Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.002 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
When used in this chapter, the following terms have the
				  following meanings:
(1) "Average
				Weekly Temporary Total Disability Benefit" means the weekly average of all
				benefits paid pursuant to paragraphs
				 440.15(2)(a) and
				(b), F.S. The weekly average shall be
				determined by dividing the total amount of temporary total disability benefits
				paid to date, by the number of weeks and days paid as calculated pursuant to
				paragraph  440.14(1)(g),
				F.S. If no temporary total benefits were paid, the average weekly temporary
				total disability benefit shall be 66 2/3% of the employee's average weekly
				wage, subject to the maximum compensation rate in accordance with section
				 440.14, F.S.
(2) "Biweekly work week" means two
				consecutive 7-day periods coinciding with the post injury employer's work week.
				For the purposes of calculating Temporary Partial Benefits pursuant to section
				 440.15(4),
				F.S., the first biweekly work week includes the week the employee returned to
				work.
(3) "Claim Administrator"
				means any insurer, claims-handling entity, qualified servicing entity, service
				company/third-party administrator (Service Co/TPA), self-serviced self-insured
				employer or fund, or managing general agent and includes all claims office
				locations that will be responsible for adjusting and submitting workers'
				compensation claims to the Division.
(4) "Class Code" means the 4-digit code
				assigned by the National Council on Compensation Insurance (NCCI) for the
				particular occupation of the injured employee, as it exists in the NCCI
				Scopes[TM] Manual 2004 Edition, which is hereby incorporated by reference. A
				listing of Class Codes may be obtained by contacting NCCI's Customer Service
				Center at (800)622-4123.
(5)
				"Compensation Rate" means 66 2/3% of the employee's average weekly wage
				pursuant to section  440.14, F.S., as calculated by
				the claim administrator, as ordered by a Judge of Compensation Claims, or to
				which the parties have stipulated.
(6) "Date Payment Mailed" means the date
				payment of a benefit 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
				deposit by electronic funds transfer.
(7) "Date Prepared" means the date the form
				was prepared by the adjuster or claims representative to be sent to the
				Division or other parties.
(8)
				"Days" means calendar days unless otherwise noted.
(9) "Denied Case" means any case for which
				the claim administrator has denied liability for all workers' compensation
				benefits.
(10) "Document" means any
				notice, form, or report which shall be submitted to the Division under this
				chapter or which the Division requests in connection with any matter covered by
				this chapter. Unless otherwise specified, this definition includes data
				submitted to the Division using Electronic Data Interchange (EDI) or another
				Division approved electronic format.
(11) "File" or "Filed" means a document has
				been received and accepted in accordance with rule
				 69L-3.003, F.A.C., by the
				Division.
(12) "Filing Period for
				Supplemental Income Benefits" means a period of 13 consecutive weeks
				(approximately 3 months) for which the employee reports any earnings and files
				a claim for supplemental income benefits. The filing period shall represent a
				"quarter" as set out in section
				 440.15  (3)(b)7., F.S. (1994),
				which is incorporated herein by reference, except for the second filing period,
				which may consist of less than 13 weeks if the first payment period was
				pro-rated. The "initial filing period" is the filing period which occurs during
				the last 13 weeks of impairment income benefits.
(13) "First Aid Case" means a work injury or
				illness which is treated at the work place, does not require medical treatment
				for which charges are incurred, and does not cause the employee to miss work
				for more than one day.
(14) "Full
				Salary in Lieu of Compensation" means the monies an employer paid the employee
				as salary, wage, or other remuneration for a period of disability for which the
				insurer would have otherwise been obligated to pay compensation
				benefits.
(15) "Full Salary End
				Date" means the date through which the employer paid full salary in lieu of
				compensation.
(16) "Indemnity Only
				Denied Case" means any case for which the claim administrator has denied all
				indemnity benefits at the time of the filing of the DFS-F2-DWC-1, however,
				compensability of the case is accepted and medical benefits will be
				provided.
(17) "Initial Payment of
				Supplemental Income Benefits" means payment of supplemental income benefits for
				the first whole or partial calendar month immediately following the expiration
				of the impairment income benefit period. The initial payment of supplemental
				income benefits shall cover the time beginning with the day after the
				expiration of impairment income benefits and ending with the last date in the
				initial calendar month pursuant to section 440.15, F.S. (1994), which is
				incorporated herein by reference.
(18) "Insurer Code #" means the
				Division-assigned number for the insurer as defined in section
				 440.02(38),
				F.S., which bears the financial risk of the claim.
(19) "Lost Time Case" means a work-related
				injury or illness, which has caused the employee to be disabled for more than 7
				calendar days or for which indemnity benefits have been paid. Lost time cases
				shall also include compensable volunteer workers to whom no indemnity benefits
				will be paid, but who have been disabled for more than 7 calendar days from
				work; compensable death cases for which there are no known or confirmed
				dependents; and injuries which result in the disability of more than 7 calendar
				days for which the employer is continuing to pay full salary in lieu of
				compensation for any portion thereof. The 7 calendar days of disability do not
				have to be consecutive, but are cumulative and can occur over a period of
				time.
(20) "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.
(21) "Medical Only to Lost Time Case" means a
				work-related injury or illness, which initially did not result in disability of
				more than 7 calendar days but later resulted in a disability of more than 7
				calendar days. Medical only to lost time cases shall include previous medical
				only cases in which Impairment Income Benefits are paid based on obtaining
				Maximum Medical Improvement with a Permanent Impairment Rating greater than
				zero (0) % and settlement only cases involving payment of indemnity
				benefits.
(22) "NAICS Code" means
				the 5 or 6-digit code published in the North American Industry Classification
				System (NAICS) 2007 and 2012 Editions, hereby incorporated by reference, that
				represents the nature of the employer's business. Classification information
				may be obtained by contacting the NAICS Association, 341 East James Circle,
				Sandy, Utah 84070, or visiting the website:
https://www.census.gov/eos/www/naics/
.
(23) "Notification" or "Knowledge" means an
				entity's earliest receipt of information, including mail, telephone, facsimile,
				direct personal contact or electronic submission.
(24) "Overall Maximum Medical Improvement"
				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.
(25)
				"Payment Period for Supplemental Income Benefits" means the period of 3
				consecutive calendar months immediately following the filing period. The first
				payment period may consist of less than 3 full months if the first monthly
				payment is pro-rated. The last payment period may consist of less than 3 full
				months if the employee has reached a maximum of 401 weeks of benefits. All
				other payment periods of supplemental income benefits shall be for 3 full
				calendar months, pursuant to section
				 440.15, F.S.
(26) "Send" means to transmit a document to
				the party or parties intended to receive it, including by mail, hand delivery,
				or electronic transmission.
(27)
				"Service Co/TPA" means an entity, which has contracted with an insurer for the
				purpose of providing all services necessary to adjust workers' compensation
				claims on the insurer's behalf.
(28) "Service Co/TPA Code #" means the
				internal audit number assigned by the Division to a service company, adjusting
				company, managing general agent or third party
				administrator.
Rulemaking Authority
					 440.185(2), (5),
					 (10),
					 440.20(3),
					 440.38(2), (6),
					 440.591 FS. Law Implemented
					  440.13,
					  440.185,
					  440.20(3),
					  440.38(2)(b) 
					 FS.
New 11-5-81, Formerly 38F-3.02, Amended 4-11-90, 1-30-91,
					 6-10-92, 11-8-94, Formerly 38F-3.002, 4L-3.002, Amended 1-10-05,
					 6-30-14.