Florida Regulations 69L-56.300

From Wcc
Jump to: navigation, search

Florida > Regulations

§ 69L-56.300 Claims EDI Reporting Requirements and Implementation Schedules.

(1) (a) On or before the implementation schedules set out in paragraphs (3)(a) and (b) of this section, every insurer shall file claims information for all "Lost Time/Indemnity," "Medical Only to Lost Time," and "Denied" cases via electronic data interchange (EDI) pursuant to paragraph (d) of this section, rather than by submitting paper forms otherwise required in Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.016, 69L-3.0213 and 69L-3.025, F.A.C. The insurer shall file the electronic form equivalent of the First Report of Injury or Illness, Notice of Denial, Claim Cost Report, Notice of Action/Change, and Aggregate Claims Administration Change Report adopted in Rule 69L-3.025, F.A.C., pursuant to the requirements and timeframes set out in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304 and 69L-56.3045, F.A.C., and in accordance with the "FL Claims EDI R3 Trading Partner Filing Specifications" contained in Section 1 of the "Florida Division of Workers' Compensation Claims Electronic Data Interchange (EDI) R3 Implementation Manual, September 2006" and "Supplement," incorporated herein by reference, and hereafter referred to as the "FL Claims EDI Implementation Manual." A copy of the FL Claims EDI Implementation Manual may be obtained from the Division of Workers' Compensation at its website, www.fldfs.com/WC/edi_clms.html.

(b) The insurer or its claim administrator shall electronically report all First Reports of Injury or Illness for which the claim administrator�s knowledge of the injury is on or after the date the claim administrator is authorized by the Division to send Electronic First Reports of Injury or Illness in production status (i.e., actual production implementation date). All other electronic form equivalents for denials, periodic claim cost information, changes, suspensions, reinstatements, and cancellations required by this rule shall be electronically reported to the Division, regardless of date of injury, once the claim administrator is approved by the Division to send these electronic filings in production status (i.e., actual production implementation date).

(c) Electronic form equivalents, hereafter also referred to as "Claims EDI Filings" required under this rule do not correspond exactly to, and may require additional information not currently contained on claims forms promulgated under Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.016, 69L-3.0213 and 69L-3.025, F.A.C. The term, "insurer," as defined in this rule chapter, refers to the entity responsible for filing electronic form equivalents on or before the compliance dates established in the insurer�s Primary and Secondary Implementation Schedules set out in paragraphs 69L-56.300(3)(a) and (b), F.A.C. The term, "claim administrator," as defined in this rule chapter, refers to the trading partner that is sending electronic transactions to the Division, which can be either an insurer filing directly with the Division on its own behalf, or a servicing company/third party administrator filing on the behalf of the insurer. For purposes of this rule, the terms "Claim Administrator" and "Trading Partner" do not mean a third party vendor.

(d) The claim administrator shall report the Claims EDI filings required in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304, 69L-56.3045 and 69L-56.307, F.A.C., using the First Report of Injury (FROI) and Subsequent Report of Injury (SROI) electronic record layouts adopted by the International Association of Industrial Accident Boards and Commissions (IAIABC). A sample of the FROI, which consists of the 148 and companion R21 records, and a sample of the SROI, which consists of the A49 and companion R22 records, are located in Section 2, "Technical Documentation" of the "IAIABC EDI Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, June 1, 2006 Edition" and "Supplement," incorporated herein by reference, and hereafter referred to as the IAIABC Claims EDI Release 3 Implementation Guide. A copy of this guide may be obtained from the IAIABC at its website, http://www.iaiabc.org/edi/implementation.asp.

1. The claim administrator shall send the FROI (148/R21), SROI (A49/R22), and combination FROI and SROI records with the Maintenance Type Code (MTC) or MTC combinations specified in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304, 69L-56.3045 and 69L-56.307, F.A.C., to represent the Claims EDI Filing being sent to the Division (Example: FROI MTC 04 = Total Denial of an Electronic First Report of Injury or Illness; SROI MTC FN = Electronic Final Claim Cost Report; FROI MTC 00 with SROI MTC IP = Electronic First Report of Injury or Illness where the Initial Payment is made by claim administrator.)

(e) In addition to the Technical Documentation and Business/Technical Process Rules located in Sections 2 and 4, respectively, of the IAIABC Claims EDI Release 3 Implementation Guide, the claim administrator shall comply with information contained in the below documents located in the Claims EDI Trading Partner Filing Specifications of the FL Claims EDI Implementation Manual:

1. "FL Claims EDI R3 Event Table" - Identifies the FROI MTC or SROI MTC, and FROI/SROI MTC combinations required to be sent for an electronic form equivalent required by this rule, and the associated filing time periods by which the FROI and SROI MTC�s shall be received by the Division in order to be considered timely filed;

2. "FL Claims EDI R3 Element Requirement Table" - Specifies the data elements required to be sent for each FROI and SROI MTC; and

3. "FL Claims EDI R3 Edit Matrix" - Identifies Division editing that will be applied to data elements and transactions, including transaction sequencing and duplicate processing rules.

(f) The claim administrator shall collect and report all data elements designated with the following codes on the FL Claims EDI R3 Element Requirement Table: "F" (Fatal Technical) - Required to be reported; "M" (Mandatory) - Required to be reported; "MC" (Mandatory/Conditional) - Required to be reported if the condition(s) set out in the table�s FROI or SROI Conditional Requirements or Event Benefits Conditions worksheets are met; "IA" (If Applicable/Available) - Required to be reported if the data element is applicable to the claim (e.g., If the claim administrator has knowledge that the employee�s Last Name Suffix is "Jr", the claim administrator shall report the Last Name Suffix of "Jr").

(g) Claims EDI filings that comply with data element reporting requirements and pass edits specified in the "FL Claims EDI R3 Element Requirement Table" and the "FL Claims EDI R3 Edit Matrix" shall be accepted and acknowledged by the Division with Application Acknowledgement Code "TA" (Transaction Accepted). Claims EDI filings that receive an Application Acknowledgement Code of "TA" shall be assigned a "Received by Division Date" for purposes of determining whether an EDI filing was timely filed with the Division in accordance with the timeframes identified in the "FL Claims EDI R3 Event Table" and as required in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304, 69L-56.3045 and 69L-56.307, F.A.C. The date assigned as the "Received by Division Date" is the date the transmission containing the accepted Claims EDI filing was sent to and received by the Division based on the technical transmission requirements set out in subsection 69L-56.310(4), F.A.C. An electronic First Report of Injury or Illness that receives an Application Acknowledgement Code of "TA" shall also be assigned a "Jurisdiction Claim Number" by the Division which the claim administrator shall report on every subsequent Claims EDI filing for that claim. Electronic transactions that do not satisfy data element requirements and edits specified in the "FL Claims EDI R3 Element Requirement Table" and the "FL Claims EDI R3 Edit Matrix" shall be rejected and acknowledged by the Division with Application Acknowledgement Code "TR" (Transaction Rejected). The claim administrator shall correct the error(s) identified in the acknowledgement returned by the Division and re-send the Claims EDI filing to the Division as appropriate (e.g., a transaction receiving fatal error # 0002-057 because it was an extra MTC in the transmission or already on file with the Division is not expected to be re-filed with the Division.)

(h) The claim administrator shall receive and process each acknowledgement transaction (AKC) returned by the Division. The Division will also send, when applicable, a re-acknowledgment transaction (ACR) to identify a Claims EDI filing that was previously acknowledged with Application Acknowledgement code "TR" due to improper processing by the Division, and which was subsequently re-processed and re-assigned an Application Acknowledgement Code of "TA." The claim administrator has the option to either process or not process reacknowledgement transactions sent by the Division.

(i) Claims EDI filings acknowledged with Application Acknowledgement Code "TA" (Transaction Accepted) that invoke one or more non-rejectable (non-fatal) edits depicted as "FL" in the "DN-Error Message Table" of the FL Claims EDI R3 Edits Matrix, shall result in an error message that will be communicated by the Division to the claim administrator in a proprietary report, separate from the acknowledgement transaction (AKC). Nonfatal error reports will be posted to the Division�s website in a password-protected file, which the claim administrator shall retrieve via the "Claims EDI" link on the Division�s web site. The Division will send an email notification to the claim administrator regarding the posting of all non-fatal error reports that require a response from the claim administrator. The claim administrator shall respond to the Division on or before 21 days after the date the report was posted to the Division�s web site. The email notification will be sent to the "EDI Business Contact(s)" identified in the claim administrator�s "EDI Trading Partner Profile," Form DFS-F5-DWC-EDI-1. The claim administrator shall notify the Division regarding any additions or deletions of "EDI Business Contacts" for this purpose. The claim administrator shall respond to all other inquiries from the Division, including by telephone, concerning written or electronic requests for information, on or before 21 days after the claim administrator�s receipt of the request from the Division.

(j) Unless an explanatory letter is alternatively permitted by this rule chapter, paper copies of Forms DFS-F2-DWC-1, DFS-F2-DWC-4 and DFS-F2-DWC-12 shall continue to be provided by the claim administrator to the employee and employer as required by Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.025, F.A.C., and as specified in Rules 69L-56.301, 69L-56.3012, 69L-56.304 and 69L-56.3045, F.A.C., and the FL Claims EDI R3 Event Table ("Paper Form" and "Receiver" columns).

(k) The claim administrator shall produce and mail to the employee and employer the informational brochures required in Rules 69L-3.0035 and 69L-3.0036, F.A.C.

(l) Claim administrators who, directly or through its third party vendor, experience a catastrophic event resulting in the insurer�s failure to meet the filing requirements of this rule, shall submit a written or electronic request to the Division for approval to submit required electronic form equivalents in an alternative filing timeline. The request shall be sent to the Division within 15 business days after the catastrophic event. The request shall contain a detailed explanation of the nature of the event, date of occurrence, and measures being taken to resume electronic submission. The claim administrator shall also provide an estimated date by which electronic submission of affected EDI filings will be resumed. Approval to submit in an alternative filing timeline shall be granted by the Division if a catastrophic event prevents electronic submission. The approval must be obtained from the Division�s Office of Data Quality and Collection, 200 E. Gaines Street, Tallahassee, Florida 32399-4226, or via email at claims.edi@fldfs.com. If approved, the electronic form equivalents that were due to be filed during the time the claim administrator was unable to file due to a catastrophic event, shall be sent with Late Reason Code "LB" (Late notification/payment due to a Natural Disaster) or "LC" (Late notification/payment due to an act of Terrorism).

(m) Non-compliance by the claim administrator with the electronic reporting requirements in this Rule shall result in referral to the Division�s Bureau of Monitoring and Audit, and may constitute a violation of Section 440.525, F.S.

(2) Trading Partner Profile Documents:

(a) At least two (2) business days prior to sending its first test transmission to the Division, the claim administrator shall send to the Division in an email addressed to claims.edi@fldfs.com, the claim administrator�s current profile information using the following forms adopted in Rule 69L-56.001, F.A.C.:

1. "EDI Trading Partner Profile," DFS-F5-DWC-EDI-1 (10/01/2006), and

2. "EDI Trading Partner Insurer/Claim Administrator ID List," DFS-F5-DWC-EDI-2 (10/01/2006), and

3. "EDI Trading Partner Claim Administrator Address List," DFS-F5-DWC-EDI-2A (10/01/2006), and

4. "EDI Transmission Profile - Sender�s Specifications, DFS-F5-DWC-EDI-3 (10/01/2006).

Claim administrators filing Electronic First Reports of Injury or Illness or Electronic Claim Cost Reports on a voluntary basis using the IAIABC Release 1 standard formats shall re-file their profile information with the Division using the forms in subparagraphs (2)(a)1.-4. above, even if the claim administrator�s profile information has not changed since previously reported to the Division.

(b) The claim administrator shall report changes to its profile information required on the forms listed in subparagraphs (2)(a)1.-4. above, at least two (2) business days prior to sending transactions containing revised profile-related information to the Division. The insurer or its claim administrator shall report revisions to its profile information by emailing to the Division at claims.edi@fldfs.com, a revised "EDI Trading Partner Profile," DFS-F5 DWC-EDI-1 (10/02/2006), and if applicable, a revised "EDI Trading Partner Insurer/Claim Administrator ID List", DFS-F5-DWC-EDI-2 (10/01/2006), and if applicable, a revised "EDI Trading Partner Claim Administrator Address List", DFS-F5-DWC-EDI-2A (10/01/2006), and if applicable, a revised "EDI Transmission Profile - Sender�s Specifications", DFS-F5-DWC-EDI-3 (10/01/2006). Failure by the claim administrator to report changes to its trading partner profile information using the forms adopted in this rule, including changes to the Submitter ID (i.e., Trading Partner FEIN/Postal Code on the Header Record), may result in the rejection of an entire transmission or individual transaction(s) containing profile information that is different from that reported on profile documents previously filed with the Division by the claim administrator.

(c) If the insurer or its claim administrator contracts with a new third party vendor, the insurer or its claim administrator shall, at least two (2) business days prior to the effective date of the change in vendors, send an email to the Division at claims.edi@fldfs.com to report the name of the new vendor and effective date on which Claims EDI transactions will be sent via the new vendor.

(3) Claims EDI Implementation Schedules:

(a) Primary Implementation Schedule: The insurer shall comply with the following implementation schedule for reporting Electronic First Reports of Injury or Illness specified in Rule 69L-56.301, F.A.C., Electronic Notices of Denial and Rescinded Denial specified in Rule 69L-56.3012, F.A.C., Electronic Periodic Claim Cost Reports specified in Rule 69L-56.3013, F.A.C., Electronic Notices of Actions or Changes, including Changes in Claims Administration specified in Rule 69L-56.304, F.A.C., and Electronic Cancellations Specified in Rule ~69L- 56.307~, F.A.C. The insurer�s Primary Implementation Schedule shall consist of three "test to production" periods as described in subparagraphs (3)(a)1.-3., of this subsection. Each insurer shall be assigned to either the first, second, or third "test to production" period based on the insurer�s Division-assigned Insurer Code #. If there are multiple or subsidiary insurer entities within an insurer�s corporate structure or organization, the insurer�s "test to production" per iod in the Primary Implementation Schedule will be based on the lowest numeric value assigned to any of the insurer�s subsidiary companies. Insurers that write large deductible policies for insureds adjusting their own claims are responsible for ensuring those insureds meet the insurer�s required "test to production" timelines and implementation schedules, even if the insured is not using the insurer�s computer system to file its Claims EDI Filings with the Division. Claim administrators voluntarily submitting Claims EDI Filings in production status using the IAIABC Release 1 national standard shall convert to Release 3 and be in production status by the same date as that required for the first group of insurers specified in subparagraph (3)(a)1. below, regardless of Insurer Code #. Each "test to production period" shall consist of three calendar months. The insurer�s compliance date for the Primary Implementation Schedule shall be the last day of the third month of the insurer�s assigned "test to production" period.

1. The first "test to production" period shall commence November 1, 2007, and shall include insurers with Division-assigned Insurer Code #�s 102 through # 199. The compliance date for the Insurer�s Primary Implementation Schedule shall be January 31, 2008.

2. The second "test to production" period shall commence February 1, 2008, and shall include insurers with Division-assigned Insurer Code #�s 200 through 599. The compliance date for the insurer�s Primary Implementation Schedule shall be April 30, 2008.

3. The third "test to production" period shall commence May 1, 2008 and shall include insurers with Division-assigned Insurer Code #�s 600 through 1122, future Insurer Code #�s 1123 through 4999 and 8000 through #9999. The compliance date for the insurer�s Primary Implementation Schedule shall be July 31, 2008.

(b) Secondary Implementation Schedule: The insurer shall comply with the Secondary Implementation Schedule for reporting the additional Electronic Notices of Action or Change, Suspensions, and Reinstatement of indemnity benefits specified in Rule 69L-56.3045, F.A.C., as follows:

1. No later than 9 months after the compliance date established in the insurer�s Primary Implementation Schedule, the insurer shall commence testing its Electronic Notice of Action or Change, Suspension, and Reinstatement of Indemnity benefits required in Rule 69L-56.3045, F.A.C. The insurer shall be in production status within three months after the commencement of testing, i.e., within one year after the compliance date established in the insurer�s Primary Implementation Schedule.

(c) Beginning August 1, 2007, a claim administrator may voluntarily commence testing any electronic form equivalent/MTC with the Division using the IAIABC EDI Release 3 standard for Claims, contingent upon the availability of Division resources.

(d) After a claim administrator has been approved for production status for filing electronic form equivalents required in the Primary Implementation Schedule or Secondary Implementation Schedule, if the claim administrator is unable to receive an Application Acknowledgement Code of "TA" from the Division for an electronic form equivalent required by this Rule Chapter, the claim administrator may alternatively file the formerly required DWC form adopted in Rule 69L-3.025, F.A.C., for a period not to exceed three months after each of the claim administrator�s production implementation dates for the Primary and Secondary Implementation Schedules.

(e) After the conclusion of the three month time period specified in paragraph 69L-56.300(3)(d), F.A.C., above, if the claim administrator is unable to receive an Application Acknowledgement Code of "TA" from the Division for an electronic form equivalent required by this rule chapter, and the claim administrator needs to meet the reporting requirements of this rule, the claim administrator shall submit an e-mail to the Division at claims.edi@fldfs.com to request approval to alternatively file a DWC form pursuant to Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.016, 69L-3.0213 and 69L-3.025, F.A.C., in lieu of the electronic form equivalent. The request shall include the following information: Claim Administrator Name and FEIN, Employee Name, Employee ID Number (Social Security Number or Division Assigned Number), Date of Injury, Claim Administrator File Number, Maintenance Type Code (MTC), Date Transmission Sent for the MTC(s) attempted unsuccessfully, the DWC form requesting to be filed (i.e., DWC-13), and an explanation of the reasons electronic submission failed. If the Division approves the claim administrator's request to send a DWC form in lieu of the electronic form equivalent, all subsequent filings due for the claim shall be sent via EDI; the claim administrator shall not file additional DWC forms for the claim unless the claim administrator has received advance approval from the Division.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History-New 1-7-07.