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-56.320 - Claims EDI Test and Production Status Requirements

Current through Reg. 50, No. 138; July 16, 2024
(1) Prior to sending an initial test
				transmission, the claim administrator shall file the EDI Trading Partner forms
				required in subsection
				 69L-56.300(2),
				F.A.C. If a form is incomplete and does not contain responses to all of the
				required fields in accordance with the form instructions, testing with the
				Division will not commence until the corrected form(s) is re-filed with the
				Division.
(2) If the claim
				administrator has contracted with a vendor to send Claims EDI filings on its
				behalf to the Division, the claim administrator shall comply with the testing
				requirements in this section before being approved for production status, even
				if the vendor has been previously approved by the Division for production
				status with another client.
(3)
				During the Claims EDI testing period and until the claim administrator is
				approved for production status for sending the required electronic form
				equivalents required by this rule, the claim administrator shall continue to
				file Forms DFS-F2-DWC-1, DFS-F2-DWC-12, DFS-F2-DWC-13 and DFS-F2-DWC-4 and
				DFS-F2-DWC-49 in accordance with Rules
				 69L-56.4011,
				 69L-56.404,
				 69L-56.4012,
				 69L-56.4013 and
				 69L-3.025, F.A.C.
(4) The claim administrator shall send test
				files in the correct IAIABC Release 3 formats specified in Section 2, Technical
				Documentation, of the IAIABC Claims EDI Release 3 Implementation Guide, and
				comply with transmission requirements set out in Rule
				 69L-56.310, F.AC.
(5) The insurer or claim administrator shall
				indicate the Maintenance Type Codes (MTC's) it will be sending, if not all
				MTC's will be initially tested at the same time (e.g., MTC's not required until
				the insurer's Secondary Implementation Schedule). The claim administrator shall
				file a revised Form DFS-F5-DWC-EDI-3, EDI Transmission Profile - Sender
				Specifications, to report any new MTC's that will be added during the test to
				production periods.
(6) The claim
				administrator shall also indicate on its Form DFS-F5-DWC-EDI-3, Transmission
				Profile - Sender Specifications, the frequency with which files will be sent to
				the Division, i.e., daily, weekly. Test files shall consist of Claims EDI
				Filings that correspond with Forms DFS-F2-DWC-1, DFS-F2-DWC-12, DFS-F2-DWC-13,
				and DFS-F2-DWC-4 adopted in Rules
				 69L-3.025, F.A.C., that were
				previously mailed to the Division at least one week prior to the date the test
				transmission containing the corresponding Electronic First Report of Injury or
				Illness, Electronic Notice of Denial, Electronic Periodic Claim Cost Report,
				and Electronic Notice of Action or Change, Suspension, and Reinstatement of
				Indemnity Benefits information is sent to the Division. If the claim
				administrator is unable to transmit test files on a daily or weekly basis due
				to a low volume of actual claim filings being mailed to the Division during the
				specified testing frequency, the claim administrator may create and send "mock"
				paper and electronic filings for Claims EDI testing purposes. The claim
				administrator shall clearly mark any mock paper filings as an "EDI Test Filing"
				and fax the mock paper filings to the Division's Claims EDI Team at
				(850)488-3453.
(7) Data element
				values sent on the test Claims EDI filings shall match values reported on the
				corresponding paper form filing. If differences are detected and cited in a
				written parallel analysis report issued to the claim administrator by the
				Division, the claim administrator shall confirm if the electronic version
				contained the accurate data, or otherwise provide an explanation for the
				discrepancy. The claim administrator shall investigate and reconcile its
				database as necessary in conjunction with data errors identified during the
				test period(s).
(8) The claim
				administrator shall send the following minimum number of Claims EDI filings
				during the test period(s), of which 90% of each of the required categories
				specified in paragraphs (5)(a) through (f) of this section shall receive an
				Application Acknowledgement Code of "TA":
(a)
				Ten (10) Electronic First Report of Injury or Illness filings utilizing at
				least two of each of the following required FROI/SROI MTC combinations: 00/IP,
				00/EP, and 00/PY. MTC's 00/CD, 00/VE, and AU/AP may be optionally included in
				the testing period. The claim administrator shall send one of the two required
				MTC 00/IP filings with Claim Type "I" and the other required MTC 00/IP filing
				with Claim Type "L."
(b) Five (5)
				Electronic Denied First Report of Injury or Illness filings utilizing at least
				one FROI MTC 04 (Full Denial) and one FROI MTC 00 with SROI PD (Partial
				Denial). The Electronic First Report of Injury or Illness shall include the
				applicable Full Denial Reason Code(s) and Partial Denial Code with Denial
				Reason Narrative, to report the Electronic Notice of Denial
				information.
(c) Ten (10)
				Electronic Periodic Claim Cost filings utilizing at least two each of the
				following SROI MTC's: SA or FN. A corresponding paper or Electronic First
				Report of Injury or Illness must have been previously accepted in test or
				production status before testing MTC SA or FN.
(d) Five (5) Electronic Notice of Denial
				filings (post-EDI DWC-1) utilizing at least one each of the following SROI
				MTC's: MTC 04 and PD. (Electronic First Report of Injury or Illness must have
				been previously accepted in test or production status before testing these EDI
				filings.)
(e) Five (5) Electronic
				Notice of Action or Change transactions based on electronic filings required in
				the insurer's Primary Implementation Schedule for the initial testing period if
				not all MTC's will be implemented by the insurer during its Primary
				Implementation Schedule, utilizing either FROI or SROI MTC 02 (Change). A
				corresponding paper or Electronic First Report of Injury or Illness must have
				been previously accepted in test or production status before testing these EDI
				filings with the Division.
(f) Five
				(5) of the following Electronic Notice of Action or Changes, Suspension and
				Reinstatement of Indemnity Benefits filings required in the insurer's Secondary
				Implementation Schedule utilizing at least two MTC 02 filings, one of which
				shall report a change in the Average Wage with no change to the Net Weekly
				Amount and one MTC 02 that reports a Benefit Redistribution. The claim
				administrator shall also send at least one each of the following MTC's: S1-S8
				(Suspensions); RB (Reinstatement); CA (Change in Amount), CB (Change in Benefit
				Type).