Florida Regulations 69L-3.0091 19

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§ Notice of Action/Change



(1) The carrier shall send to the Division, with copies to the employer, employee, legal counsel if represented, and dependents of the deceased employee and their legal counsel, LES Form DWC-4 within 14 days of the action or change which it is reporting.

(2) The carrier is not required to send LES Form DWC-4, Notice of Action/Change, if indemnity benefits have never been paid with respect to an industrial accident or injury.

(3) If a carrier initially denies a case and later rescinds its denial, the carrier shall complete and send LES Form DWC-4 in addition to LES Form DWC-12. The carrier shall report the "initial indemnity started effective date" on form DWC-4 as the date disability began. The carrier shall also state the indemnity disability type, the average weekly wage and the compensation rate.

(4) The carrier shall use the following codes to identify a particular disability type on LES Form DWC-4, where the carrier must indicate "initial indemnity started" or "indemnity reinstated after suspension":

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 additional 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 1/1/94.

(f) IB means impairment income benefits paid pursuant to s. 440.15(3)(a)3., F.S. (1994) for dates of accident on or after 1/1/94.

(g) WL means wage loss benefits for dates of accident prior to 1/1/94.

(h) SB means supplemental income benefits paid pursuant to s. 440.15(3)(b), F.S. (1994) for dates of accident on or after 1/1/94.

(i) PT means permanent total disability benefits.

(j) DB means death benefits.

(5) The carrier shall send LES Form DWC-4 when the carrier suspends payment of all indemnity benefits and does not intend to continue the benefits under another disability type. If the carrier suspends benefits for any of the reasons stated in paragraphs (a)-(h) below, the carrier shall send the Division LES Form DWC-4, and not LES Form DWC-12. The carrier must state the effective date of the suspension and the applicable suspension reason code. The following 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 carrier 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 s. 440.13(5)(d), F.S. (1994), or failed to report for an evaluation by an expert medical advisor appointed by a JCC pursuant to s. 440.13(9)(c), F.S. (1994).

(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. s. 440.15(1)(e)3., F.S. (1994).

2. s. 440.15(1)(f)2.b., F.S. (1994).

3. s. 440.15(2)(d), F.S. (1994).

4. s. 440.15(7), F.S. (1994).

5. s. 440.15(8), F.S. (1994).

6. s. 440.15(10), F.S. (1994).

(d) S4 means claimant death. The carrier has suspended all indemnity benefits because of the employee's death, whether or not the death is compensable. This code is used if there are no known or confirmed dependents to whom death benefits must be paid or because 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 claimant's whereabouts unknown. The carrier'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 carrier can send compensation checks; or compensation checks have been returned to the carrier indicating that the employee has moved, address unknown, or not 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 carrier determines the claim is compensable under the Federal Employer's Liability Act, the Longshoremen's and Harbor Workers'Compensation Act, or the Jones Act.

(6) The carrier shall send LES Form DWC-4 when it reinstates indemnity benefits after a suspension. It must state the effective date of the reinstatement and the disability type of disability benefits being reinstated.

(7) The carrier shall send LES Form DWC-4 when the employee has resumed work, or has been medically released to return to work. The date the employee resumed work is the employee's "actual return to work date." The date the employee's medical release states that the employee may resume work is the employee's "released to return to work date." The carrier must indicate whether the employee was given any physical restrictions.

(8) The carrier shall send LES Form DWC-4 when a final indemnity settlement has been approved pursuant to s. 440.20(11), F.S. It must state the date the final indemnity settlement was paid. The date the settlement was paid shall not be reported as earlier than the date the settlement was actually approved.

(9) The carrier shall send LES Form DWC-4 when the employee has reached overall maximum medical improvement or has been given a permanent impairment rating. It must state the date the employee reached overall maximum medical improvement and the percentage of permanent impairment on which it will calculate payment of wage loss benefits, permanent impairment benefits, or impairment income benefits.

(10) The carrier shall send LES Form DWC-4 to report the date of the employee's death, whether or not the death is considered compensable.

(11) The carrier shall send LES Form DWC-4 when it pays permanent impairment benefits for dates of injury that occurred prior to 1/1/94. It must state the date the permanent impairment benefits are paid.

(12) The carrier shall send LES Form DWC-4 when it begins payment of impairment income benefits for dates of injury on and after 1/1/94. It must state the date the impairment income benefits were started, the weekly rate at which the benefits will be paid, and the total number of weeks the employee is entitled to the benefits.

(13) The carrier shall send LES Form DWC-4 when it amends either the employee's average weekly wage or the compensation rate. It shall state the previous average weekly wage and previous compensation rate and the amended average weekly wage and amended compensation rate. It shall also indicate if the average weekly wage change was retroactive to the date of injury, and if not, the date on which the new average weekly wage was effective.

(14) The carrier shall send LES Form DWC-4 when the employee is accepted or adjudicated as permanently and totally disabled. It shall include the date on which the employee was accepted or adjudicated as permanently and totally disabled. It shall also send this form to report the rate at which permanent total supplemental benefits are being paid and the effective date of the permanent total supplemental payment rate, as well as to report annual changes in this rate. If the employee's permanent total supplemental benefits are suspended because the employee has reached age 62 and is eligible for Social Security benefits, the carrier will report $0 as the permanent total supplemental rate. The effective date is the date on which permanent total supplemental benefits will no longer be paid.

(15) The carrier shall send LES Form DWC-4 when it adjusts or offsets the employee's weekly compensation rate. It shall include the Benefit Adjustment Type code, the weekly amount by which the employee's payment is being reduced, and the date the offset or adjustment is effective. If the offset or adjustment is temporary, the carrier shall send LES Form DWC-4 when it resumes payment at the former rate to report the date the adjustment ends.

(a) If the carrier sends LES Form DWC-4 to report a change in the employee's weekly compensation rate due to a social security offset, it must send a completed LES Form DWC-14 when it submits LES Form 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 s. 440.39(2), F.S. (1994).

3. "C" means overpayment credit. The weekly benefit amount has been reduced for benefits paid but not owed, pursuant to s. 440.15(13), F.S. (1994).

4. "H" means child support or alimony reduction. The weekly benefit amount has been reduced for income deduction orders, pursuant to s. 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 s. 440.491(6)(b), F.S. or the employee has failed to timely cancel an independent medical examination pursuant to s. 440.13(5)(d), F.S. (1994).

6. "P" means advance recoupment. The weekly benefit amount has been reduced for reimbursement of benefit payments advanced pursuant to s. 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 s. 440.15(10), 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 s. 440.15(10), F.S.

9. "U" means unemployment compensation offset. The weekly benefit amount has been reduced for unemployment compensation benefits, pursuant to s. 440.15(11), F.S.

10."V" means safety violation offset. The weekly benefit amount has been reduced for safety violation(s) pursuant to s. 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 s. 440.16, F.S.

(16) The carrier shall send LES Form DWC-4, or the electronic equivalent, to report a correction in the employee's social security number, date of accident, name, or the carrier or servicing company handling the case. When reporting corrections to the employee's name, social security number, or date of accident, the carrier shall include the original (incorrect) information at the top of the form, and the corrected (new) information in the "corrections of" section. When reporting a change in the employer liable for compensation, the carrier of the employer which has become liable for compensation shall send this form, and additionally state the name and address of the employer now liable for compensation in the "remarks" section.

(17) The carrier may send LES Form DWC-4 to report or change information on risk class code, SIC code or Carrier/Servicing Company, or it may use other forms as provided in this chapter.

Specific Authority 440.591, 440.185, 440.20(3), F.S. Law Implemented 440.185, 440.20, F.S. History¬タヤNew 1-30-91, Amended 11-8-94.