 3.0045(2), F.A.C., within 14 days of the claims-handling entity's knowledge of the action or change which it is reporting. The claims-handling entity shall complete the applicable fields for each required Form DFS-F2-DWC-4; the "Remarks" section may only be used to supplement the information reported. The claims-handling entity shall send to the employee and the employer copies of Form DFS-F2-DWC-4, for each action or change required by this section within 14 days of the claims-handling entity's knowledge of the action or change which it is reporting to the Division.

(1) The claims-handling entity shall use the following codes to identify the "Disability Type" or the "Disability Type Adjusted" on Form DFS-F2-DWC-4. "Disability Types":

(a) "TT" means temporary total disability benefits. (b) "TTC" means increased temporary total disability benefits payable at 80% of the average weekly wage. (c) "TTE" means temporary total compensation paid during training and education. (d) "TP" means temporary partial disability benefits. (e) "PI" means permanent impairment benefits for dates of accident prior to January 1, 1994. (f) "IB" means impairment income benefits paid pursuant to Section 440.15(3), F.S., for dates of accident on or after January 1, 1994. (g) "WL" means wage loss benefits for dates of accident prior to January 1, 1994. (h) "SB" means supplemental income benefits paid pursuant to Section 440.15(3)(b), F.S. (1994) for dates of accident on or after January 1, 1994 through September 30, 2003. (i) "PT" means permanent total disability benefits. (j) "DB" means death benefits.

(2) If the claims-handling entity suspends benefits for any of the reasons stated in paragraphs (a)-(h) below, the claims-handling entity shall send the Division Form DFS-F2-DWC-4, and not Form DFS-F2-DWC-12, as adopted in Rule 69L- 3.025, F.A.C. The claims-handling entity shall state the "Effective Date" of the suspension and the applicable suspension "Reason Code" in the applicable fields. The "Effective Date" of the suspension shall be the last date through which benefits were paid. The following "Suspension Reason Codes" shall be used to identify the reason for which all indemnity benefits have been suspended:

(a) "S1" means returned to work, or medically determined or qualified to return to work. All indemnity benefits have been suspended because the employee has returned to work, or has been medically released to return to work, and the claims-handling entity does not anticipate paying further indemnity benefits of any kind. (b) "S2" means medical non-compliance. The employee failed to report for an independent medical examination pursuant to Section 440.13(5)(d), F.S., or failed to report for an evaluation by an expert medical advisor appointed by a Judge of Compensation Claims pursuant to Section 440.13(9)(c), F.S. (c) "S3" means administrative non-compliance. The employee has failed to comply with one or more of the following statutory sections and any applicable rules:

1. Section 440.15(1)(e)3., F.S. (1994), which is incorporated herein by reference - employee in PT status failed to attend vocational evaluation or testing. 2. Section 440.15(1)(f)2.b., F.S. (1994), which is incorporated herein by reference - employee in PT status failed to report or apply for social security benefits. 3. Section 440.15(2)(d), F.S. (1994), which is incorporated herein by reference - employee in TT status failed or refused to complete and return the Form DFS-F2-DWC-19. 4. Section 440.15(7), F.S. (1994), which is incorporated herein by reference - employee in TP status failed or refused to complete and return the Form DFS-F2-DWC-19. 5. Section 440.15(6), F.S. (2003), which is incorporated herein by reference - employee refused suitable employment. 6. Section 440.15(9), F.S. (2003), which is incorporated herein by reference - employee failed or refused to sign and return the release for social security benefits earnings on the Form DFS-F2-DWC-14, or unemployment compensation earnings on Form DFSF2- DWC-30, as adopted in Rule 69L- 3.025, F.A.C. 7. Section 440.491(6)(b), F.S. (2003), which is incorporated herein by reference - employee failed or refused to accept vocational training or education. 8. Section 440.15(4)(d), F.S. (2003), which is incorporated herein by reference - employee in TP status failed to notify the claimshandling entity of the establishment of earnings capacity within 5 business days of returning to work. 9. Section 440.15(4)(e), F.S. (1994), which is incorporated herein by reference - employee in TP status terminated from post-injury employment due to the employee's misconduct. 10. Section 440.105(7), F.S. (2003), which is incorporated herein by reference - employee refused to sign and return the fraud statement.

(d) "S4" means employee death. This code is used if there are no known or confirmed dependents to whom death benefits must be paid or if the death was not compensable. (e) "S5" means incarceration. The employee has become an inmate of a public institution and compensation benefits have been suspended because there are no known or confirmed dependents. (f) "S6" means employee's whereabouts unknown. The claims-handling entity's good faith repeated attempts to locate and send compensation checks to the employee have been unsuccessful; or the employee has no known address, representative or guardian to whom the claims-handling entity can send compensation checks; or compensation checks have been returned to the claims-handling entity indicating that the employee has moved, with the address unknown, or does not reside at that address. (g) "S7" means benefits exhausted, or entitlement to benefits exhausted, due to statutory limits. The employee is no longer eligible for or entitled to any indemnity benefits. (h) "S8" means jurisdiction change. The employee elects to receive workers' compensation benefits under another state's law, or the claims-handling entity determines the claim is compensable under the Federal Employer's Liability Act, the Longshoremen's and Harbor Workers' Compensation Act, or the Jones Act.

(3) The claims-handling entity shall send Form DFS-F2-DWC-4 when it reinstates indemnity benefits after a suspension. It shall state the "Effective Date" of the "Indemnity Reinstated After Suspension" and the "Disability Type" of benefits being reinstated in the applicable fields.

(4) The claims-handling entity shall send Form DFS-F2-DWC-4 when the employee has resumed work, has been medically released to return to work, or to report the assignment of physical restrictions or the removal of all physical restrictions. The date the employee resumed work is the employee's actual return to work date and is to be reported in the "Actual Return To Work Date" field. The date the employee's medical release states that the employee may resume work is the employee's released to return to work date and is to be reported in the "Released To Return To Work Date" field. The claims-handling entity must indicate whether the employee was given any physical restrictions in the "Restriction?" fields identified as either "Yes" or "No".

(5) The claims-handling entity shall send Form DFS-F2-DWC-4 reporting the date payment mailed resulting from a final order for indemnity benefits pursuant to Section 440.20(11), F.S. This date is to be placed in the "Date Final Settlement Mailed" field and shall not be reported as earlier than the date the settlement was actually approved.

(6) The claims-handling entity shall send Form DFS-F2-DWC-4 when it is paying benefits to the employee after establishing the overall maximum medical improvement date and a permanent impairment rating to the body as a whole greater than zero. The date on which the overall maximum medical improvement is established is to be reported in the "MMI Date" field and the permanent impairment rating is to be reported in the "PI Rating" field.

(7) The claims-handling entity shall send Form DFS-F2-DWC-4 to report the date of the employee's death in the "Date of Death" field, whether or not the death is considered compensable.

(8) The claims-handling entity shall send Form FDS-F2-DWC-4 when it begins payment of impairment income benefits for dates of injury on and after January 1, 1994. It shall state the date the impairment income benefits were started in the "Start Date" field, the initial weekly rate at which the benefits will be paid in the "Weekly Rate" field, and the total number of weeks the employee is entitled to the benefits in the "Total Number of Weeks of Entitlement" field.

(9) The claims-handling entity shall send Form DFS-F2-DWC-4 when it amends either the employee's average weekly wage or the compensation rate. It shall state the previous average weekly wage in the "Previous AWW" field and previous compensation rate in the "Previous Comp Rate" field and the amended average weekly wage in the "Amended AWW" field and the amended compensation rate in the "Amended Comp Rate" field. It shall also indicate if the average weekly wage change was retroactive to the date of injury in the "Yes" or "No" boxes in the "Retroactive to D/A" field, and if not, the date on which the new average weekly wage was effective in the "If No, Give Effective Date" field.

(10) (a) The claims-handling entity shall send Form DFS-F2-DWC-4 if the employee is permanently and totally disabled. The following information, when applicable, shall be provided:

1. The date on which the employee was accepted or adjudicated as permanently and totally disabled in the "Date Accepted/Adjudicated" field 2. The claims-handling entity shall report any changes to the weekly rate at which the permanent total supplemental benefits will be paid, corresponding to the rate change in PT Supplemental Benefits, including the annual rate increases in the "Weekly PT Supplemental Rate" field. 3. The effective date of the change in the permanent total supplemental benefits rate, including the effective date for annual rate increases is to be reported in the "PT Supp Effective Date" field.

(b) If the employee's permanent total supplemental benefits are suspended because the employee has reached age 62 and is eligible for Social Security benefits, then the claims-handling entity reports $0 as the permanent total supplemental rate in the "Weekly PT Supplemental Rate" field. The effective date is the date on which permanent total supplemental benefits will no longer be paid and is to be reported in the "PT Supp Effective Date" field.

(11) The claims-handling entity shall send Form DFS-F2-DWC-4 when it adjusts or offsets the employee's weekly compensation rate. It shall include the Benefit Adjustment Code in the "Benefit Adjustment Code" section, the "Disability Type" in the "Disability Type Adjusted" field, the weekly amount by which the employee's payment is being reduced in the "Weekly Adj Amount" field, and the date the offset or adjustment is effective in the "Effective Date" field. If the offset or adjustment is temporary, the claims-handling entity shall send Form DFS-F2- DWC-4 when it resumes payment at the former rate to report the date the adjustment ends in the "Adjustment End Date" field.

(a) If the claims-handling entity sends Form DFS-F2-DWC-4 to report a change in the employee's weekly compensation rate due to a social security offset, it shall send a completed Form DFS-F2-DWC-14 when it submits Form DFS-F2-DWC-4. (b) The following codes shall be used to show that the rate of pay has been adjusted due to the corresponding reason(s), or that the rate of pay has been offset because of the below reason(s). BENEFIT ADJUSTMENT CODES:

1. "A" means apportionment or contribution. The weekly benefit amount has been reduced for shared or partial liability(s). 2. "B" means subrogation or third party offset. The weekly benefit amount has been reduced for recovery from third party tort-feasor pursuant to Section 440.39(2), F.S. 3. "C" means overpayment credit. The weekly benefit amount has been reduced for benefits paid but not owed, pursuant to Section 440.15(12), F.S. 4. "H" means child support or alimony reduction. The weekly benefit amount has been reduced for income deduction orders, pursuant to Section 61.1301, F.S. 5. "N" means medical non-compliance offset. The weekly benefit amount has been reduced because the employee has failed to accept training and education pursuant to Section 440.491(6)(b), F.S., for dates of accident prior to October 1, 2003 or the employee has failed to timely cancel an independent medical examination pursuant to Section 440.13(5)(d), F.S. 6. "P" means advance recoupment. The weekly benefit amount has been reduced for reimbursement of benefit payments advanced pursuant to Section 440.20(13), F.S. 7. "R" means social security retirement offset. The weekly benefit amount has been reduced for retirement benefits paid under the Federal Old Age, Survivors, and Disability Insurance Act, pursuant to Section 440.15(9), F.S. 8. "S" means social security disability offset. The weekly benefit amount has been reduced for disability benefits paid under the Federal Old Age, Survivors, and Disability Insurance Act, pursuant to Section 440.15(9), F.S. 9. "U" means unemployment compensation offset. The weekly benefit amount has been reduced for unemployment compensation benefits, pursuant to Section 440.15(10), F.S. 10. "V" means safety violation offset. The weekly benefit amount has been reduced for safety violation(s) pursuant to Section 440.09(5), F.S. 11. "X" means death or dependent change. The weekly benefit amount has been adjusted because of a change in number or kind of dependents entitled to death benefits pursuant to Section 440.16, F.S.

(12) The claims-handling entity shall send Form DFS-F2-DWC-4, to report a correction in the employee's social security number in the "Social Security Number/Correct #" field, date of accident in the "Date of Accident/Correct Date" field, employee's name in the "Employee's Name/Correct Name" field, or the claims-handling entity handling the case in the "Claims-handling Entity" field. When reporting corrections to the employee's name, social security number, or date of accident, the claims-handling entity shall include the original (incorrect) information at the top of the form, and the corrected (new) information in the applicable field in the "Corrections Of" section. The claims-handling entity shall report these changes only for lost time cases as defined in subsections 69L- 3.002(19), F.A.C.

(13) The claims-handling entity shall send Form DFS-F2-DWC-4 to report or change the class code of the employee in the "Class Code" field or the employer's NAICS code in the "NAICS Code" field.

Specific Authority 440.185, 440.20(3), 440.591 FS. Law Implemented 440.15(3)(d)2., 440.185, 440.20, 440.207(2), 440.51(8), (9) FS. History-New 1-30-91, Amended 11-8-94, Formerly 38F-3.0091, 4L-3.0091, Amended 1-10-05.