1 Florida Division of Workers Compensation Claims EDI Release 3 Training 2008 (Continued)

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

Claims EDI Claims EDI Release 3 Release 3

TrainingTraining 2008 2008

(Continued)(Continued)

MTC “02” MTC “02” Change Change

Processing Processing RulesRules

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Change Processing RulesChange Processing RulesTransaction UsageTransaction Usage

MTC 02 (Change) transaction MTC 02 (Change) transaction is intended to: is intended to: Allow Claim Administrators Allow Claim Administrators to correct data previously to correct data previously reported erroneously and/or, reported erroneously and/or,

Allow Claim Administrators Allow Claim Administrators to update previously to update previously reported data.reported data.

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02

Change Processing RulesChange Processing RulesTransaction UsageTransaction Usage

MTC “02” MTC “02” should not be should not be used to report used to report a change in a change in data where data where other other transactions transactions are intended are intended to serve that to serve that purpose.purpose.

CACBABRB

P7

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Change Processing RulesChange Processing Rules Transaction UsageTransaction Usage

If a data element designated as If a data element designated as

FYFY, , fyfy, , YY, , YY11, Y, Y22, Y, Y33, Y, Y44 or or YCYC in in the MTC 02 column of the the MTC 02 column of the Element Requirement table is Element Requirement table is changed, the Claim changed, the Claim Administrator must trigger an Administrator must trigger an “02” (Change) transaction, “02” (Change) transaction, unless another MTC applies.unless another MTC applies.

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If a data element designated as If a data element designated as NN11

in the MTC 02 column of the in the MTC 02 column of the Element Requirement table is Element Requirement table is changed, the Claim Administrator changed, the Claim Administrator can send an “02” (Change) can send an “02” (Change) transaction, unless another MTC transaction, unless another MTC applies; however, an 02 is not applies; however, an 02 is not required every time the value in required every time the value in this field changes.this field changes.

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An example of a data element An example of a data element designated as designated as NN11 is Benefit Type is Benefit Type Amount Paid. If you have reported Amount Paid. If you have reported this incorrectly, then an MTC 02 this incorrectly, then an MTC 02 should be sent; however, if the should be sent; however, if the Benefit Type Amount Paid changes Benefit Type Amount Paid changes because you have paid another bi-because you have paid another bi-weekly check, we do not need or weekly check, we do not need or want an MTC 02. want an MTC 02.

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Change Processing RulesChange Processing RulesFlorida has expanded on the ERT standard Florida has expanded on the ERT standard Requirement Codes for MTC 02.Requirement Codes for MTC 02. See bottom of SROI Element See bottom of SROI Element Requirements.Requirements.

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Change Processing Change Processing Rules Rules

R3 Limitations R3 Limitations

Known to DateKnown to Date

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Change Processing RulesChange Processing Rules R3 Limitations Known to DateR3 Limitations Known to Date

The current R3 MTC “02” has several The current R3 MTC “02” has several known limitations, e.g., a transaction known limitations, e.g., a transaction must not include changes to more must not include changes to more than one “Match” data element at a than one “Match” data element at a time.time.

A full listing of these limitations can A full listing of these limitations can be found in be found in Section 4 of the Release 3 Section 4 of the Release 3 Implementation Guide Implementation Guide (02 Change (02 Change Processing Rules).Processing Rules).

The IAIABC is currently working on The IAIABC is currently working on resolving these limitations. resolving these limitations.

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Change Change Processing RulesProcessing Rules

Claim Claim Administrator Administrator

ConsiderationsConsiderations

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Change Processing RulesChange Processing RulesClaim Administrator ConsiderationsClaim Administrator Considerations

Claim administrators Claim administrators must send MTC “02” must send MTC “02” (Change) transactions at (Change) transactions at the appropriate time to the appropriate time to avoid transactionsavoid transactions rejecting. rejecting.

(e.g., must send SSN change via MTC (e.g., must send SSN change via MTC 02 before sending next the 02 before sending next the transaction containing the new SSN).transaction containing the new SSN).

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Change Processing RulesChange Processing RulesClaim Administrator ConsiderationsClaim Administrator Considerations

Claim administrators Claim administrators should analyze should analyze Florida’s Florida’s Element Requirement Element Requirement TableTable and and Edit MatrixEdit Matrix to to learn how data element(s) learn how data element(s) will be processed on will be processed on MTC MTC 0202 Change transactions. Change transactions.

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Electronic Notice of Electronic Notice of ChangeChange

MTC “02”MTC “02”

(Required by(Required by PrimaryPrimary Implementation Schedule)Implementation Schedule)

See Rule 69L-56.304, F.A.C. See Rule 69L-56.304, F.A.C.

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An An Electronic Notice of Change, Electronic Notice of Change, MTC 02MTC 02 is due if: is due if:

A DN designated as A DN designated as “Y”, “YC”, “Y”, “YC”, “Y“Y11”, “Y”, “Y22”, “Y”, “Y33”, “Y”, “Y44”,”, “fy”“fy” or or “FY”“FY” in the FROI/SROI 02 in the FROI/SROI 02 columns of the FL Element columns of the FL Element Requirement Table changes, Requirement Table changes, unless specifically indicated in unless specifically indicated in the Rule as not required until the Rule as not required until the Secondary Implementation the Secondary Implementation Schedule.Schedule.

MTC “02” Changes MTC “02” Changes (Primary)(Primary)

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If any of the following DN(s) If any of the following DN(s) change, an MTC 02 is required change, an MTC 02 is required during the during the PrimaryPrimary Implementation (DWC-4):Implementation (DWC-4):

1. Insurer FEIN (not due to change 1. Insurer FEIN (not due to change in claims administration)in claims administration)

2. Claim Admin. FEIN (not due to 2. Claim Admin. FEIN (not due to change in claims administration)change in claims administration)

3. Claim Admin. Postal Code 3. Claim Admin. Postal Code (not (not due to change in claims due to change in claims administration) …administration) …

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(cont’d) …

4. Claim Administrator Claim Claim Administrator Claim

NumberNumber

5. Employee SSN or Division-5. Employee SSN or Division-

Assigned #Assigned #

6. Employee Name (First, 6. Employee Name (First,

Middle, Last, Suffix)Middle, Last, Suffix)

7. Date of Injury……


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(cont’d) …

8. Employee Date of Death9. Manual (Risk) Class Code

(FROI 02 Only)

10 Industry Code (NAICS) (FROI Industry Code (NAICS) (FROI

O2 Only)O2 Only)


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Electronic Notice of Electronic Notice of ChangeChange

MTC “02”MTC “02”

(Required by(Required by Secondary Secondary Implementation Schedule)Implementation Schedule)

See Rule 69L-56.3045, F.A.C. See Rule 69L-56.3045, F.A.C.

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If any of the following DN(s) If any of the following DN(s) change, an MTC 02 is required change, an MTC 02 is required during the during the SecondarySecondary Implementation (DWC-4):Implementation (DWC-4):

1.1. MMIMMI2.2. PIPI3.3. Initial RTW Initial RTW (and RTW Type (and RTW Type

Code, Code, Physical Physical Restrictions Indicator)Restrictions Indicator)

4.4. Current RTW Current RTW (and RTW Type (and RTW Type Code, Code, Physical Physical Restrictions Indicator) …Restrictions Indicator) …

MTC “02” Changes MTC “02” Changes (Secondary)(Secondary)

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(cont’d) …(cont’d) …

5. PI Minimum Payment 5. PI Minimum Payment

Indicator Indicator 6. RTW with Same Employer 6. RTW with Same Employer

Indicator Indicator 7. Suspension Effective Date7. Suspension Effective Date8. Suspension Narrative (not 8. Suspension Narrative (not required, required, but used to report but used to report a change if a change if previously sent previously sent inaccurately). inaccurately).


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9.9. Average WageAverage Wage10.10. Wage Effective DateWage Effective Date11.11. Calculated Weekly Calculated Weekly Comp. Amnt.Comp. Amnt.

12.12. Gross Weekly AmountGross Weekly Amount13.13. Gross Weekly Amount Gross Weekly Amount Eff. DateEff. Date

14.14. Net Weekly Amount Eff. Net Weekly Amount Eff. Date … Date …

MTC “02” Changes MTC “02” Changes (Secondary) No Change to (Secondary) No Change to

Net to require CANet to require CA

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15.15. Benefit Adjustment Benefit Adjustment CodeCode

16.16. Benefit Adjustment Benefit Adjustment Start DateStart Date

17.17. Benefit Adjustment End Benefit Adjustment End DateDate

18.18. Benefit Credit CodeBenefit Credit Code19.19. Benefit Credit Start Benefit Credit Start

DateDate20.20. Benefit Credit End DateBenefit Credit End Date

MTC “02” Changes MTC “02” Changes (Secondary) No Change to (Secondary) No Change to

Net to require CANet to require CA

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An MTC 02 must be sent when An MTC 02 must be sent when there is there is NO CHANGE TO THE NO CHANGE TO THE NET WEEKLY AMNTNET WEEKLY AMNT because: because: The indemnity benefit being The indemnity benefit being paid will continue to be paid at paid will continue to be paid at the same statutory maximum the same statutory maximum weekly rate, ORweekly rate, OR

A code, date, or amount A code, date, or amount

previously reported is being previously reported is being

correctedcorrected ANDAND the Net Weekly the Net Weekly

Amount is unchanged: Amount is unchanged:

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21. Benefit Redistribution 21. Benefit Redistribution AmountAmount22. Benefit Redistribution Start 22. Benefit Redistribution Start DateDate23. Benefit Redistribution End 23. Benefit Redistribution End

DateDate

Benefit Redistribution Code is not Benefit Redistribution Code is not listed because FL only accepts listed because FL only accepts one valid Redistribution Code; one valid Redistribution Code; therefore, it will reject if invalid therefore, it will reject if invalid and can not be changed via MTC and can not be changed via MTC 02.02.


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Note:Note: If reporting the End If reporting the End Date for a Benefit Date for a Benefit Redistribution in Redistribution in conjunction with the conjunction with the suspension of indemnity, suspension of indemnity, the Benefit Redistribution the Benefit Redistribution End Date may be reported End Date may be reported on the MTC Sx in lieu of on the MTC Sx in lieu of sending MTC 02.sending MTC 02.

MTC “02” ChangesMTC “02” Changes

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Important: The JCN Important: The JCN sent on the SROI MTC sent on the SROI MTC “02” must match the “02” must match the JCN ‘on file’ for the JCN ‘on file’ for the existing SSN/DOI.existing SSN/DOI.


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Important: If you are trying to Important: If you are trying to change the date the initial payment change the date the initial payment was mailed, you must send an 02 was mailed, you must send an 02 change reflecting a new Benefit change reflecting a new Benefit Payment Issue Date Payment Issue Date ANDAND Payment Payment Issue Date. DWC’s system will be Issue Date. DWC’s system will be updated from the corresponding updated from the corresponding Payment Issue Date in the Payment Payment Issue Date in the Payment segment.segment.


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Important: If you are trying to Important: If you are trying to change certain data related to the change certain data related to the initial payment, and subsequent initial payment, and subsequent MTC’s have been accepted since MTC’s have been accepted since the FROI/SROI, the 02 will not the FROI/SROI, the 02 will not update certain fields. You will update certain fields. You will need to contact your EDI Liaison need to contact your EDI Liaison to make the change manually.to make the change manually.


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Change Processing Change Processing RulesRules

If the Element If the Element Requirement Table for Requirement Table for MTC 02 indicates that a MTC 02 indicates that a data element can be data element can be changed on both the changed on both the FROI and SROI, an 02 FROI and SROI, an 02 can be sent on can be sent on eithereither the the FROI or SROI. FROI or SROI.

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A single MTC 02 transaction can A single MTC 02 transaction can not be sent to change multiple not be sent to change multiple match data elements, such as match data elements, such as SSN, Claim Admin. Claim Number, SSN, Claim Admin. Claim Number, etc.etc.

If two match data elements need If two match data elements need to be changed, a second MTC 02 to be changed, a second MTC 02 transaction will need to be sent transaction will need to be sent after the first MTC 02 is accepted.after the first MTC 02 is accepted.


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Exceptions:Exceptions:

Employee Name fields will be treated Employee Name fields will be treated as one match data field if more than as one match data field if more than one aspect of the name is changed; one aspect of the name is changed;

Employee ID & Employee ID Type Employee ID & Employee ID Type Qualifier can both change on a single Qualifier can both change on a single MTC 02; MTC 02;

The same is true for Claim The same is true for Claim Administrator FEIN and Claim Administrator FEIN and Claim Administrator Postal CodeAdministrator Postal Code


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If multiple MTC 02’s to change If multiple MTC 02’s to change match data elements are sent in the match data elements are sent in the same batch (i.e., same same batch (i.e., same transmission, same day), the Claim transmission, same day), the Claim Administrator will have to Administrator will have to incorporate the prior change(s) in incorporate the prior change(s) in each subsequent MTC 02 each subsequent MTC 02 transaction(s) and risk that each transaction(s) and risk that each prior MTC 02 was accepted, so that prior MTC 02 was accepted, so that the match data elements will match the match data elements will match ‘down the line’.‘down the line’.


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Changes to data elements Changes to data elements designated as designated as “N”, “NA” or “N”, “NA” or “X”“X” on FL’s Element on FL’s Element Requirement Table, that are Requirement Table, that are sent on an MTC “02” sent on an MTC “02” transaction, transaction, will not be will not be processed/loaded to the processed/loaded to the Division’s database.Division’s database.


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Also, invalid data sent Also, invalid data sent on an MTC “02” on an MTC “02” transaction will not transaction will not overlay existing data on overlay existing data on the Division’s database.the Division’s database.


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Data previously required Data previously required or reported on another or reported on another transaction will be transaction will be expected to be included expected to be included on the MTC 02 on the MTC 02 transaction. transaction.


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Change Change Previously Previously Sent Data Sent Data to Spacesto Spaces

Data

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Change Previously Sent Change Previously Sent Data to SpacesData to Spaces

Florida will Florida will notnot be setting data be setting data to spaces based on MTC 02.to spaces based on MTC 02.

If a data element was If a data element was reported in error and needs to reported in error and needs to be be removedremoved (vs. changed), the (vs. changed), the Claim Administrator should Claim Administrator should contact the Division for contact the Division for special handling. special handling.

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SROI SROI MTC “02”MTC “02”

Reporting a Benefit Reporting a Benefit Redistribution for Child Redistribution for Child SupportSupport (after Initial Payment)(after Initial Payment)

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Benefit Redistribution for Benefit Redistribution for Child SupportChild SupportIf a portion of the Net If a portion of the Net Weekly Amount is being Weekly Amount is being directed to another party directed to another party due to a court ordered lien due to a court ordered lien for child support, an for child support, an Electronic Notice of Action Electronic Notice of Action or Change is represented or Change is represented by sending:by sending:

MTC 02MTC 02

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NoteNote: MTC “CA” does not : MTC “CA” does not apply as the Net Weekly apply as the Net Weekly Amount is unchanged. Amount is unchanged.

Benefit Redistribution for Benefit Redistribution for Child SupportChild Support

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SCENARIO: SCENARIO:

SROI MTC “02”SROI MTC “02”

Reporting a Benefit Reporting a Benefit

Redistribution for Child Redistribution for Child

SupportSupport (after Initial (after Initial Payment)Payment)

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Reporting a Benefit Redistribution for Reporting a Benefit Redistribution for Child SupportChild Support

Court-ordered child support Court-ordered child support in the amount of $50/week in the amount of $50/week has been assessed has been assessed against the employee’s WC against the employee’s WC benefits. Amount is to be benefits. Amount is to be paid directly paid directly to employee’s ex-to employee’s ex-wife.wife.

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We are going to fill out the We are going to fill out the Benefit and ACR segment Benefit and ACR segment live (time permitting). The live (time permitting). The following slide is the IP following slide is the IP transaction that transaction that immediately preceded the immediately preceded the Benefit Redistribution. Benefit Redistribution.

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The Benefit Redistribution The Benefit Redistribution is now to be reported at is now to be reported at the time the next bi-the time the next bi-weekly is sent. weekly is sent. Please complete the Please complete the Benefit and ACR segment Benefit and ACR segment to report this event. to report this event.

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Benefit Segment last reported Benefit Segment last reported to DWC for IP:to DWC for IP:

IIPP

2007072007071313

1313,,000000

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160001600000

$1,600.0$1,600.0002007062920070629 June 29, June 29,

20072007

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Now lets build the Benefit Now lets build the Benefit and ACR Segments for a and ACR Segments for a

Redistribution of BenefitsRedistribution of Benefits

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Variable Segment Counters

0288 Number of Benefits 01

0283 Number of Payments 00

0282Number of Other Benefits 00

0289 Number of Benefit ACR 001

0284 Number of Recoveries 00

0285Number of Reduced Earnings 00

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0275Number of Concurrent Employers 00

0277Number of Full Denial Reason Code 00

0276Number of Denial Reason Narratives 00

0287Number of Suspension Narratives 00

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Benefits 1 Occ

0085 Benefit Type Code 050 Temporary Total

0002Maintenance Type Code 02 Change

0174 Gross Weekly Amount 00000040000 $400.00

0175Gross Weekly Amount Effective Date 20070615

June 15, 2007

0087 Net Weekly Amount 00000040000 $400.00

0211Net Weekly Amount Effective Date 20070615

June 15, 2007

0088Benefit Period Start Date 20070616

June 16, 2007

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0089Benefit Period Through Date 20070727

July 27, 2007

0090Benefit Type Claim Weeks 0006

0091Benefit Type Claim Days 0

0086Benefit Type Amount Paid 00000240000 $2,400.00

0192Benefit Payment Issue Date N/A

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Benefit ACR 1 Occurrence

0130

Benefit Redistribution Code H050

Court Ordered Lien

0131

Benefit Redistribution Start Date 20070720

July 20, 2007

0132 Benefit Redistribution End Date

Blank because redistribution is

continuing

0133

Benefit Redistribution Weekly Amount 00000005000 $50.00

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Reporting Benefit Reporting Benefit Redistribution for Child Redistribution for Child Support (after initial Support (after initial payment):payment):If the lien for Child Support If the lien for Child Support ends and indemnity is ends and indemnity is ongoing, MTC 02 should be ongoing, MTC 02 should be sent with a Benefit sent with a Benefit Redistribution segment Redistribution segment reflecting an End Date.reflecting an End Date.

If all indemnity is being If all indemnity is being suspended, the Benefit suspended, the Benefit Redistribution segment Redistribution segment reflecting an End Date can be reflecting an End Date can be sent on the Sx. sent on the Sx.

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Questions?Questions?

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SuspensionsSuspensions(Full)(Full)

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Pop Quiz: Pop Quiz:

Are Suspensions an Are Suspensions an

““Event”Event” Benefit Benefit Segment, or Segment, or

““Sweep”Sweep” Benefit Benefit Segment?Segment?

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Answer: Answer:

““Event”Event” Benefit Benefit Segment Segment

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Suspensions Suspensions (Full) (Full) If If ALLALL payments of payments of

indemnity benefits have indemnity benefits have stopped (not just one class stopped (not just one class of benefits), of benefits), an an Electronic Electronic Notice of SuspensionNotice of Suspension is is represented by sending:represented by sending:

SROI S1-S8.SROI S1-S8.See Rule 69L-56.3045(5), F.A.C.See Rule 69L-56.3045(5), F.A.C.

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Suspensions Suspensions (Full) (Full) Please be aware that if Please be aware that if

you previously sent a you previously sent a paper DWC-4 to report a paper DWC-4 to report a suspension of one type of suspension of one type of benefit, or return to work; benefit, or return to work; however, however, ALL ALL benefits benefits were really were really NOTNOT suspended, you will have suspended, you will have to reinstate benefits (MTC to reinstate benefits (MTC RB) prior to sending the RB) prior to sending the next event.next event.

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SuspensionsSuspensionsHint:Hint: If you file an If you file an incorrect Suspension Code incorrect Suspension Code MTC via R3, you can MTC via R3, you can correct the Suspension correct the Suspension MTC by sending in a MTC by sending in a subsequent Suspension subsequent Suspension MTC, as long as the MTC, as long as the Suspension Effective Date Suspension Effective Date is the is the same assame as the the previous one. previous one.

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Full Suspension Full Suspension MTC CodesMTC Codes

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S1S1 Suspension, Suspension, RTW, or RTW, or Medically Determined to RTWMedically Determined to RTW

S2S2 Suspension, Suspension, MedicalMedical Non- Non-Compliance Compliance

S3S3 Suspension, Suspension, Administrative Administrative Non-ComplianceNon-Compliance

S4S4 Suspension, Suspension, Claimant DeathClaimant Death

Full Suspension Full Suspension MTC’sMTC’s

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S5S5 Suspension, Suspension, Incarceration Incarceration

S6S6 Suspension, Suspension, Whereabouts Whereabouts UnknownUnknown

S7S7 Suspension, Suspension, Benefits Benefits

Exhausted Exhausted

S8S8 Suspension, Suspension, Jurisdiction Jurisdiction

Change Change

Full Suspension Full Suspension MTC’sMTC’s

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SCENARIO:SCENARIO:

SROI MTC “S1”SROI MTC “S1”

Suspension,Suspension, RTWRTW

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SROI MTC “S1”SROI MTC “S1” ScenarioScenario

Suspension,Suspension, RTW or Medically RTW or Medically Released to RTWReleased to RTWTT Benefits commenced TT Benefits commenced

effective 6/16/07.effective 6/16/07.

On 8/27/07, the Clm. Admin. On 8/27/07, the Clm. Admin. receives notification receives notification the EEthe EE RTW’d with the same employer RTW’d with the same employer on 8/25/07, with no restrictions,on 8/25/07, with no restrictions, and mails the EE’s last TT and mails the EE’s last TT check.check.

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SROI MTC “S1” SROI MTC “S1” ScenarioScenario

Suspension,Suspension, RTW or Medically Released to RTW or Medically Released to RTWRTWOn 8/27/07, the Clm. Admin. On 8/27/07, the Clm. Admin.

sends a sends a SROI “S1” SROI “S1” to DWC to DWC to report the suspension of to report the suspension of all indemnity benefits.all indemnity benefits.

Partial Display of SROI Record Layout – (only pertinent DN’s displayed)

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Suspension, RTW or Medically Released to RTWEE RTW 8/25/07 w/same EE RTW 8/25/07 w/same employer, no restrictions. employer, no restrictions. TT was suspended effective TT was suspended effective 8/24/07.8/24/07.


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““SUSPENSION EFFECTIVE SUSPENSION EFFECTIVE DATE” DATE”

For MTC’s S1-S8 For MTC’s S1-S8 (Suspension):(Suspension):

The The last date last date throughthrough which which allall indemnity benefits are indemnity benefits are duedue..

Note:Note: This date is not always the This date is not always the last day through which benefits last day through which benefits were paid if there was an were paid if there was an overpayment.overpayment.

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SROI MTC “S1” SROI MTC “S1” ScenarioScenarioSince Suspension MTC’s are Since Suspension MTC’s are

considered Events”, the MTC is considered Events”, the MTC is required in the required in the BenefitsBenefits segment. segment.All required benefit information is also All required benefit information is also sent.sent.

0

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SUSPENSION NARRATIVE SUSPENSION NARRATIVE SEGMENTSEGMENT

Per IAIABC Variable Segment Per IAIABC Variable Segment Rules:Rules:

Maximum of 3 “Suspension Maximum of 3 “Suspension Narrative” segments may be Narrative” segments may be sent, and sent, and

Must equal the Must equal the ““Number of Number of SuspensionSuspension Narratives” sent Narratives” sent..

Note:Note: This is an “If This is an “If Available/Applicable” field for Available/Applicable” field for FL, but not required.FL, but not required.

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Only 1 Benefit Type was paid, and Only 1 Benefit Type was paid, and Suspension Narrative was sent with Suspension Narrative was sent with < 50 characters, so corresponding < 50 characters, so corresponding Number (segment counters) = 1.Number (segment counters) = 1.


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Suspension,Suspension, RTW or Medically RTW or Medically Released to RTWReleased to RTW

The “Suspension Narrative” The “Suspension Narrative” segment:segment:


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SROI MTC “S1” SROI MTC “S1” ScenarioScenario Suspension,Suspension, RTW or RTW or

Medically Released to RTWMedically Released to RTWThis scenario does not reflect any This scenario does not reflect any “Other Benefits”“Other Benefits” segments segments because the majority of medical-because the majority of medical-type expenses (e.g., physician, type expenses (e.g., physician, hospital, etc.), are not required to hospital, etc.), are not required to be reported to the Division via the be reported to the Division via the Claims EDI R3 format. Claims EDI R3 format.

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SROI MTC “S1” SROI MTC “S1” ScenarioScenario Suspension,Suspension, RTW or RTW or

Medically Released to RTWMedically Released to RTWSee FL’s “Element See FL’s “Element Requirement Table” (and Requirement Table” (and rule) for “Other Benefit rule) for “Other Benefit Types” required to be Types” required to be reported for Claims EDI R3 reported for Claims EDI R3 filings. filings.

(e.g., Funeral, Total Other (e.g., Funeral, Total Other Medical, Voc Rehab).Medical, Voc Rehab).

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Issues with S1 transactions:Issues with S1 transactions:1.1. If EE released to return to work with restrictions, If EE released to return to work with restrictions,

but is not returning to work, an IRTW date must but is not returning to work, an IRTW date must still be reported, with a RTW Type Code “R” for still be reported, with a RTW Type Code “R” for Released.Released.

2.2. If EE returned to work light duty, and TP benefits If EE returned to work light duty, and TP benefits might be paid when earnings are obtained, an S1 might be paid when earnings are obtained, an S1 should not be filed. The return to work information should not be filed. The return to work information should be reported via MTC 02.should be reported via MTC 02.

3.3. If TP is subsequently paid, it would be reported via If TP is subsequently paid, it would be reported via MTC CB. MTC CB.

4.4. Do not send an Sx unless Do not send an Sx unless ALLALL indemnity is indemnity is suspended.suspended.

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SROI MTC “S8”SROI MTC “S8”Suspension,Suspension, Jurisdiction Jurisdiction

ChangeChange

SROI MTC “S8” SROI MTC “S8” Suspension,Suspension, Jurisdiction Jurisdiction

ChangeChange

Another state’s workers’ comp Another state’s workers’ comp Act, Act,

Or ,Or , U.S. Longshoremen’s and U.S. Longshoremen’s and Harbor Workers’ Compensation Harbor Workers’ Compensation

Act, Act,

Or ,Or ,

MTC “S8”MTC “S8” is used to report the is used to report the suspension of all indemnity suspension of all indemnity benefits when a claim is transferred benefits when a claim is transferred to another jurisdiction after to another jurisdiction after indemnity benefits have been indemnity benefits have been initiated, i.e.,initiated, i.e.,

SROI MTC “S8” SROI MTC “S8” Suspension,Suspension, Jurisdiction Jurisdiction

ChangeChange Federal Employers’ Liability Federal Employers’ Liability

Act,Act,

Or,Or,

Federal Employees’ Federal Employees’ Compensation Act,Compensation Act,

Or,Or,

Jones Act. Jones Act.

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No further EDI filings No further EDI filings

(e.g., SROI MTC FN) are (e.g., SROI MTC FN) are required to be sent to required to be sent to the Division after the the Division after the acceptance of MTC “S8”.acceptance of MTC “S8”.

SROI MTC “S8”SROI MTC “S8”

Suspension,Suspension, Jurisdiction Jurisdiction ChangeChange

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Reminder:Reminder: Jurisdiction Jurisdiction Transfer Transfer

Claim administrator then Claim administrator then sends the following to the sends the following to the appropriate state (if appropriate state (if applicable):applicable):

FROI MTC FROI MTC “00”“00” SROI MTC SROI MTC “IP”“IP” (or other applicable SROI)(or other applicable SROI)

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If a claim is If a claim is transferred transferred TOTO FL FL fromfrom another another jurisdiction (i.e., a jurisdiction (i.e., a different state, or different state, or compensation act, compensation act, etc.)… etc.)…


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The claim administrator The claim administrator should send should send FROI 00 and FROI 00 and SROI IPSROI IP (or other (or other FROI/SROI filing FROI/SROI filing equivalent), equivalent), and and

Report Report Late Reason Code Late Reason Code “L4” – Late Notification, “L4” – Late Notification, Jurisdiction TransferJurisdiction Transfer . .


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If no indemnity was paid If no indemnity was paid (e.g., 04, 00/PD, 00/CD, or (e.g., 04, 00/PD, 00/CD, or 00/VE on file), 00/VE on file), or indemnity or indemnity was paid but check(s) was was paid but check(s) was returned/voided/cancelled returned/voided/cancelled prior to the change in prior to the change in jurisdiction, the Claim Admin. jurisdiction, the Claim Admin. should send:should send:MTC “01” to Cancel the MTC “01” to Cancel the claim with the Division (since claim with the Division (since indemnity is not being indemnity is not being suspended) and not an S8.suspended) and not an S8.

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Partial Partial Suspension Suspension

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Partial Suspension Partial Suspension

A Partial Suspension A Partial Suspension occurs when 1 of the occurs when 1 of the 2 “concurrent” 2 “concurrent” benefits is benefits is suspended, but the suspended, but the other Benefit Type other Benefit Type continues.continues.

For Concurrent Benefit For Concurrent Benefit Types OnlyTypes Only

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SROI MTC “P7”:SROI MTC “P7”: Partial Partial Suspension, Suspension, Benefits ExhaustedBenefits Exhausted

Partial Suspension Partial Suspension For Concurrent Benefit For Concurrent Benefit Types OnlyTypes Only

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For FL – For FL – SROI MTC “P7”SROI MTC “P7” is is used when Permanent used when Permanent Total Supplemental (021) Total Supplemental (021) benefits are suspended, benefits are suspended, but Permanent Total but Permanent Total (020) benefits are (020) benefits are continuing.continuing.

See Rule 69L-56.3045(5)(j), See Rule 69L-56.3045(5)(j), F.A.C.F.A.C.

For Concurrent Benefit For Concurrent Benefit Types OnlyTypes Only

Partial Suspension Partial Suspension

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EXISTING CLAIMEXISTING CLAIM:: Suspension of PT Suspension of PT Supp Supp Only Only (Partial (Partial Suspension)Suspension)

If PT Supplemental Benefits If PT Supplemental Benefits (021) are being suspended, (021) are being suspended, but PT Benefits (020) are but PT Benefits (020) are continuing to be paid, an continuing to be paid, an

Electronic Notice of Electronic Notice of Action or Action or Change is dueChange is due

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SCENARIO:SCENARIO:

SROI MTC SROI MTC “P7”“P7”

Partial Suspension of a Partial Suspension of a Concurrent Benefit Type Concurrent Benefit Type

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SROI MTC “P7” SROI MTC “P7” ScenarioScenario Previously Submitted Reports:Previously Submitted Reports:

1.1. FROI MTC “FROI MTC “00”00” (Original) sent (Original) sent withwith

SROI MTC “SROI MTC “IP”IP” (Initial Payment) (Initial Payment)

2.2. SROI MTC SROI MTC “CB”“CB” (Change in (Change in Benefit) Benefit) -TTD to IB-TTD to IB

andand ……

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Previously Submitted Reports:Previously Submitted Reports:


3.3. SROI MTC SROI MTC “CB”“CB” (Change in (Change in Benefit)Benefit)- IB to PT- IB to PT

4.4. SROI MTC SROI MTC “AB”“AB” (Add Concurrent (Add Concurrent Benefit)Benefit)

-- PT Supp after PTPT Supp after PT

SROI MTC “P7” SROI MTC “P7” ScenarioScenario

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Because the employee Because the employee will reach age 62 on will reach age 62 on 2/10/09, the claim 2/10/09, the claim administrator by law is administrator by law is not required to continue not required to continue payment of PT Supp payment of PT Supp Benefits after that date.Benefits after that date.


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On 2/16/09, the claim On 2/16/09, the claim administrator suspends Benefit administrator suspends Benefit Type 021 (PT Supp), and sends Type 021 (PT Supp), and sends SROI SROI “P7”“P7” to DWC to report the to DWC to report the partial suspension of indemnity partial suspension of indemnity benefits, specifically, PT Supp benefits, specifically, PT Supp Benefits, effective 2/10/09, along Benefits, effective 2/10/09, along with corresponding payment with corresponding payment

information.information.


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PT Supplemental Benefits PT Supplemental Benefits are suspended effective are suspended effective

2/10/09.2/10/09.


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SROI SROI “P7”“P7” (Partial (Partial Suspension of a Concurrent Suspension of a Concurrent Benefits) is sent to DWC on Benefits) is sent to DWC on 02/16/2009.02/16/2009.


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Three different Benefit Three different Benefit Types have been paid on Types have been paid on

this claim.this claim.


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MTC “P7”MTC “P7” is reported in is reported in the the Benefits Benefits segment segment for the “concurrent” for the “concurrent” benefit type that is benefit type that is being stopped.being stopped.

Partial Partial SuspensionsSuspensionsBecause a Partial Because a Partial

Suspension is Suspension is considered an considered an “Event”“Event”, ,

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MTC MTC “P7”“P7” is placed in the is placed in the Benefits Benefits segment for BTC 021 segment for BTC 021 (PT Supp).(PT Supp).


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Required Benefit information is Required Benefit information is provided.provided.


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The two remaining Benefit Type The two remaining Benefit Type Codes are sent as “Sweep” Codes are sent as “Sweep” BenefitsBenefits segments. segments.


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Reinstatement Reinstatement of Benefitsof Benefits

By Claim By Claim AdministratorAdministrator

SROI MTC “RB”SROI MTC “RB”

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If Indemnity payments If Indemnity payments previously paid by the previously paid by the Claim Administrator Claim Administrator are are being resumed by the being resumed by the Claim Administrator, Claim Administrator, an an Electronic Notice of Electronic Notice of ReinstatementReinstatement is is represented by sending:represented by sending:

SROI RBSROI RB

MTC “RB” Reinstatement of MTC “RB” Reinstatement of BenefitsBenefits

By Claim AdministratorBy Claim Administrator

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Note:Note: The reinstated Benefit The reinstated Benefit Type Type may or may notmay or may not have have been previously paid.been previously paid.



See Rule 69L-56.3045(6)(a), See Rule 69L-56.3045(6)(a), F.A.C.F.A.C.

SROI SROI MTC MTC “S1-S8”“S1-S8” (Full Suspension),(Full Suspension),

Or, Or,

A previous Subsequent A previous Subsequent Report (SROI) must have Report (SROI) must have been filed terminating all been filed terminating all indemnity benefits via indemnity benefits via either:either:



Where the SROI “04” or Where the SROI “04” or “PD”“PD”is acting like a suspension is acting like a suspension because all indemnity because all indemnity benefits are being benefits are being terminated at the time of terminated at the time of denial.denial.

SROI MTC SROI MTC “04”“04” (Full (Full Denial) or Denial) or SROI MTC SROI MTC “PD”“PD” with with Partial Partial Denial Codes A Denial Codes A or E. or E.



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For all MTC’s that initiate or For all MTC’s that initiate or reinstatereinstate a Benefit Type Code a Benefit Type Code (AB, IP, (AB, IP, RBRB, EP, ER, CB): , EP, ER, CB): The “Benefit Period Start The “Benefit Period Start Date” is the Date” is the first date of the first date of the uninterrupted perioduninterrupted period of of benefit payments that benefit payments that corresponds to the Benefit corresponds to the Benefit Type Code being paid.Type Code being paid.

““Benefit Period Start Benefit Period Start Date”Date”



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SCENARIO:SCENARIO:

SROI MTC “RB”SROI MTC “RB”Reinstatement of Reinstatement of BenefitsBenefits

by Claim Administrator by Claim Administrator After Prior SuspensionAfter Prior Suspension

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SROI MTC “RB” ScenarioSROI MTC “RB” ScenarioReinstatement of BenefitsReinstatement of Benefits by Claim by Claim

Admin. Admin. after Prior Suspensionafter Prior Suspension TThe Claim Administrator he Claim Administrator

initiated payment of TT Benefits initiated payment of TT Benefits effective 6/16/07 (MTC 00/IP).effective 6/16/07 (MTC 00/IP).

The Claim Admin. subsequently The Claim Admin. subsequently suspended all indemnity suspended all indemnity benefits because the employee benefits because the employee RTW’d full duty, no restrictions RTW’d full duty, no restrictions (SROI MTC S1).(SROI MTC S1).

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SROI MTC “RB” SROI MTC “RB” ScenarioScenario Reinstatement Reinstatement by by

Claim AdministratorClaim AdministratorEmployee’s doctor determined EE Employee’s doctor determined EE

reached MMI on 10/8/07, with a PI reached MMI on 10/8/07, with a PI rating of rating of 25% to the whole body.25% to the whole body.

On 10/21/07, Clm. Admin. mails On 10/21/07, Clm. Admin. mails aa check to the employee for the check to the employee for the initial installment of IB benefits. initial installment of IB benefits. EE EE is due IB’s at weekly rate of is due IB’s at weekly rate of 50% of 50% of

the comp rate.the comp rate.

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The Date of MMI is also The Date of MMI is also reported.reported.

SROI MTC “RB” SROI MTC “RB” ScenarioScenario

Reinstatement Reinstatement by Claim by Claim AdministratorAdministrator

On 10/21/07, the Claim Admin. On 10/21/07, the Claim Admin. notifies DWC re: the re-notifies DWC re: the re-instatement indemnity benefits.instatement indemnity benefits.


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SROI MTC “RB” SROI MTC “RB” ScenarioScenarioOne Permanent Impairment One Permanent Impairment

segment segment reports 25% “Whole Body” reports 25% “Whole Body” impairmentimpairment

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Two Benefit Types have been Two Benefit Types have been paid.paid.



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EventEvent Benefits Benefits segment for the segment for the reinstated Benefit Type has reinstated Benefit Type has complete details.complete details.



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SweepSweep Benefits Benefits segment (for the segment (for the previously reported benefit type)previously reported benefit type)


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Electronic Notice Electronic Notice of of Reinstatement Reinstatement of of Employer PaidEmployer Paid

BenefitsBenefits

Rule 69L-56.3045(6)(b), Rule 69L-56.3045(6)(b), F.A.C.F.A.C.

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If If the employerthe employer is resuming is resuming payment of salary in lieu of payment of salary in lieu of compensation following the compensation following the suspension of all prior suspension of all prior employer paidemployer paid indemnity indemnity benefits, an Electronic benefits, an Electronic Notice of Action or Change Notice of Action or Change is represented by sending:is represented by sending:

SROI ERSROI ER

Reinstatement of Reinstatement of Employer Employer PaidPaid Benefits Benefits

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1 Florida Division of Workers Compensation Claims EDI Release 3 Training 2008 (Continued)

Documents

Transcript of 1 Florida Division of Workers Compensation Claims EDI Release 3 Training 2008 (Continued)