Florida Regulations 69L-3.016

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§ 69L-3.016 Claim Cost Report

History:



(1) The claims-handling entity shall send Form DFS-F2-DWC-13, as adopted in Rule 69L- 3.025, F.A.C., to the Division for the following cases:

(a) Lost time cases as defined in subsection 69L- 3.002(19), F.A.C., which include lost time cases in which no indemnity benefits have been paid for compensable volunteers pursuant to Section 440.02(15), F.S., and compensable death cases with no dependents. (b) Lost time cases in which the employee has received full salary in lieu of compensation for 8 or more days of disability. (c) Cases in which the only indemnity benefits paid were for impairment income benefits, a lump sum settlement or a final settlement. (d) Denied cases in which indemnity benefits were paid.

(2) The claims-handling entity shall send Form DFS-F2-DWC-13, to the Division at the following times:

(a) Initial Claim Cost Report: The Form DFS-F2-DWC-13 shall reflect all cumulative claim costs paid within the first 6 months of the date of accident. This report shall be sent within 30 days after the 6-month anniversary of the date of accident. The initial claim cost report shall not be sent prior to the 6-month anniversary unless the case is closed. The claims-handling entity shall indicate the type of report as "Initial Report Summarizing First Six Months."

1. If the case status changed to lost time after the 6-month anniversary of the date of accident, the claims-handling entity shall submit Form DFS-F2-DWC-13, in accordance with paragraph 69L- 3.016(2)(b), F.A.C. The claims-handling entity shall indicate the type of report as "Initial Report Summarizing First Six Months" and "Annual Report On Open Case." 2. If the case is closed within 6 months of the date of accident, the claims-handling entity shall submit Form DFS-F2-DWC-13 and indicate the type of report as "Initial Report Summarizing First Six Months" and "Final Report - Case Closed - No Activity in Past Year or Case Settled."

(b) Annual Claim Cost Report: The Form DFS-F2-DWC-13 shall reflect all cumulative claim costs paid on the case since the date of accident. The Form DFS-F2-DWC-13 shall be sent to the Division within 30 days after each annual anniversary of the date of accident for all open cases. The claims-handling entity shall indicate the type of report, as an "Annual Report On Open Case." The annual DFS-F2-DWC-13 filing shall not occur prior to the anniversary date of the date of accident unless the case is closed. (c) Final Claim Cost Report:

1. The Form DFS-F2-DWC-13 shall reflect all cumulative claim costs paid on the case since the date of accident. The form shall be sent within 30 days after the annual anniversary of the date of accident for lost time cases closed since the last required filing of the Form DFS-F2-DWC-13. However, the claimshandling entity may send the Final Form DFS-F2-DWC-13 prior to the anniversary date if it has closed a case with respect to medical and indemnity benefits. The claims-handling entity shall indicate the type of report as a "Final Report-Case Closed - No Activity In Past Year Or Case Settled." 2. After filing a Final Claim Cost Report, if the claims-handling entity makes a subsequent payment for any category of benefits required to be reported on Form DFS-F2-DWC-13, the claims-handling entity shall send another Final Form DFS-F2- DWC-13 in accordance with subparagraph 69L- 3.016(2)(c)1., F.A.C.

(3) The claims-handling entity shall complete Form DFS-F2-DWC-13 for all lost time cases, and shall include the following information, where applicable:

(a) The type of report being sent. (b) The exact "Average Weekly Wage" and "Compensation Rate" as of the date the report is sent, in dollars and cents. (c) The "Full Salary End Date" for employees who receive full salary in lieu of compensation for any period after the date of accident. When the employer pays full salary in lieu of compensation through the time the form is sent, the claims-handling entity shall mark the "Full Salary In Lieu Of Compensation for Any Period Of Time" box "Yes" and leave the "Full Salary End Date" blank. (d) The number of "Weeks" and "Days" for which a particular indemnity benefit was paid, except for statutory permanent impairment and wage loss benefits for dates of accident prior to January 1, 1994. Indemnity benefits are payable only for entire days and not fractions thereof. (e) The exact cumulative total amount, in dollars and cents, of all benefits paid up to the date the form is sent, including amounts reported on previous Forms DFS-F2-DWC-13 in the "Total (Paid To Date Columns I & II)" field. (f) The cumulative total of any recoveries the claims-handling entity has obtained up to the filing of the form, except for recovery of overpayments. Totals entered as "paid to date" in Columns I and II are not reduced for recoveries, except for recovery of overpayment. Recovery of a deductible amount chargeable to an employer is reported in "All Other Recoveries Except Overpayments." (g) The amount of money for indemnity and medical benefits settled and paid in a lump sum, or the amount paid to an employee as a lump sum settlement for medical benefits only, and the date payment mailed is to be reported in the "Date Payment Mailed" field for either settlement type as applicable. This latter settlement amount shall be reported only for lost time cases on Form DFS-F2-DWC-13 as "Medical Settlement Amt." For multiple settlements, the cumulative amount of the settlements and the latest date payment mailed shall be reported. (h) In the event that claims are transferred from one claims-handling entity to another, the insurer shall provide cumulative totals by specific claim cost type for all applicable data elements on Form DFS-F2-DWC-13 on each transferred case to the acquiring claims-handling entity. All subsequent reporting on Form DFS-F2-DWC-13 shall include all historical data.

Specific Authority 440.185, 440.591 FS. Law Implemented 440.185, 440.51(6) FS. History-New 10-30-79, Amended 11-5-81, Formerly 38F-3.16, Amended 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.016, 4L- 3.016, Amended 1-10-05.