Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-56 - ELECTRONIC DATA INTERCHANGE (EDI) REQUIREMENTS FOR PROOF OF COVERAGE AND CLAIMS (NON-MEDICAL) › Section 69L-56.002 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
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, January 1,
				  2009 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, 6/01/07 Edition", and in the IAIABC
				  "Glossary", October 2008, and in the IAIABC Claims EDI R3 "Supplement" January
				  2009 and the IAIABC POC EDI R2.1 "Supplement", June 2007, 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
, under "EDI"
				  link, then "Implementation Guides" link.
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, F.S.
(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 State Holidays under
http://dms.myflorida.com/human_resource_support/human_resource_management/for_state_hr_practitioners
).
(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)
				"Cancellation/Non-Renewal Effective Date" means the Transaction Set Type
				Effective Date as defined in the IAIABC EDI Implementation Guide for Proof of
				Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records,
				Release 2.1, 6/01/07, for a cancellation or non-renewal of any workers'
				compensation insurance policy, contract of insurance or renewal; and shall be
				effective at 12:01 a.m. on the Transaction Set Type Effective Date reported to
				the Division, or the Cancellation/Non-Renewal Effective Date derived by the
				Division as determined in Rule
				 69L-56.200, F.A.C.
(10) "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, F.S., 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.
(11) "Claim Administrator" means any insurer,
				service company/third party administrator, self-serviced self-insured employer
				or fund, or managing general agent, responsible for adjusting workers'
				compensation claims, that is electronically sending its data directly to the
				Division.
(12) "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.
(13) "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.
(14) "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").
(15) "Client Company" is as defined in
				Section  468.520(6),
				F.S.
(16) "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).
(17) "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.
(18) "Days" means calendar days, unless
				otherwise noted.
(19) "Denied Case"
				means a "Full Denial" or "Partial Denial" case for which all indemnity benefits
				are initially denied by the claim administrator.
(20) "Department" means the Department of
				Financial Services.
(21) "Division"
				means the Division of Workers' Compensation.
(22) "Electronic Data Interchange" (EDI)
				means a computer-to-computer exchange of business transactions in a
				standardized electronic format.
(23) "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 do not include information sent by facsimile, file data attached to
				electronic mail, or computer-generated paper forms.
(24) "Employee Leasing" is as defined in
				Section  468.520(4),
				F.S.
(25) "Employee Leasing
				Company" is as defined in Section
				 468.520(5),
				F.S.
(26) "Employee Leasing Policy
				Identification Code" is a code which identifies a policy written as an employee
				leasing policy, and the type of leasing operation.
(27) "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.
(28) "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).
(29) "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, January 1, 2009, which is
				incorporated herein by reference. A copy of the guide may be obtained from the
				IAIABC's website at
http://www.iaiabc.org
, under "EDI" link,
				then "Implementation Guides" link.
(30) "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).
(31) "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.
(32) "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.
(33) "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.
(34) "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) 2007 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
.
(35) "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, F.S., after fulfilling
				the seven (7) day waiting week requirement in Section
				 440.12, F.S. The Initial Date of
				Lost Time does not mean the "Initial Date Disability Began."
(36) "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.
(37)
				"Insurer" means an insurer as defined in Section
				 440.02, F.S.
(38) "Insurer Code #" means the
				Division-assigned number for the insurer bearing the financial risk of the
				claim.
(39) "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.
(40) "Knowledge" or "Notification" means an
				entity's earliest receipt of information, including by mail, telephone,
				facsimile, direct personal contact, or electronic submission.
(41) "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 pursuant to Section 440.02(15)(d)6., F.S., 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, F.S., 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).
(42) "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.
(43) "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[TM] Manual 2009 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.
(44) "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.
(45) "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).
(46) "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.
(47) "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."
(48) "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.
(49) "Permanent Impairment Percentage" means
				"Permanent Impairment" as defined in Section
				 440.02, F.S.
(50) "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.