1 Florida Division of Workers’ Compensation Claims EDI Basic Overview 2013.

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Florida Division of Workers’ Florida Division of Workers’ Compensation Compensation

Claims EDI Claims EDI Basic Basic

Overview Overview 2013 2013

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Presenter:Presenter:

Tonya GrangerTonya Granger Administrator, Claims & POC Administrator, Claims & POC

EDI TeamEDI Team

Bureau of Data Quality and Bureau of Data Quality and CollectionCollection

FL Division of Workers’ FL Division of Workers’ CompensationCompensation

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This training includes:This training includes:

Overview of EDI Overview of EDI terminology and terminology and Administrative Rule 69L-56, Administrative Rule 69L-56, F.A.C.F.A.C. How to investigate errors How to investigate errors and utilize and utilize EDI resources EDI resources (e.g., Edit Matrix, (e.g., Edit Matrix, Element Element Req. Table.) to understand Req. Table.) to understand errors and make necessary errors and make necessary corrections.corrections. Review of various EDI Review of various EDI scenarios. scenarios.

Rule Chapter 69L-Rule Chapter 69L-5656 of the of the

Florida Florida Administrative CodeAdministrative Code is the EDI Rule for is the EDI Rule for

Proof of Proof of Coverage and Coverage and

Claims (non-medical)Claims (non-medical)

EDI Rule 69L-56 EDI Rule 69L-56 F.A.C. was effective F.A.C. was effective

on on January January 7, 20077, 2007..

It requires all It requires all insurers to insurers to

implement the implement the IAIABCIAIABC Claims EDI Claims EDI

Release 3 electronic Release 3 electronic format.format.

So Here’s A So Here’s A Little Little

Background Background On EDI …On EDI …

On a National level, in 1990 the On a National level, in 1990 the IAIABC spearheaded a programIAIABC spearheaded a program

to utilize the concept of EDI for to utilize the concept of EDI for

Workers’ Compensation data.Workers’ Compensation data.

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What is the What is the IAIABC?IAIABC? The International Association The International Association

of Industrial Accident Boards of Industrial Accident Boards and Commissions.and Commissions.

A A 99 year old99 year old organization of organization of jurisdictional workers’ jurisdictional workers’ compensation administrators compensation administrators and others interested in WC.and others interested in WC.

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What is EDI?What is EDI?Electronic Data InterchangeElectronic Data Interchange is the is the

electronic exchange of data electronic exchange of data between between businessbusiness trading partners trading partners (i.e., claim administrators to state (i.e., claim administrators to state agencies), in a standardized agencies), in a standardized format. format.

This does not include This does not include reporting by reporting by

Injured Workers!Injured Workers!

Developing an Electronic Developing an Electronic StandardStandard

Bringing Together the Bringing Together the Important ParticipantsImportant Participants

Jurisdictions

TPA’s Vendors

Carriers

Developing a National Developing a National Standard through the Standard through the IAIABC EDI Development IAIABC EDI Development Committees was a process Committees was a process that required “give” and that required “give” and “take” from all “take” from all participants.participants.

The end result is a national The end result is a national standard format for the standard format for the reporting of workers’ reporting of workers’ compensation data compensation data

electronically.electronically.

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FL DWC chose to FL DWC chose to implement the national implement the national standard for Proof of standard for Proof of Coverage and Claims Coverage and Claims reporting to provide claim reporting to provide claim administrators with a administrators with a consistent standard for consistent standard for electronic reporting across electronic reporting across multiple states.multiple states.

Where can you Where can you find the IAIABC find the IAIABC

R3 R3 ImplementatioImplementatio

n Guide & n Guide & Codes?Codes?

www.iaiabc.org

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The IAIABC The IAIABC Release 3Release 3 Claims EDI Claims EDI Implementation Guide Implementation Guide contains essential contains essential information for information for implementing EDI, implementing EDI, including the transaction including the transaction record layouts, data record layouts, data dictionary, business and dictionary, business and technical rules, national technical rules, national scenarios, etc.scenarios, etc.

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The The Release 3Release 3 Claims Claims Implementation Guide can Implementation Guide can be purchased for be purchased for $195 from the IAIABC’s from the IAIABC’s website: website: www.iaiabc.org, , or it is free if your or it is free if your company is an IAIABC EDI company is an IAIABC EDI Member.Member. The latest R3 The latest R3 Guide is dated Guide is dated January 1, January 1, 2013.2013.

www.iaiabc.org

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The national standard The national standard format contains different format contains different terminology, edits and terminology, edits and various rules, such as various rules, such as sequencing rules, that sequencing rules, that must be followed and may must be followed and may be different from what you be different from what you are accustomed to in the are accustomed to in the paper reporting paper reporting environment.environment.

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Each Trading Partner Each Trading Partner should purchase the should purchase the IAIABC IAIABC EDI Claims Release 3 EDI Claims Release 3 Implementation Guide Implementation Guide each each year.year. DWC can not furnish DWC can not furnish copies of any portions of copies of any portions of this Guide. this Guide.

Become familiar with the Become familiar with the data elements, definitions data elements, definitions and other information in and other information in the Guide. the Guide.

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It is recommended that at It is recommended that at least one person within least one person within every company have every company have access to the Claims EDI R3 access to the Claims EDI R3 Implementation Guide. Implementation Guide.

The requirements of this The requirements of this guide are incorporated by guide are incorporated by reference in the FL EDI reference in the FL EDI Rule 69L-56 F.A.C. Rule 69L-56 F.A.C.

STANDARD USAGE FOR ALL STANDARD USAGE FOR ALL PRODUCTSPRODUCTS

GlossaryGlossary

Glossary

GlossaryGlossaryThe purpose of theThe purpose of the glossary glossary is to acquaint the reader is to acquaint the reader with easy-to-understand with easy-to-understand definitions of workers' definitions of workers' compensation terms. compensation terms.

GlossaryGlossary The glossary defines terms The glossary defines terms that are common to that are common to FROI/SROI, MED, and POC FROI/SROI, MED, and POC EDI reporting. EDI reporting.

Not all of the terms are Not all of the terms are directly related to one of directly related to one of the IAIABC EDI reporting the IAIABC EDI reporting products, but they are products, but they are commonly used in the commonly used in the business and data business and data reporting environment.reporting environment.

GlossaryGlossary

Alphabetical by term

GlossaryGlossaryTerms that are Terms that are specific to approved specific to approved data elements will be data elements will be found in the Data found in the Data Dictionary sections of Dictionary sections of the individual the individual Implementation Implementation Guides.Guides.

AcronymsAcronyms

ACRONYMSACRONYMS

EDI Committee participants EDI Committee participants frequently use acronyms in frequently use acronyms in their discussions, and their discussions, and newcomers (and veterans, newcomers (and veterans, too!) can easily lose their place too!) can easily lose their place in what is going on if they in what is going on if they don’t understand what the don’t understand what the acronyms stand for. acronyms stand for.

ACRONYMACRONYMExamples:Examples:

FTPFTP File Transfer Protocol File Transfer Protocol

FEIN FEIN Federal Employer Identification Federal Employer Identification Number Number

FROIFROI First Report of Injury First Report of Injury

GUI GUI Graphical User InterfaceGraphical User Interface

HTTHTTPP

Hyper Text Transfer Protocol Hyper Text Transfer Protocol

SROI SROI Subsequent Report of Injury Subsequent Report of Injury

URL URL Uniform Resource Locator Uniform Resource Locator

Release 3 Release 3 Combined Combined Business & Business & Technical Data Technical Data DictionaryDictionary

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The IAIABC The IAIABC Release 3Release 3 Claims EDI Claims EDI Implementation Guide Implementation Guide contains the data contains the data dictionary, which defines dictionary, which defines each element that is each element that is required. required. It is It is recommended that this recommended that this section be saved to your section be saved to your desktop for ready desktop for ready reference. reference.

ReleasRelease 3 e 3

Data Data DictionDiction

aryary

Section 6 in Section 6 in the the

ImplementatImplementation Guideion Guide

Data Element DictionaryData Element Dictionary

Identifies the Identifies the Data Data NumberNumber (DN)(DN)

Gives the Gives the DefinitionDefinition of of the Data the Data ElementElement

Gives the Gives the Last Revision Last Revision DateDate of the Data of the Data ElementElement

Data Element DictionaryData Element Dictionary

Gives the Gives the FormatFormat (i.e. 2 A/N = (i.e. 2 A/N = two characters alpha/numeric) two characters alpha/numeric)

Lists the Lists the Valid ValuesValid Values for for the DNthe DN Gives Gives DP DP (Data Population)(Data Population) RuleRule to to Help Identify Help Identify the Correct Use the Correct Use of the of the Data ElementData Element

Release 3 DictionaryRelease 3 Dictionary

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Let’s Get Let’s Get Started…Started…

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Rule 69L-56 Rule 69L-56 Rule Section Rule Section

OverviewOverview

Claim Administrators Claim Administrators mustmust be familiar with the be familiar with the

requirements of this rule.requirements of this rule.

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EDI Rule 69L-56, EDI Rule 69L-56, F.A.C. was effective F.A.C. was effective

1/7/2007 1/7/2007 (Revised (Revised effective 5/17/2009)effective 5/17/2009)

It requires all It requires all insurers to insurers to

implement the implement the IAIABCIAIABC Claims EDI Claims EDI

Release 3 electronic Release 3 electronic format.format.

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EDI Rule 69L-56, EDI Rule 69L-56, F.A.C.F.A.C.This EDI Implementation This EDI Implementation

applies to applies to allall required required form filings for form filings for allall Dates Dates of Injuries, and not just of Injuries, and not just those injuries that occur those injuries that occur after the Insurer’s EDI after the Insurer’s EDI Implementation date. Implementation date. This includes legacy This includes legacy claims.claims.

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69L-56.00169L-56.001 Forms and Forms and InstructionsInstructions

69L-56.00269L-56.002 DefinitionsDefinitions

Rule 69L-56 Rule 69L-56 Rule Section Rule Section

OverviewOverview(Claim Administrators must be (Claim Administrators must be

familiar with the requirements of familiar with the requirements of this rule.)this rule.)

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69L-56.10069L-56.100 Proof of Proof of Coverage Coverage (POC) (POC) Electronic Reporting Electronic Reporting RequirementsRequirements69L-56.11069L-56.110 Technical Technical Requirements for POC EDI Requirements for POC EDI

TransmissionsTransmissions69L-56.20069L-56.200 Policy Policy Cancellation or Cancellation or Non-Non-renewal Requirementsrenewal Requirements69L-56.21069L-56.210 Time Periods Time Periods for Filing for Filing Electronic Electronic Policy InformationPolicy Information

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69L-56.30069L-56.300 Claims EDI Claims EDI Reporting Reporting Requirements Requirements and and Implementation Implementation SchedulesSchedules69L-56.30169L-56.301 Electronic First Electronic First Report Report of Injury or Illnessof Injury or Illness69L-56.3012 69L-56.3012 Electronic Electronic Notice of Notice of Denial and Denial and Rescinded DenialRescinded Denial69L-56.3013 69L-56.3013 Electronic Electronic Periodic Periodic Claim Cost Claim Cost ReportsReports

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69L-56.304 69L-56.304 Electronic Notice of Electronic Notice of Action or Action or Change, Including Change, Including Change in Claims Change in Claims Administration, Administration, Required by the Required by the Insurer’s Insurer’s PrimaryPrimary Implementation Implementation ScheduleSchedule

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69L-56.3045 69L-56.3045 Electronic Notice of Electronic Notice of Action Action or Change, Suspensions, or Change, Suspensions, and and Reinstatement of Reinstatement of Indemnity Benefits Indemnity Benefits Required Required by the Insurer’s by the Insurer’s SecondarySecondary Implementation ScheduleImplementation Schedule

**** The Secondary The Secondary Implementation Schedule is Implementation Schedule is currently not being used. currently not being used.

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69L-56.30769L-56.307 Electronic Electronic Cancellation Cancellation of Claimof Claim

69L-56.31069L-56.310 Technical Technical Requirements for Claims Requirements for Claims EDI EDI TransmissionsTransmissions

69L-56.32069L-56.320 Claims EDI Claims EDI Test to Test to Production Production Status Status RequirementsRequirements

Insurer’s Insurer’s Responsibilities Responsibilities

Where Third Party Where Third Party Services Are UtilizedServices Are Utilized

69L-56.500, F.A.C.

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Insurer’s Responsibilities Where Insurer’s Responsibilities Where Third Party Services Are UtilizedThird Party Services Are UtilizedIf an insurer contracts If an insurer contracts with any third party with any third party (TPA or vendor) or uses (TPA or vendor) or uses their software to send their software to send EDI transactions to DWC, EDI transactions to DWC, the insurerthe insurer is still is still responsible for the responsible for the following…following…

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Insurer’s Responsibilities Where Insurer’s Responsibilities Where Third Party Services Are UtilizedThird Party Services Are Utilized……the timely filing of the timely filing of transactions transactions required required by this ruleby this rulethe processing of the processing of acknowledgementsacknowledgementsany penalties and fines any penalties and fines that that may result from a may result from a third third party’s untimely party’s untimely EDI filings.EDI filings.

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The former DWC paper forms The former DWC paper forms previously previously filed with the filed with the DivisionDivision have been replaced by have been replaced by electronic transactions:electronic transactions:DWC-1 First Report Of Injury or IllnessDWC-1 First Report Of Injury or Illness

DWC-12 Notice of DenialDWC-12 Notice of Denial

DWC-13 Claim Cost ReportDWC-13 Claim Cost Report

DWC-4 Notice of Action/ChangeDWC-4 Notice of Action/Change

DWC-49 Aggregate Claims DWC-49 Aggregate Claims Administration Change ReportAdministration Change Report

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Rule 69L-56, F.A.C.Rule 69L-56, F.A.C. identifies EDI filing identifies EDI filing requirements (i.e., when requirements (i.e., when a claim administrator a claim administrator must file these EDI must file these EDI transactions with DWC). transactions with DWC).

Rule 69L-3, F.A.C. Rule 69L-3, F.A.C. identifies paper form identifies paper form copies still required to be copies still required to be sent to other parties. sent to other parties.

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Read Rule 69L-56, Read Rule 69L-56, F.A.C. in it’s F.A.C. in it’s entirety.entirety. http://www.myfloridacfo.com/wc/edi_clms.html

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The Most The Most Important Important Thing Thing Necessary to Necessary to Begin Filing Begin Filing Claims EDI Claims EDI is…is…

……Accurately Accurately submitting and submitting and

maintaining maintaining your EDI your EDI

Trading Partner Trading Partner Profile Profile

DocumentsDocuments

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At least At least two (2) business days two (2) business days before sending the first test before sending the first test transmission, the Clm. Admin. transmission, the Clm. Admin. shall send its current profile shall send its current profile information to the DWC at information to the DWC at [email protected]@myfloridacfo.com, , using the following forms using the following forms adopted in Rule 69L-56.001, adopted in Rule 69L-56.001, F.A.C.:F.A.C.:

EDI Trading Partner EDI Trading Partner Profile DocumentsProfile Documents

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EDI Trading Partner Profile EDI Trading Partner Profile DocumentsDocuments

DFS-F5-DWC-DFS-F5-DWC-EDI-1EDI-1: : EDI Trading Partner ProfileEDI Trading Partner Profile

DFS-F5-DWC-DFS-F5-DWC-EDI-2EDI-2: : EDI Trading Partner EDI Trading Partner Insurer / Insurer / Claim Claim Administrator ID ListAdministrator ID List

DFS-F5-DWC-DFS-F5-DWC-EDI-2AEDI-2A: : EDI Trading Partner Claim EDI Trading Partner Claim Admin. Address List Admin. Address List

DFS-F5-DWC-DFS-F5-DWC-EDI-3EDI-3: : EDI Transmission Profile – EDI Transmission Profile – Sender’s Sender’s

SpecificationsSpecifications

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If a form is incomplete and If a form is incomplete and does not contain responses does not contain responses to all of the required fields to all of the required fields in accordance with the in accordance with the instructions on the form, or instructions on the form, or does not match does not match information in DWC’s information in DWC’s database, it will be database, it will be returned. returned.


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A claim administrator can A claim administrator can not begin testing with the not begin testing with the DWC until the corrected DWC until the corrected form(s) is re-filed accurately.form(s) is re-filed accurately.This is the number 1 This is the number 1 problem that claim problem that claim administrator’s encounter administrator’s encounter when beginning EDI testing.when beginning EDI testing.


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AllAll Changes to profile Changes to profile information information shall be reported shall be reported by sending revised Trading by sending revised Trading Partner Profile documents to Partner Profile documents to DWC at DWC at [email protected], , at at least least two (2)two (2) business days business days prior to sending transactions prior to sending transactions containing revised profile-containing revised profile-related information. related information.


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Failure to report changes to profile Failure to report changes to profile information may result in the information may result in the rejection of an entire transmission rejection of an entire transmission or rejection or rejection of individual transaction(s).of individual transaction(s).

Changes in FEIN, address/postal Changes in FEIN, address/postal codes or addition of an Insurer or codes or addition of an Insurer or new claims office requires Trading new claims office requires Trading Partner documents to be updated.Partner documents to be updated.


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An MTC An MTC “02”“02” that is sent to that is sent to report a change in the report a change in the Insurer or Insurer or Claim Admin. FEIN, Claim Admin. Claim Admin. FEIN, Claim Admin. Postal Code, or Claim Admin. Postal Code, or Claim Admin. Claim NumberClaim Number due to the due to the creation or elimination of a creation or elimination of a claims office location or claims office location or subsidiary entity within the subsidiary entity within the insurer’s organization insurer’s organization does not does not replacereplace the need to file revised the need to file revised TP Profile docs.TP Profile docs.


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The MTC The MTC “02”“02” would actually would actually reject if it reported a different reject if it reported a different Claim Administrator FEIN/Postal Claim Administrator FEIN/Postal Code that was not already in Code that was not already in DWC’s profile database.DWC’s profile database.

Therefore, before MTC Therefore, before MTC “02”“02” is is filed to report, e.g., the transfer filed to report, e.g., the transfer of a file to a of a file to a newnew claims office claims office location, revised TP Profile location, revised TP Profile documents must be filed with the documents must be filed with the DWC to report the new location.DWC to report the new location.


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NOTE:NOTE: All 9 digits of the All 9 digits of the Trading Partner’s Postal Code Trading Partner’s Postal Code should be sent in the should be sent in the Sender Sender IDID. . This postal code must This postal code must match either the Physical or match either the Physical or Mailing Sender Address Mailing Sender Address Postal Code, and should be a Postal Code, and should be a valid Home or Claims Office valid Home or Claims Office location for the company.location for the company.


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Insurer/Claim Administrator Insurer/Claim Administrator ID ListID List

DFS-F5-DWC-EDI-2DFS-F5-DWC-EDI-2If the Sender/Trading Partner If the Sender/Trading Partner is an is an InsurerInsurer who is also who is also reporting for a TPA in its reporting for a TPA in its group, it is very helpful to group, it is very helpful to DWC if the Insurers listed on DWC if the Insurers listed on the EDI-2 form are grouped. the EDI-2 form are grouped. The Insurers that are part of The Insurers that are part of the corporate group should be the corporate group should be listed together, then the listed together, then the Insurers for which the TPA will Insurers for which the TPA will be the Claim Administrator be the Claim Administrator should be listed under the TPA should be listed under the TPA name. name.

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IMPORTANT:IMPORTANT: If a 9-digit Postal Code If a 9-digit Postal Code is listed for a claims office location is listed for a claims office location on the EDI 2-A form, the DWC profile on the EDI 2-A form, the DWC profile will be established with all 9 digits; will be established with all 9 digits; therefore all 9 digits must be sent on therefore all 9 digits must be sent on the transaction in order to match. the transaction in order to match.

If only 5 digits are listed on the form, If only 5 digits are listed on the form, the last 4 digits must be sent on the the last 4 digits must be sent on the filing as blanks (spaces). If zeros are filing as blanks (spaces). If zeros are sent in the last 4 digits, this will not sent in the last 4 digits, this will not match and will cause a rejection.match and will cause a rejection.


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If two different claims office If two different claims office locations are in the same zip code locations are in the same zip code area, the 9-digit Postal Code must area, the 9-digit Postal Code must be sent for each location on both be sent for each location on both the EDI-2A and the transaction. the EDI-2A and the transaction.

Postal code mis-matches between Postal code mis-matches between what is listed on the form vs. what is listed on the form vs. what is sent in the transaction is what is sent in the transaction is one of the top reasons a one of the top reasons a transaction rejects. transaction rejects.


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There must be a one to one There must be a one to one match between a physical match between a physical address and a mailing address and a mailing address for each claims address for each claims office location. The EDI 2-A office location. The EDI 2-A must reflect each of these must reflect each of these unique combinations. unique combinations.

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For example: If you have 5 For example: If you have 5 physical locations on Tab 1 physical locations on Tab 1 of the EDI 2-A, then you of the EDI 2-A, then you must list 5 corresponding must list 5 corresponding mailing locations on Tab 2 mailing locations on Tab 2 (even if they are the same (even if they are the same address).address).All FEINs for which an All FEINs for which an address applies should be address applies should be listed on each Tab.listed on each Tab.

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For For

New Trading New Trading Partners Partners

still in still in Test Test StatusStatus……

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It is It is highly recommendedhighly recommended you you test using the actual program test using the actual program you will use in production, and you will use in production, and to test with actual claim data.to test with actual claim data.

Some Insurers that tested with Some Insurers that tested with “mock” data experienced “mock” data experienced unanticipated errors not unanticipated errors not discovered in test when they discovered in test when they started sending real claim data. started sending real claim data.

For NEW TP’s still For NEW TP’s still testing:testing:

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DWC also DWC also recommends recommends having claim reps who will having claim reps who will actually handle the live actually handle the live production cases be involved production cases be involved in the testing process. in the testing process.

This will ensure that claims This will ensure that claims staff are familiar with edits staff are familiar with edits received, how to look up received, how to look up records in the data records in the data warehouse, and how to warehouse, and how to resolve the errors. resolve the errors.


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After you are After you are approved for production approved for production status, a 30 day grace status, a 30 day grace period will be applied for period will be applied for FROI filings that are FROI filings that are accepted after their accepted after their filing due datefiling due date (See (See Rule Rule 69L-24.0231(d), F.A.C69L-24.0231(d), F.A.C.).)


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After the completion of the 30 day After the completion of the 30 day grace period, all electronic First grace period, all electronic First Reports of Injury or Illness must Reports of Injury or Illness must be assigned an Application be assigned an Application Acknowledgement Code of Acknowledgement Code of Transaction Accepted (TA) by the Transaction Accepted (TA) by the Division within the required filing Division within the required filing timeframes established in timeframes established in subsections 69L-56.301(1) and subsections 69L-56.301(1) and (2), F.A.C., to be considered (2), F.A.C., to be considered timely filed.timely filed.

69L-24.006(1)6.69L-24.006(1)6.

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In order to be eligible for In order to be eligible for the 30 day grace period, the the 30 day grace period, the transaction errors transaction errors MUSTMUST be be resolved within those 30 resolved within those 30 days, and days, and RECEIVE A TARECEIVE A TA. .

It does not apply to filings It does not apply to filings received but not received but not successfully filed/accepted successfully filed/accepted during those first 30 days . during those first 30 days .

69L-24.006(1)6.69L-24.006(1)6. This rule is often This rule is often misunderstood. misunderstood.

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If a rejection is not If a rejection is not resolved and accepted resolved and accepted within those first 30 within those first 30 days, penalties may days, penalties may apply in apply in accordance with accordance with rule rule 69L-56.301, F.A.C.69L-56.301, F.A.C.

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It is strongly It is strongly recommended that First recommended that First Report/Initial Payments Report/Initial Payments transactions are transactions are triggered triggered immediately immediately upon mailing the first upon mailing the first indemnity checkindemnity check, , or upon or upon decision to denydecision to deny. This . This will allow for the will allow for the maximum time possible maximum time possible to resolve any errors.to resolve any errors.

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Ensure your IT staff Ensure your IT staff or Vendor is prepared or Vendor is prepared to react to to react to programming problems programming problems discovered with your discovered with your production data, and production data, and can implement can implement solutions quickly during solutions quickly during those initial 30 days. those initial 30 days.

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ProductionProduction Trading Trading

Partners… Partners…

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Reminder:Reminder: Test files Test files CANCAN be sent after a be sent after a trading partner is trading partner is approved for production; approved for production; however, it will only load however, it will only load to DWC’s Test system. If a to DWC’s Test system. If a production file is production file is accidentally sent with a accidentally sent with a “T” for Test, you “T” for Test, you will not will not receive credit for filing receive credit for filing those claims until re-sent those claims until re-sent with a “P” for production. with a “P” for production.

FL Claims EDI FL Claims EDI WebpageWebpage

ClaimClaims EDIs EDI

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http://www.myfloridacfo.com/wc/

FL’s Claims EDI WebpageFL’s Claims EDI Webpage

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The Claims EDI Webpage is your The Claims EDI Webpage is your complete resource for all of DWC’s complete resource for all of DWC’s “Claims EDI” requirements“Claims EDI” requirements

Scroll Scroll Down Down for for much much more more infoinfo

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These are These are the the RequiremenRequirement Tablest Tables

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If you haven’t already, you If you haven’t already, you should become familiar with should become familiar with FL’s requirement tables FL’s requirement tables (including updated supplement) (including updated supplement) to determine:to determine: When each When each transaction must transaction must be sent be sent (Event Table)(Event Table) Data Elements Data Elements required for required for each each transaction / MTC transaction / MTC (Element (Element Requirement Table) Requirement Table)


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(Cont’d)…(Cont’d)…

Review FL’s requirement Review FL’s requirement tables (including updated tables (including updated supplement) to determine: supplement) to determine: Edits that will reject the Edits that will reject the record record (Edit Matrix)(Edit Matrix)

The Population Restrictions Tab of The Population Restrictions Tab of the Edit Matrix will assist you in the Edit Matrix will assist you in trouble shooting why you received trouble shooting why you received a particular error.a particular error.


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FL Supplement Overview:FL Supplement Overview:

Tracks all monthly additions or Tracks all monthly additions or corrections to the requirement corrections to the requirement tables.tables.

Check the EDI website Check the EDI website periodically for updates to periodically for updates to this Supplement.this Supplement.

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The webpage also contains The webpage also contains helpful resource documents helpful resource documents including:including:FL EDI Migration Strategies FL EDI Migration Strategies MTC Filing InstructionsMTC Filing InstructionsFL R3 Business ScenariosFL R3 Business ScenariosFL Quick Code Reference GuideFL Quick Code Reference GuideMTC to Form CrosswalkMTC to Form CrosswalkCrosswalks of paper DWC Claims Forms Crosswalks of paper DWC Claims Forms to to EDI Data Elements EDI Data Elements


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Helpful ResourcesHelpful Resources

Other Other ResourcesResources

DWC DWC Form Form CrosswalCrosswalksks

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TrainiTrainingng

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Crosswalk of Crosswalk of MTC’s MTC’s

to DWC Formsto DWC Forms

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The MTC to The MTC to Form Form Crosswalk Crosswalk helps helps identify identify what MTC’s what MTC’s equate to equate to which DWC which DWC forms. forms.

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MTC’s to DWC MTC’s to DWC FormsForms

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MTC’s to DWC MTC’s to DWC FormsForms

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Not all MTC filing Not all MTC filing requirements set out in requirements set out in Rule Rule 69L-56, F.A.C., can 69L-56, F.A.C., can be be equated to a DWC equated to a DWC Form.Form.

See rule 69L-56 F.A.C. See rule 69L-56 F.A.C. and and “FL Claims EDI “FL Claims EDI Event Table”Event Table” (also (also “MTC Filing “MTC Filing Instructions”) for a Instructions”) for a complete accounting of complete accounting of MTC’s required by FL.MTC’s required by FL.

Acronyms Acronyms (see FL (see FL

Claims EDI Claims EDI webpage for webpage for

list)list)

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http://www.myfloridacfo.com/wc/edi_clms.html

EDI R3 Acronyms

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FL ACRONYMSFL ACRONYMSExamples:Examples:

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How Will EDI How Will EDI Errors Be Errors Be Communicated to Communicated to Claim Claim Administrators?Administrators?

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The Division will The Division will acknowledge every acknowledge every EDI R3 transaction EDI R3 transaction received with the received with the standard EDI standard EDI Acknowledgement Acknowledgement format: format: ‘AKC’.‘AKC’.

AKC AKC

ReporRepor

tt

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The The ‘AKC’ ‘AKC’ acknowledgement will acknowledgement will identify how many identify how many transactions passed edits transactions passed edits ((TATA -Transaction -Transaction Accepted); how many Accepted); how many failed edits (failed edits (TRTR - -Transaction Rejected); Transaction Rejected);

and the specific and the specific error(s) error(s) that that caused thecaused thetransaction to reject.transaction to reject.

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FL does FL does notnot use the use the TETE – “Transaction – “Transaction Accepted with Errors” Accepted with Errors” Acknowledgement Acknowledgement Code; however, certain Code; however, certain errors will display in errors will display in the warehouse as “the warehouse as “TA-TA-FLFL” and must be ” and must be addressed by the claim addressed by the claim administrator.administrator.

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Acknowledgement Acknowledgement results from the results from the previous day’s previous day’s transmission(s) will transmission(s) will be posted by be posted by 9:00 9:00 a.ma.m.. the following the following morning in the morning in the EDI EDI Data Warehouse.Data Warehouse.

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Transmissions received Transmissions received on or on or beforebefore 9:00 p.m., 9:00 p.m., E.S.T., will be processed E.S.T., will be processed by DWC the same day by DWC the same day the transmission was the transmission was sent.sent.

Transmissions will be Transmissions will be acknowledged the next acknowledged the next calendar day (usually by calendar day (usually by 9:00 a.m. E.S.T.) 9:00 a.m. E.S.T.)

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Transmissions received Transmissions received afterafter 9:00 p.m. EST will 9:00 p.m. EST will be processed by DWC the be processed by DWC the following calendar day,following calendar day,

and will be acknowledged and will be acknowledged the day after the the day after the transmission is transmission is processed.processed.

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FL processes FL processes transmissions transmissions 7 days a 7 days a week, week, including including holidays.holidays.

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If you need to confirm if If you need to confirm if or when a particular filing or when a particular filing or group of filings were or group of filings were received by the Division, received by the Division, you can “you can “Search for Search for BatchesBatches” in the ” in the Claims EDIClaims EDI Data WarehouseData Warehouse to to determine when the FROI determine when the FROI and/or SROI batch was and/or SROI batch was received (Click on the received (Click on the “Batch ID” for batch “Batch ID” for batch details. details.

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If a transaction is If a transaction is improperly rejected by improperly rejected by the Division, the entire the Division, the entire batch will be re-processed batch will be re-processed and re-acknowledged using and re-acknowledged using the the ‘ARC’ ‘ARC’ Acknowledgement format.Acknowledgement format. (see the (see the technical training technical training PowerPoint for more PowerPoint for more details on the details on the Acknowledgement Acknowledgement Process)Process)

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If DWC re-processes If DWC re-processes (re-loads) a (re-loads) a transaction, the transaction, the Claim Administrator Claim Administrator will receive credit will receive credit for the date the for the date the transaction was transaction was originally received originally received by the Division.by the Division.

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FL provides EDI Claim FL provides EDI Claim Administrators the Administrators the capability of viewing all capability of viewing all FROI’s & SROI’s FROI’s & SROI’s received, via the on-line received, via the on-line Claims EDI Claims EDI Data Warehouse. Data Warehouse.

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The Claims EDI Data The Claims EDI Data Warehouse will assist Warehouse will assist claim administrators in claim administrators in resolving EDI errors resolving EDI errors faster, faster,

and may also assist and may also assist in resolving in resolving

issues issues with the with the Centralized Centralized Performance System Performance System (CPS).(CPS).

Claims Claims EDI EDI

WarehouWarehousese

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More detailed More detailed information regarding information regarding the on-line Claims EDI the on-line Claims EDI Data Warehouse is Data Warehouse is provided in the Claims provided in the Claims EDI Data Warehouse EDI Data Warehouse Webinar/Training.Webinar/Training.

Claims Claims EDI EDI

WarehouWarehousese

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A A PowerPoinPowerPoint t presentatipresentation on use on on use of the of the Data Data WarehousWarehouse is also e is also posted on posted on the Claims the Claims EDI web EDI web page.page.

**Updated **Updated version version will be will be posted posted soon.soon.

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Florida has made Florida has made many corrections and many corrections and adjustments to its EDI adjustments to its EDI program to program to accommodate filing accommodate filing situations we did not situations we did not initially anticipate. initially anticipate.

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FL may enhance its FL may enhance its EDI program weekly or EDI program weekly or bi-weekly as needed. bi-weekly as needed. But if a new filing But if a new filing requirement will result requirement will result in a rejection, we in a rejection, we typically allow a 3 typically allow a 3 month implementation month implementation period before enforcing period before enforcing the new edit.the new edit.

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After you have After you have thoroughly thoroughly investigatedinvestigated the error the error (using DWC resource (using DWC resource documents) and you still documents) and you still do not understand the do not understand the error...error...

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... ... please send an email to please send an email to the Claims EDI Team at the Claims EDI Team at [email protected]

The EDI Team will answer The EDI Team will answer all questions via an email all questions via an email so that both parties have a so that both parties have a copy of the response for copy of the response for future reference.future reference.

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By emailing your By emailing your question, the EDI Team question, the EDI Team has the opportunity to has the opportunity to research the specific research the specific details of the problem details of the problem thoroughly. Phone calls thoroughly. Phone calls do not allow for do not allow for adequate time for this adequate time for this research. We appreciate research. We appreciate your understanding.your understanding.

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Reminder: Reminder: To avoid late filing To avoid late filing penaltiespenalties, the , the Electronic First Report Electronic First Report of Injury or Illnessof Injury or Illness (payment or denial) (payment or denial) should be triggered should be triggered immediately upon the immediately upon the Claim Admin.’s Claim Admin.’s disposition of the disposition of the claim. claim.

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This will allow time for This will allow time for correction of potential correction of potential filing errors and filing errors and resubmission and resubmission and subsequent subsequent receipt/acceptance by receipt/acceptance by the Division within the the Division within the filing due dates specified filing due dates specified in Rule 69L-56, F.A.C.in Rule 69L-56, F.A.C.

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Hot Hot TopicTopic

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The following information The following information is reported via Medical EDI is reported via Medical EDI and should not be included and should not be included in OBT (Other Benefit Type in OBT (Other Benefit Type Code) 370.Code) 370.Physician (includes physical therapy, functional capacity evaluations, and work hardening)HospitalDentalPharmacyDurable Medical Expenses

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If you are currently reporting If you are currently reporting this information under OBT this information under OBT 370, it should be corrected 370, it should be corrected using the following:using the following:

SROI 02 SROI 02

SA (amended) SA (amended)

FN (amended)FN (amended)

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ALL QuestionsALL Questions, either Business , either Business or Technical, should be sent via or Technical, should be sent via

email to email to [email protected]

This email address is copied to This email address is copied to all members of the EDI team. It all members of the EDI team. It

is the quickest and most is the quickest and most efficient way for us to respond efficient way for us to respond

to your concerns. to your concerns.

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Questions?

1 Florida Division of Workers’ Compensation Claims EDI Basic Overview 2013.

Documents

Transcript of 1 Florida Division of Workers’ Compensation Claims EDI Basic Overview 2013.