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REQUIREMENTS FOR PROOF OF COVERAGE AND CLAIMS (NON-MEDICAL) › Section 69L-56.3012 - Electronic Notice of Denial and Rescinded Denial

Current through Reg. 50, No. 138; July 16, 2024
(FROI/SROI MTC 04, SROI MTC PD as found in the IAIABC
				  Implementation Guide for Claims: First, Subsequent, Header, Trailer &
				  Acknowledgement Detail Records, Release 3, January 1, 2009 Edition).
On or before the compliance date established in the insurer's
				  Primary Implementation Schedule set forth in paragraph
				   69L-56.301(3)(a),
				  F.A.C., the insurer shall file the electronic form equivalent for the denial
				  information otherwise reported on Form DFS-F2-DWC-12, adopted in Rules
				   69L-56.4012 and
				   69L-3.025, F.A.C. The claim
				  administrator shall send to the Division an Electronic Notice of Denial to
				  report the reason for the denial of indemnity benefits for the following types
				  of denial notices, and by the following time periods:
(1) Electronic Notice of Denial - Full (Both
				Indemnity and Medical Benefits Denied):
(a)
				If the entire compensability of the claim is initially denied and both
				indemnity and medical benefits will not be paid by the claim administrator, the
				claim administrator shall file the Electronic Notice of Denial by reporting the
				applicable Full Denial Reason Code(s) and Full Denial Effective Date on the
				same FROI MTC 04 (Denial) the claim administrator sends to the Division to
				report the Electronic First Report of Injury or Illness, in accordance with
				filing time periods in subsection
				 69L-56.301(2),
				F.A.C. The Denial Reason Narrative shall also be sent on the FROI MTC 04
				(Denial) to supplement the Full Denial Reason Code(s).
(b) If the claim administrator initially
				accepts compensability but subsequently denies liability for the entire claim
				after having previously paid indemnity benefits and the Electronic First Report
				of Injury or Illness has already been filed with the Division, the claim
				administrator shall file the Electronic Notice of Denial by sending a SROI MTC
				04 (Denial). The Electronic Notice of Denial will be considered timely filed
				with the Division if it is received by the Division and is assigned an
				Application Acknowledgement Code of "TA" (Transaction Accepted) on or before 14
				days after the date the claim administrator decided to deny benefits. The claim
				administrator shall report the applicable Full Denial Reason Code(s) and Full
				Denial Effective Date on the SROI MTC 04 (Denial). The Denial Reason Narrative
				shall also be sent on the SROI MTC 04 (Denial) to supplement the Denial Reason
				Code(s).
(c) In addition to filing
				the Electronic Notice of Denial with the Division, the claim administrator
				shall produce and mail a paper copy of Form DFS-F2-DWC-12, Notice of Denial,
				adopted in Rules  69L-56.4012 and
				 69L-3.025, F.A.C., to the
				employer and employee, in accordance with the filing time period set out for
				Form DFS-F2-DWC-12 in Rule
				 69L-56.4012,
				F.A.C.