Florida Division of Workers’ Compensation

1. Florida Division of Workers’ Compensation • Claims EDI Release 3 Training • February 12, 2014 • Day 2

2. Discussion Topics • 2014 Error Resolution Expectations • MTC CA (Change in Benefit Amount) with A/C/R Segments (Adjustment, Credit, Redistribution) • Proper Reporting and Calculation of Gross and Net Weekly Amounts • Lump Sum Payment & Settlements • (cont’d…)

3. Discussion Topics • Recent Law Update and Court Case Decision • Updated IAIABC Data Elements • Acquired Claims • New IAIABC Data Element Employer Paid Salary Prior to Acquisition Code ‘E’

4. 2014 Error Resolution Expectations

5. Error Resolution Expectations • In the past, the EDI Team has conducted webinars, • teleconferences • and on-site visits at the Division • in an effort to assist • Trading Partners with • submitting claims • successfully.

6. Error Resolution Expectations • This year, the EDI Team will take a more active approach to our Triage Assistance to reduce the overall error rejection percentages.

7. The EDI Team will be contacting entities with high rejection rates and entities with multiple rejections and/or a high volume of Missing Sub-Annuals (SA).

8. If we identify your company as falling into either of these categories, the EDI Team will be contacting you to schedule a teleconference with your EDI staff, your vendor (if applicable) and me (Linda Yon).

9. We will develop an action plan with timelines to reduce errors and/or the repetitious filing of transactions (where the error itself has not been addressed).

10. If you or your company would like help with reducing the rate of rejections and the EDI Team has yet to reach out to you, we encourage you to contact us to set up a personalized session(s) for more direct assistance.

11. EDI Triage Assistance could include • review of: • Basic EDI training • FROI/SROI combo filings • Claims EDI Warehouse navigation • Specific Maintenance Type Codes • Event vs. Sweep Benefit Segments • Gross Weekly Amount calculations or • Direct explanation of rejected filings, etc…

12. If you would like to schedule a conference or webinar session with the team, you may do so by submitting an email to: claims.edi@myfloridacfo.com and a member of the team will contact you.

13. MTC CA (Change in Amount)

14. MTC CA (Change in Amount) • If the Net Weekly Amount increases or decreases due to: • A change to the Average Weekly Wage • which affected the Compensation Rate • The recalculation of the Gross Weekly • Amount, or • The application of adjustments or credits, • an MTC CA transaction should be sent to the Division.

15. MTC CA is sent when: • Indemnity benefits are currently being paid and the Net Weekly Amount changes due to a re-calculation of the Gross Weekly Amount or an application of adjustments and/or credits… • OR…

16. MTC CA is also sent when: • The Net Weekly Amount changes after a suspension • and an adjustment check is issued for • the same previously paid period of indemnity.

17. MTC CA is also sent when: • The Net Weekly Amount changes due to the change in a Benefit Adjustment or Credit Weekly Amount OR • Due to the ending of an adjustment or credit.

18. MTC CA should notbe sent when: • The Average Weekly Wage (AWW) or Concurrent Employer Wage changes but the Net Weekly Amount does not change • (i.e. Comp Rate is at the max for the current year). • In this case, an MTC ‘02’ should be filed • instead.

19. MTC CA is not required to be sent when: • The Net Weekly Amount payable for BTC 070 (Temporary Partial) fluctuates due to variations in the employee’s weekly earnings. • The Net Weekly Amount payable for BTC 030 (Impairment Income Benefits) changes due to the employee’s weekly work status/income.

20. POP QUIZ: What MTC is filed when you need to report a change in AWW/CR, but the Gross/Net Weekly Amount is not changed?

21. ANSWER: SROI 02

22. Questions Regarding MTC CA

23. Adjustments, Credits and Redistributions (A/C/R Segments)

24. An Adjustment/Credit/Redistribution (A/C/R) Segment should always • and onlybe included on each SROI transaction when: • The A/C/R is currently being applied to the Benefits Segment that is being reported • OR • The A/C/R is ending

25. A/C/R Segments are also reported on Sub-Annuals (MTC SA) when still being applied to a BTC that is currently being paid.

26. A/C/R Segments are notrequired to be reported on subsequent transactions if the A/C/R has already ended at the time of the current filing event.

27. A Benefit A/C/R End Date is only sent when an adjustment, credit or redistribution has ended or benefits are suspended (MTC S1-7).

28. However, if A/C/R Segments have not ended at the time of the current filing, A/C/R information must continue to be reported on all SROIs until the A/C/R has ended. An A/C/R end date is not required if the claim has been subsequently denied/settled.

29. Benefit Adjustments

30. Benefit Adjustment Code • The Benefit Adjustment Code is a code • identifying reductions or increases applied to the Gross Weekly Amount • resulting in anew Net Weekly Amount for the specific benefit type noted. Format:4 A/N (BNNN) B = Benefit Adjustment Code NNN= Benefit Type Code (e.g. V050)

31. Benefit Adjustment Code • Some commonly used Benefit Adjustment Codes include: • S = Social Security Disability • V = Safety Violation • E = Employer Provided Pension (Grice)

32. Benefit Adjustment Start Date The Benefit Adjustment Start Date is the first date of the uninterrupted period in which the current Benefit Adjustment Weekly Amount was applied to the Benefit Type Code.

33. Benefit Adjustment End Date The Benefit Adjustment End Date is the last datethrough which the benefit adjustment was applied to the Benefit Type Code. If the Benefit Adjustment is ongoing, the Benefit Adjustment End Date is left blank.

34. Benefit Adjustment Weekly Amount The Benefit Adjustment Weekly Amount is the weekly amount of the benefit adjustment corresponding to the Benefit Adjustment Code.

35. Let’s take a look at a claim scenario where there is an adjustment for a Safety Violation. • A Safety Violation adjustment is for the life of the claim, • so the claim administrator continued to report the A/C/R Segment • without a Benefit Adjustment • End Date.

36. Example with Safety Violation Adjustment • Average Wage (AWW) = $600 • Calculated Weekly Compensation Amount • (Comp Rate) = $400 • Gross Weekly Amount for TTD Benefits =$400 • Safety Violation (V050) Benefits reduced by 25% per week ($100)

37. The injured worker was employed by the City of DQC as a chemist and burned her hands while mixing chemicals.

38. The injured worker failed to wear protective gloves as required when mixing chemicals; therefore, the safety violation was applied to the weekly benefits. Date of Injury = 5/18/12 Initial Date Disability Began = 5/19/12

39. On 6/1/12, the claim administrator filed the 00/IP reporting the initial payment of TT (050) and • the Benefit Adjustment Code for the safety violation (V050). 00/IP: Number of Benefit A/C/R Segments: 001

40. The Benefit Adjustment has not yet ended so the claim administrator must report the A/C/R Segment without the Benefit Adjustment End Date.

41. POP QUIZ: By what percentage are indemnity benefits reduced if the injured worker violates a safety regulation?

42. ANSWER: 25%

43. Let’s take a look at the same claim with the next event – • Change in Benefit Type.

44. On 6/29/12, the claim admin filed an MTC CB reporting the change in benefits from TT (050) to TP (070) … MTC CB:

45. ending the Benefit Adjustment Segment for TT (V050) and beginning the Benefit Adjustment Segment for TP (V070). On 6/29/12, the claim administrator filed an MTC CB reporting the change in benefits from TT (050) to TP (070), MTC CB: Number of Benefit A/C/R Segments: 002

46. Questions Regarding Adjustments

47. Benefit Credits

48. Benefit Credit Code • The Benefit Credit Code identifies a reduction that is applied to the Gross Weekly Amount to • yield a new Net Weekly Amount, • to recoup monies previously paid. Values: C = OverpaymentP = Advance

49. Benefit Credit Start Date The Benefit Credit Start Date is the first date of the uninterrupted period in which the current Benefit Credit Weekly Amount was applied to the Benefit Type Code.

50. Benefit Credit End Date The Benefit Credit End Date is the last datethrough which the benefit credit was applied to the Benefit Type Code. If the Benefit Credit is ongoing, the Benefit Credit End Date is left blank.