Florida Regulations 69L-56.002

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§ 69L-56.002 Definitions.

History:



Unless otherwise defined in this section, definitions of data elements and terms used in this rule are defined in the Data Dictionary located in Section 6 of the "IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, June 1, 2006 Edition", and in the Data Dictionary located in Section 6 of the "IAIABC Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 10/01/06 Edition", and in the IAIABC "Glossary", and in the IAIABC "Supplement" for both IAIABC products, all of which are incorporated herein by reference. Copies of the IAIABC guides, supplements, and glossary may be obtained from the IAIABC's website at, http://www.iaiabc.org/edi/implementation.asp.

When used in this chapter, the following terms have the following meanings:

(1) "Acknowledge" or "acknowledgement" means a response provided by the Division to communicate the acceptance or rejection of an electronic transaction sent to the Division. An acknowledgement returned by the Division will reflect the assignment of an Application Acknowledgment Code of "TA" (Transaction Accepted) if the transaction was accepted by the Division, or "TR" (Transaction Rejected) if the transaction was rejected by the Division. If a transaction was assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) the date the transaction was received by the Division will be used in determining whether an electronic form was timely filed with the Division.

(2) "Award/Order Date" means the date an award, stipulated agreement, advance, lump sum settlement order, or order approving attorney fees for a lump sum settlement was signed by a Judge of Compensation Claims.

(3) "Average Wage" means the employee's average weekly wage as determined in Section 440.14, FS.

(4) "Batch" means a set of records containing one header record, one or more detailed transactions, and one trailer record.

(5) "Became Medical Only Case" means a work-related injury or illness that was initially reported to the Division in error as a "Lost Time/Indemnity Case" or "Medical Only to Lost Time Case" and subsequently determined to be a "Medical Only Case" where FROI MTC 01 is being filed to cancel the claim. A "Became Medical Only Case" is represented by Claim Type Code "B" (Became Medical Only) and is only allowed for FROI MTC 01 (Cancel) filings.

(6) "Benefit Payment Issue Date" reported for MTC "IP" (Initial Payment), "AP" (Acquired Payment), "PY" (Payment), and "RB" (Reinstatement of Benefits) means the date payment of a specific indemnity benefit corresponding to the MTC being reported left the control of the claim administrator (or the claim administrator's legal representative if delivery is made by the legal representative) for delivery to the employee or the employee's representative, whether by U.S. Postal Service or other delivery service, hand delivery, or transfer of electronic funds. "Benefit Payment Issue Date" for MTC "S1-8" (Suspension reasons) means the date the last indemnity check prior to the suspension of benefits left the control of the claim administrator (or the claim administrator's legal representative if delivery is made by the legal representative) for the delivery to the employee or the employee's representative, whether by U.S. Postal Service or other delivery service, hand delivery, or transfer of electronic funds. The Benefit Payment Issue Date shall not be sent as the date the check is requested, created, or issued in the claim administrator's system unless the check leaves the control of the claim administrator the same day it is requested, created, or issued for delivery to the employee or the employee's representative.

(7) "Business day" means a day on which normal business is conducted by the State of Florida and excludes observed holidays as set out in Section 110.117(1), F.S. (see also http://www.myflorida.com/myflorida/government/policies/holidays.html).

(8) "Calculated Weekly Compensation Amount" means 66 2/3 % of the employee's average weekly wage pursuant to Section 440.14, F.S., subject to the minimum and maximum amounts set out in Section 440.12, F.S., (a/k/a, the statutory compensation rate).

(9) "Catastrophic Event" means the occurrence of an event outside the control of an insurer, claim administrator, or third party vendor, such as a telecommunications failure due to a natural disaster or act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent an insurer, claim administrator, or third party vendor from meeting the filing requirements of Chapter 440, FS., and this rule. Programming errors, systems malfunctions, or electronic data interchange failures that are not the direct result of a catastrophic event are not considered to be a catastrophic event as defined in this rule.

(10) "Claim Administrator" means any insurer, service company/third party administrator, self-serviced selfinsured employer or fund, or managing general agent, responsible for adjusting workers' compensation claims, that is electronically sending its data directly to the Division.

(11) "Claim Administrator Primary Address", "Claim Administrator Secondary Address", "Claim Administrator City", "Claim Administrator State Code", and "Claim Administrator Postal Code" comprise the address associated with the physical location of the claims office at which a workers' compensation claim is being adjusted.

(12) "Claim Administrator Alternate Postal Code" means the zip code associated with the Claim Administrator's mailing address established for receiving mail on behalf of the claims office at which a workers' compensation claim is being adjusted.

(13) "Claim Type Code" means a code representing the current classification of the claim as either a "Lost Time/Indemnity Case" (Claim Type Code "I"), "Medical Only to Lost Time Case" (Claim Type Code "L"), "Became Medical Only Case" (Claim Type Code "B") or "Medical Only Case" (Claim Type Code "M").

(14) "Date of Maximum Medical Improvement" (MMI) means the date on which maximum medical improvement has been achieved with respect to all compensable medical or psychiatric conditions caused by a compensable injury or disease (i.e., overall MMI).

(15) "Date Claim Administrator Had Knowledge of Lost Time" means the date the claim administrator was notified or became aware that the employee was disabled for eight (8) or more days and was entitled to indemnity benefits. If the claim administrator acquires a claim from another claim administrator and is filing the Electronic First Report of Injury or Illness with the Division, the "Date Claim Administrator Had Knowledge of Lost Time" shall be the date the acquiring claim administrator had knowledge of the employee's 8th day of disability.

(16) "Days" means calendar days, unless otherwise noted.

(17) "Denied Case" means a "Full Denial" or "Partial Denial" case for which all indemnity benefits are initially denied by the claim administrator.

(18) "Department" means the Department of Financial Services.

(19) "Division" means the Division of Workers' Compensation.

(20) "Electronic Data Interchange" (EDI) means a computer-to-computer exchange of business transactions in a standardized electronic format.

(21) "Electronic Form Equivalent" means information sent in Division-approved electronic formats as specified in this rule, instead of otherwise required paper documents. Electronic form equivalents may require additional information not required in Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.016, 69L-3.0213, 69L-3.025, F.A.C., for paper form filings. Electronic form equivalents do not include information sent by facsimile, file data attached to electronic mail, or computer-generated paper forms.

(22) "Employer Paid Salary in Lieu of Compensation" means the employer paid the employee salary, wages, or other remuneration for a period of disability for which the insurer would have otherwise been obligated to pay indemnity benefits. This does not include the waiting week if the employee was not disabled for 22 or more days.

(23) "File" or "Filed" means a transaction has been received by the Division and passes quality and structural edits and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted).

(24) "FROI" means the First Report of Injury Record Layout adopted by the IAIABC as a Claims EDI Release 3 standard, and is comprised of the First Report of Injury Record identified by Transaction Set ID "148" paired with the First Report of Injury Companion Record identified by Transaction Set ID "R21". The "FROI" record layout (148/R21) is located in the Technical Documentation, Section 2, in the IAIABC EDI Implementation Guide for First, Subsequent, Acknowledgement Detail, Header, & Trailer Records, Release 3, June 1, 2006, which is incorporated herein by reference. A copy of the guide may be obtained from the IAIABC's website at http://iaiabc.org/edi/implementation.asp.

(25) "Full Denial" means any case for which the claim administrator has denied liability for all workers' compensation benefits (i.e., both indemnity and medical benefits). A "Full Denial" is represented by a FROI or SROI MTC 04 (Denial).

(26) "Gross Weekly Amount" means the weekly amount payable for a specific Benefit Type and excludes the application of any Benefit Adjustments or Benefit Credits. The Gross Weekly Amount is usually equal to the Calculated Weekly Compensation Amount (a/k/a/ statutory compensation rate) except when the weekly rate for a Benefit Type is paid as a percentage of either the Calculated Weekly Compensation Amount (Comp Rate), Average Wage, or average temporary total disability benefits, such as for Permanent Total Supplemental Benefits, Death Benefits, and Impairment Income Benefits.

(27) "Header Record" means the first record of a batch. The header record shall uniquely identify a sender, as well as the date and time a batch is prepared, and the transaction set within the batch.

(28) "IAIABC" means the International Association of Industrial Accident Boards and Commissions (www.iaiabc.org), which is a professional trade association comprised of state workers' compensation regulators and insurance representatives.

(29) "Industry Code" means the 5 or 6-digit code that represents the nature of the employer's business as published in the North American Industry Classification System (NAICS) 2002 Edition, hereby incorporated by reference. NAICS code information may be obtained by contacting the NAICS Association, 341 East James Circle, Sandy, Utah, 84070, or from the NAICS website at www.naics.com.

(30) "Initial Date of Lost Time" means the employee's eighth (8th) day of disability, i.e., the first day on which the employee sustains disability as defined in Section 440.02, FS., after fulfilling the seven (7) day waiting week requirement in Section 440.12, FS. The Initial Date of Lost Time does not mean the "Initial Date Disability Began".

(31) "Initial Disposition" means the first action taken by the claim administrator following its knowledge of an injury to accept or deny compensability of the claim and pay or deny benefits, including payment or denial of both indemnity and medical benefits, or denial of indemnity benefits only.

(32) "Insurer" means an insurer as defined in Section 440.02, FS.

(33) "Insurer Code #" means the Division-assigned number for the insurer bearing the financial risk of the claim.

(34) "Jurisdiction Designee Received Date" means the date on which a third party vendor received Proof of Coverage data from an insurer that is not submitting their electronic Proof of Coverage data directly with the Division. This date shall be used in place of the date the Division received electronic Proof of Coverage data for purposes of calculating the effective date of the cancellation or non-renewal, and timely filings of electronic Proof of Coverage data.

(35) "Knowledge" or "Notification" means an entity's earliest receipt of information, including by mail, telephone, facsimile, direct personal contact, or electronic submission.

(36) "Lost Time/Indemnity Case" means a work-related injury or illness which causes the employee to be disabled for more than 7 calendar days, or for which indemnity benefits have been paid. A Lost Time/Indemnity Case shall also include: A case involving a compensable volunteer as defined in Section 440.02, FS., where no indemnity benefits will be paid, but where the employee is disabled for more than 7 calendar days; a compensable death case pursuant to Section 440.16, FS., for which there are no known or confirmed dependents; a case where a compensable injury results in disability of more than 7 calendar days where the "Employer Paid Salary in Lieu of Compensation" as defined in this section; a case for which indemnity benefits were paid prior to the date the claim administrator learned of a change in jurisdiction and filed SROI MTC S8 (Suspension, Jurisdiction Change); and a case where indemnity benefits were paid but subsequently suspended because the employee could not be located and the claim administrator filed SROI MTC S6 (Suspension, Claimant's Whereabouts Unknown). The first 7 calendar days of disability do not have to occur consecutively, but are determined on a cumulative basis and can occur over a period of time. A "Lost Time/Indemnity Case" is represented by Claim Type Code "I" (Indemnity).

(37) "Maintenance Type Code" (MTC) defines the specific purpose of individual claims transactions within the batch being sent, i.e., a code that represents the type of filing being sent electronically (For example: MTC IP = initial payment, MTC 04 = Total or Full Denial). MTC's and data elements required by this rule may not exactly match paper claim forms and associated data reporting requirements set out in Rule Chapter 69L- 3, F.A.C.

(38) "Manual Classification Code" means the 4-digit code assigned by the National Council on Compensation Insurance (NCCI) for the particular occupation of the injured employee as documented in the NCCI Scopes&trade Manual 2006 Edition, which is hereby incorporated by reference. A listing of Manual Classification Codes may be obtained by contacting NCCI's Customer Service Center at 1(800)622-4123.

(39) "Medical Only Case" means a work-related injury or illness which requires medical treatment for which charges will be incurred, but which does not cause the employee to be disabled for more than 7 calendar days. A "Medical Only Case" is represented by Claim Type "M" (Medical Only) and is limited to being reported on MTC 04 and PD filings where the claim was initially accepted as a Medical Only Case prior to the denial of indemnity benefits.

(40) "Medical Only to Lost Time Case" means a work-related injury or illness which initially does not result in disability of more than 7 calendar days, but later results in disability of more than 7 days, where disability is either delayed and does not immediately follow the accident, or where one or more broken periods of disability occur within the first 7 days after disability has commenced and the combined disability periods eventually total more than 7 days. A "Medical Only to Lost Time Case" includes a case for which Impairment Income Benefits are the first and only indemnity benefits paid, or for which the initial payment of indemnity benefits is made in a lump sum for an award, advance, stipulated agreement or settlement. A "Medical Only to Lost Time Case" is represented by Claim Type Code "L" (Became Lost Time/Indemnity).

(41) "Net Weekly Amount" means the weekly amount paid for an indemnity benefit such as temporary total benefits, impairment income benefits, etc., inclusive of any Benefit Adjustments or Benefit Credits being applied to the benefit type. The Net Weekly Amount equals the "Gross Weekly Amount" where no adjustments or credits are applied.

(42) "Partial Denial" means a case where compensability is accepted but the claim administrator initially denies all indemnity benefits and only medical benefits will be paid; Partial Denial also means a case where a specific indemnity benefit(s) was previously paid but subsequently denied, either in whole or in part. A "Partial Denial" is represented by a SROI MTC "PD".

(43) "Payment Issue Date" for MTC "IP"(Initial Payment), and "PY" (Payment) means the date payment of a specific indemnity benefit corresponding to the MTC being reported left the control of the claim administrator (or the claim administrator's legal representative if delivery is made by the legal representative) for delivery to the employee or the employee's representative, whether by U.S. Postal Service or other delivery service, hand delivery, or transfer of electronic funds. The Payment Issue Date shall not be sent as the date the check is requested, created, or issued in the claim administrator's system unless the check leaves the control of the claim administrator the same day it is requested, created, or issued for delivery to the employee or the employee's representative.

(44) "Permanent Impairment Percentage" means "Permanent Impairment" as defined in Section 440.02, FS.

(45) "Sender" means one of the following entities sending electronic filings to the Division:

(a) Claim Administrator,

(b) Insurer, or

(c) Third Party Vendor (Proof of Coverage only).

For Claims EDI filing purposes, "sender" does not include an entity acting as an intermediary for sending transmissions to the Division on behalf of an insurer or claim administrator where the sender is not the insurer or claim administrator handling the claim.

(46) "SROI" means the Subsequent Report of Injury Record Layout adopted by the IAIABC as a Claims EDI Release 3 standard, and includes the Subsequent Report Record identified by Transaction Set "A49" paired with the Subsequent Report Companion Record identified with Transaction Set ID "R22". The "SROI" record layout (A49/R22) is located in the Technical Documentation, Section 2, in the IAIABC EDI Implementation Guide for First, Subsequent, Acknowledgement Detail, Header, & Trailer Records, Release 3, June 1, and Supplement, which is incorporated herein by reference. A copy of the guide may be obtained from the IAIABC's website at http://iaiabc.org/edi/implementation.asp.

(47) "Third Party Vendor" means an entity acting as a submission agent or vendor on behalf of an insurer, service company or third party administrator, which has been authorized to electronically send required data to the Division.

(48) "Trading Partner" means an entity approved by the Division in accordance with Rules 69L-56.110, 69L-56.310 and 69L-56.320, F.A.C., to exchange data electronically with the Division.

(49) "Trailer Record" means the last record that designates the end of a batch of transactions. It shall provide a count of transactions contained within the batch, not including the header and trailer transactions.

(50) "Transaction" is one or more records within a batch which communicates information representing an electronic form equivalent.

(51) "Transaction Accepted Code TA" means an Application Acknowledgement Code returned by the Division on the acknowledgement transaction to represent that a transaction was received by the Division and passed required edits.

(52) "Transaction Rejected Code TR" means an Application Acknowledgement Code returned by the Division on the acknowledgement transaction to represent that a transaction was received by the Division and did not pass required edits.

(53) "Transmission" consists of one or more batches sent to or received by the Division or a trading partner.

(54) "Triplicate Code" is a series of three two-digit numeric codes that define the specific purpose of individual records in a Proof of Coverage transmission, i.e., new policy, renewal, endorsement, cancellation or non-renewal. It is a combination of the Transaction Set Purpose Code, Transaction Set Type Code and Transaction Set Reason Code as defined in the Data Dictionary, Section 6 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 10/01/06 Edition, which is incorporated herein by reference. A copy of the guide may be found at http://iaiabc.org/edi/implementation.asp.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History-New 3-5-02, Formerly 38F-56.002, 4L-56.002, Amended 5-29-05, 1-7-07.