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-56.300 - Claims EDI Reporting Requirements and Implementation Schedules

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a) On
				or before the implementation schedules set out in paragraphs (3)(a) and (b) of
				this section, every insurer shall file claims information for all "Lost
				Time/Indemnity," "Medical Only to Lost Time," and "Denied" cases via electronic
				data interchange (EDI) pursuant to paragraph (d) of this section, rather than
				by submitting paper forms otherwise required in Rules
				 69L-56.4011,
				 69L-56.404,
				 69L-56.4012,
				 69L-56.4013, and
				 69L-3.025, F.A.C. The insurer
				shall file the electronic form equivalent of the First Report of Injury or
				Illness, Notice of Denial, Claim Cost Report, Notice of Action/Change, and
				Aggregate Claims Administration Change Report adopted in Rule
				 69L-3.025, F.A.C., pursuant to
				the requirements and timeframes set out in Rules
				 69L-56.301,
				 69L-56.3012,
				 69L-56.3013,
				 69L-56.304 and
				 69L-56.3045, F.A.C., and in
				accordance with the "FL Claims EDI R3 Trading Partner Filing Specifications"
				contained in Section 1 of the "Florida Division of Workers' Compensation Claims
				Electronic Data Interchange (EDI) R3 Implementation Manual, September 2006" and
				"Supplement," incorporated herein by reference, and hereafter referred to as
				the "FL Claims EDI Implementation Manual." A copy of the FL Claims EDI
				Implementation Manual may be obtained from the Division of Workers'
				Compensation at its website,
http://www.myfloridacfo.com/Division/WC/EDI/Clms_EDI.htm
.
(b) The insurer or its claim administrator
				shall electronically report all First Reports of Injury or Illness for which
				the claim administrator's knowledge of the injury is on or after the date the
				claim administrator is authorized by the Division to send Electronic First
				Reports of Injury or Illness in production status (i.e., actual production
				implementation date). All other electronic form equivalents for denials,
				periodic claim cost information, changes, suspensions, reinstatements, and
				cancellations required by this rule shall be electronically reported to the
				Division, regardless of date of injury, once the claim administrator is
				approved by the Division to send these electronic filings in production status
				(i.e., actual production implementation date).
(c) Electronic form equivalents, hereafter
				also referred to as "Claims EDI Filings" required under this rule do not
				correspond exactly to, and may require additional information not currently
				contained on claims forms promulgated under Rules
				 69L-56.4011,
				 69L-56.404,
				 69L-56.4012,
				 69L-56.4013, and
				 69L-3.025, F.A.C. The term,
				"insurer," as defined in this rule chapter, refers to the entity responsible
				for filing electronic form equivalents on or before the compliance dates
				established in the insurer's Primary and Secondary Implementation Schedules set
				out in paragraphs  69L-56.300(3)(a) and
				(b), F.A.C. The term, "claim administrator,"
				as defined in this rule chapter, refers to the trading partner that is sending
				electronic transactions to the Division, which can be either an insurer filing
				directly with the Division on its own behalf, or a servicing company/third
				party administrator filing on the behalf of the insurer. For purposes of this
				rule, the terms "Claim Administrator" and "Trading Partner" do not mean a third
				party vendor.
(d) The claim
				administrator shall report the Claims EDI filings required in Rules
				 69L-56.301,
				 69L-56.3012,
				 69L-56.3013,
				 69L-56.304,
				 69L-56.3045 and
				 69L-56.307, F.A.C., using the
				First Report of Injury (FROI) and Subsequent Report of Injury (SROI) electronic
				record layouts adopted by the International Association of Industrial Accident
				Boards and Commissions (IAIABC). A sample of the FROI, which consists of the
				148 and companion R21 records, and a sample of the SROI, which consists of the
				A49 and companion R22 records, are located in Section 2, "Technical
				Documentation" of the "IAIABC EDI Implementation Guide for Claims: First,
				Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3,
				January 1, 2009 Edition" and "Supplement," incorporated herein by reference,
				and hereafter referred to as the IAIABC Claims EDI Release 3 Implementation
				Guide. A copy of this guide may be obtained from the IAIABC at its website,
http://www.iaiabc.org
, under "EDI"
				link, then "Implementation Guides" link.
The claim administrator shall send the FROI (148/R21), SROI
				  (A49/R22), and combination FROI and SROI records with the Maintenance Type Code
				  (MTC) or MTC combinations specified in Rules
				   69L-56.301,
				   69L-56.3012,
				   69L-56.3013,
				   69L-56.304,
				   69L-56.3045 and
				   69L-56.307, F.A.C., to represent
				  the Claims EDI Filing being sent to the Division. (Example: FROI MTC 04 = Total
				  Denial of an Electronic First Report of Injury or Illness; SROI MTC FN =
				  Electronic Final Claim Cost Report; FROI MTC 00 with SROI MTC IP = Electronic
				  First Report of Injury or Illness where the Initial Payment is made by claim
				  administrator.)
(e) In
				addition to the Technical Documentation and Business/Technical Process Rules
				located in Sections 2 and 4, respectively, of the IAIABC Claims EDI Release 3
				Implementation Guide, the claim administrator shall comply with information
				contained in the below documents located in the Claims EDI Trading Partner
				Filing Specifications of the FL Claims EDI Implementation Manual:
1. "FL Claims EDI R3 Event Table" -
				Identifies the FROI MTC or SROI MTC, and FROI/SROI MTC combinations required to
				be sent for an electronic form equivalent required by this rule, and the
				associated filing time periods by which the FROI and SROI MTC's shall be
				received by the Division in order to be considered timely filed;
2. "FL Claims EDI R3 Element Requirement
				Table" - Specifies the data elements required to be sent for each FROI and SROI
				MTC; and,
3. "FL Claims EDI R3 Edit
				Matrix" - Identifies Division editing that will be applied to data elements and
				transactions, including transaction sequencing and duplicate processing
				rules.
(f) The claim
				administrator shall collect and report all data elements designated with the
				following codes on the FL Claims EDI R3 Element Requirement Table: "F" (Fatal
				Technical) - Required to be reported; "M" (Mandatory) - Required to be
				reported; "MC" (Mandatory/Conditional) - Required to be reported if the
				condition(s) set out in the table's FROI or SROI Conditional Requirements or
				Event Benefits Conditions worksheets are met; "IA" (If Applicable/Available) -
				Required to be reported if the data element is applicable to the claim (e.g.,
				If the claim administrator has knowledge that the employee's Last Name Suffix
				is "Jr", the claim administrator shall report the Last Name Suffix of
				"Jr").
(g) Claims EDI filings that
				comply with data element reporting requirements and pass edits specified in the
				"FL Claims EDI R3 Element Requirement Table" and the "FL Claims EDI R3 Edit
				Matrix" shall be accepted and acknowledged by the Division with Application
				Acknowledgement Code "TA" (Transaction Accepted). Claims EDI filings that
				receive an Application Acknowledgement Code of "TA" shall be assigned a
				"Received by Division Date" for purposes of determining whether an EDI filing
				was timely filed with the Division in accordance with the timeframes identified
				in the "FL Claims EDI R3 Event Table" and as required in Rules
				 69L-56.301,
				 69L-56.3012,
				 69L-56.3013,
				 69L-56.304,
				 69L-56.3045 and
				 69L-56.307, F.A.C. The date
				assigned as the "Received by Division Date" is the date the transmission
				containing the accepted Claims EDI filing was sent to and received by the
				Division based on the technical transmission requirements set out in subsection
				 69L-56.310(4),
				F.A.C. An electronic First Report of Injury or Illness that receives an
				Application Acknowledgement Code of "TA" shall also be assigned a "Jurisdiction
				Claim Number" by the Division which the claim administrator shall report on
				every subsequent Claims EDI filing for that claim. Electronic transactions that
				do not satisfy data element requirements and edits specified in the "FL Claims
				EDI R3 Element Requirement Table" and the "FL Claims EDI R3 Edit Matrix" shall
				be rejected and acknowledged by the Division with Application Acknowledgement
				Code "TR" (Transaction Rejected). The claim administrator shall correct the
				error(s) identified in the acknowledgement returned by the Division and re-send
				the Claims EDI filing to the Division as appropriate. (e.g., a transaction
				receiving fatal error # 0002-057 because it was an extra MTC in the
				transmission or already on file with the Division is not expected to be
				re-filed with the Division.)
(h)
				The claim administrator shall receive and process each acknowledgement
				transaction (AKC) returned by the Division. The Division will also send, when
				applicable, a re-acknowledgment transaction (ACR) to identify a Claims EDI
				filing that was previously acknowledged with Application Acknowledgement code
				"TR" due to improper processing by the Division, and which was subsequently
				re-processed and re-assigned an Application Acknowledgement Code of "TA." The
				claim administrator has the option to either process or not process
				re-acknowledgement transactions sent by the Division.
(i) Claims EDI filings acknowledged with
				Application Acknowledgement Code "TA" (Transaction Accepted) that invoke one or
				more non-rejectable (non-fatal) edits depicted as "FL" in the "DN-Error Message
				Table" of the FL Claims EDI R3 Edits Matrix, shall result in an error message
				that will be communicated by the Division to the claim administrator in a
				proprietary report, separate from the acknowledgement transaction (AKC).
				Non-fatal error reports will be posted to the Division's website in a
				password-protected file, which the claim administrator shall retrieve via the
				"Claims EDI" link on the Division's website. The Division will send an email
				notification to the claim administrator regarding the posting of all non-fatal
				error reports that require a response from the claim administrator. The claim
				administrator shall respond to the Division on or before 21 days after the date
				the report was posted to the Division's website. The email notification will be
				sent to the "EDI Business Contact(s)" identified in the claim administrator's
				"EDI Trading Partner Profile," Form DFS-F5-DWC-EDI-1. The claim administrator
				shall notify the Division regarding any additions or deletions of "EDI Business
				Contacts" for this purpose. The claim administrator shall respond to all other
				inquiries from the Division, including by telephone, concerning written or
				electronic requests for information, on or before 21 days after the claim
				administrator's receipt of the request from the Division.
(j) Unless an explanatory letter is
				alternatively permitted by this rule chapter, paper copies of Forms
				DFS-F2-DWC-1, DFS-F2-DWC-4 and DFS-F2-DWC-12 shall continue to be provided by
				the claim administrator to the employee and employer as required by Rules
				 69L-56.4011,
				 69L-56.404,
				 69L-56.4012,
				 69L-3.025, F.A.C., and as
				specified in Rules  69L-56.301,
				 69L-56.3012,
				 69L-56.304 and
				 69L-56.3045, F.A.C., and the FL
				Claims EDI R3 Event Table ("Paper Form" and "Receiver" columns).
(k) The claim administrator shall produce and
				mail to the employee and employer the informational brochures required in Rules
				 69L-3.0035 and
				 69L-3.0036, F.A.C.
(l) Claim administrators who, directly or
				through its third party vendor, experience a catastrophic event resulting in
				the insurer's failure to meet the filing requirements of this rule, shall
				submit a written or electronic request to the Division for approval to submit
				required electronic form equivalents in an alternative filing timeline. The
				request shall be sent to the Division within 15 business days after the
				catastrophic event. The request shall contain a detailed explanation of the
				nature of the event, date of occurrence, and measures being taken to resume
				electronic submission. The claim administrator shall also provide an estimated
				date by which electronic submission of affected EDI filings will be resumed.
				Approval to submit in an alternative filing timeline shall be granted by the
				Division if a catastrophic event prevents electronic submission. The approval
				must be obtained from the Division's Bureau of Data Quality and Collection, 200
				E. Gaines Street, Tallahassee, Florida 32399-4226, or via email at
				claims.edi@myfloridacfo.com. If approved, the electronic form equivalents that
				were due to be filed during the time the claim administrator was unable to file
				due to a catastrophic event, shall be sent with Late Reason Code "LB" (Late
				notification/payment due to a Natural Disaster) or "LC" (Late
				notification/payment due to an act of Terrorism).
(m) Non-compliance by the claim administrator
				with the electronic reporting requirements in this rule shall result in
				referral to the Division's Bureau of Monitoring and Audit, and may constitute a
				violation of Section  440.525,
				F.S.