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SROI MTC 04 Full Denial after Payment Electronic Notice of Denial

SROI MTC 04 Full Denial after Payment Electronic Notice of Denial EDI DWC-12 Equivalent required to be filed with the Division per Rule 69L-56.3012(1), F.A.C. SROI 04 - Full Denial after Payment EDI DWC-12 Equivalent

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SROI MTC 04 Full Denial after Payment Electronic Notice of Denial

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  1. SROI MTC 04 Full Denial after Payment Electronic Notice of Denial EDI DWC-12 Equivalent required to befiled with the Division per Rule69L-56.3012(1), F.A.C.

  2. SROI 04 - Full Denial after Payment EDI DWC-12 Equivalent • A SROI 04 should be filed if no further indemnity or medical benefits will be paid, and/or the entire compensability of the claim is denied following the Initial Payment (or equivalent).

  3. SROI 04 - Full Denial after Payment EDI DWC-12 Equivalent • You would not send a SROI PD with a new PD Code in this situation. • The current status of the denial is required to be reported; thus, if no further indemnity and medical will be paid, this is a Total Denial, not a Partial Denial.

  4. SROI 04 DENIAL RULES • A SROI 04 acts like a suspension when benefit(s) are being terminated at the time of the denial. • Therefore, an Sx is not required after the 04 before filing an FN.

  5. SROI 04 DENIAL RULES • In general, a SROI 04 is expected to report all of the previously reported BTC’s and at least the same amount of $ previously reported …

  6. SROI 04 DENIAL RULES • … However, we were made aware of a filing situation where this did not hold true, and therefore submitted an IRR to solicit a change to the standard…

  7. Pending IRR • Scenario: After having filed an AQ, the acquiring Claim Admin decided to deny payment of all further indemnity and medical benefits and filed a SROI 04…

  8. Pending IRR • …But the SROI 04 rejected because our program edits expected to see the same BTC’s previously reported. • The prior BTC’s were correctly reported under OBT 430, but because OBT’s are “X” on the ERT for SROI 04…

  9. Pending IRR • … our program did not take these benefits into account. • We have therefore requested that the ERT be changed to allow OBT’s to be evaluated on a SROI 04. • Note: Until then, we will apply special processing if this situation occurs.

  10. SROI MTC PD Partial Denial after Payment EDI DWC-12 Equivalent required to befiled with DWC per Rule 69L-56.3012(2), F.A.C.

  11. SROI PD - Partial Denial after Payment Electronic DWC-12 Equivalent • A ‘standalone’ SROI PD should be filed if indemnity benefits are denied (in whole or part) following the report of Initial Payment.

  12. SROI PD - Partial Denial after Payment Electronic DWC-12 Equivalent • The SROI PD must include: • Partial Denial Code A, B, E, or G, and • Denial Reason Narrative.

  13. POP QUIZ: If a Full (Total Denial) or Indemnity Only Denied First Report of Injury or Illness was filed, and you subsequently rescind the denial, what MTC is used to report the Electronic Notice of Denial Rescission?

  14. ANSWER: To report a rescission of a previous denial of indemnity: • SROI IP, EP, ER, RB, AP,or • PD, or • 02 • with ‘Denial Rescission Date’

  15. Electronic Denial Rescission EDI DWC-12 Equivalent • ASROI PYwill also rescind a denial if Denial Rescission Date is sent, but • Denial Rescission Dateis not required on a PY with Lump Sum Payment/Settlement Code SF or SP (full settlements)…

  16. Electronic Denial Rescission EDI DWC-12 Equivalent • … But if the PY reports, for example, an Advance, Denial Rescission Dateshould be included, and an IP would also be required to report ongoing payment of indemnity.

  17. Payment After Denial (Electronic Notice of Denial Rescission) EDI DWC-12 Equivalent required to befiled with the Division per Rule 69L-56.3012(6), F.A.C.

  18. Payment After Denial (Denial Rescission) • A SROIIP (or equivalent), RB, PD, AP, or 02 should be filed if you are rescinding a Full Denial. Note: SROI02 is used to rescind if no indemnity is payable at the time of rescission.

  19. Payment After Denial (Denial Rescission) • A SROI IP, RB, or 02 should be filed if you are rescinding a Partial Denial(where some or all indemnity benefits previously denied will now be paid). • Again,SROI 02 is used to rescind if no indemnity is payable at the time of rescission.

  20. Payment After Denial (Denial Rescission) • Whichever MTC is used to rescind, the Denial Rescission Date must be included. • Recap: The Denial Rescission Date equates to the date you took the action to rescind the denial, NOT the effective date from which benefits will be paid.

  21. Payment After Denial (Denial Rescission) • If a denial notice is not ‘on file’ (e.g., PD rejected), you will not be able to file a denial rescission transaction (e.g., IP).

  22. Payment After Denial (Denial Rescission) • DWC edits do not allow an IP to rescind the denial if the Denial Rescission Date on the IP is prior to the ‘effective date’, a/k/a MTC Date of the PD.

  23. Payment After Denial (Denial Rescission) • This may become an issue since the R3 transaction does not have an actual date field that identifies when the Partial Denial was ‘effective’ - FL uses the MTC Date of the PD for this purpose. • The PD MTC Date may be later than the date you initially took action to partially deny if the PD rejected multiple times...

  24. Payment After Denial (Denial Rescission) For example: • PD sent with MTC Date of 12/17/09; PD rejected; • IP sent on 12/18/09 with Denial Rescission Date of 12/17/09; IP rejected …

  25. Payment After Denial (Denial Rescission) … • PD re-sent with MTC Date of 12/30/09; PD accepted. • IP re-sent with Denial Rescission Date of 12/17/09; IP rejects since Denial Rescission Date is prior to the effective date of the PD (MTC Date of 12/30/09.) Therefore, the IP must be re-sent with Denial Rescission Date on or after 12/30/09.

  26. Payment After Denial (Denial Rescission) This issue will be forwarded to the IAIABC for resolution, e.g., changing ‘Full Denial Effective Date’ to ‘Denial Effective Date’ so there will be one (unchanging) date to compare to Denial Rescission Date.

  27. Questions?

  28. Change in Benefit Amount

  29. SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent • A SROI CA, EDI DWC-4 Equivalent,is required to be filed with DWCif the Net Weekly Amount increases or decreases due to the recalculation of the Gross Weekly Amount, or due to the application of adjustments or credits. • See Rule 69L-56.3045(2), F.A.C. .

  30. SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent • If you receive a wage statement (after the 00/IP) that either raises or lowers the AWW/CR and therefore changes the Gross/Net Weekly Amounts, ifnot also changing benefits, you would file a CA.

  31. SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent • MTC “CA” is typically used when: • Indemnity benefits are currently being paid, • The Net Weekly Amount changesdue to re-calculation of the Gross Weekly Amount or application of adjustments and/or credits, …

  32. SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent • … Additionally, you would also file a CA in relation to non-current benefits where a suspension (Sx) was previously filed, after which the Net Weekly Amount changed. • Additional adjustment check to EE must be for the same period of indemnity previously paid (i.e., end dates cannot advance.)

  33. SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent • MTC “CA” is NOT used when: • The Average Wage or Concurrent Employer Wage changes, but the Net Weekly Amount does not change. (Comp Rate at max) • MTC “02” should be filed instead.

  34. SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent • Also, FL does not require MTC CA to be filed each time the payment rate for TP (070) changes due to fluctuations in the EE’s earnings.

  35. SROI CA - Change in Benefit Amount EDI DWC-4 Equivalent • However, Rule 69L-56 will be amended to require SROI CA to report a change in Net Weekly Amount for IB (030) when IB payment rate changes due to wage fluctuations (per court case discussed earlier.)

  36. Caveats andTips for Successfully Filing SROI MTC CA

  37. Caveats and Tips for Successful Filing of CA • If you are trying to file a CA, but a Suspension transaction (Sx) was filed in error: • Do not file an RB to get around the edit that indicates an RB should have been filed after the Sx…

  38. Caveats and Tips for Successful Filing of CA • … Instead, contact the EDI Team for special processing assistance. • We will manually remove the suspension status from DWC’s database and re- process the CA.

  39. Caveats and Tips for Successful Filing of CA • One error we are seeing a lot for SROI CA filings is: • NBR OF BENEFITS SHOULD NOT BE > WHAT IS ON FILE

  40. Caveats and Tips for Successful Filing of CA • This means the CA contained a BTC(s) that was not previously reported. • A CB will need to be filed to ‘introduce’ the new BTC.

  41. Caveats and Tips for Successful Filing of CA • Conversely, the error.. BEN TYPE CODE PREVIOUSLY REPORTED NOT SENT ON SROI … is occurring where a BTC(s) ‘on file’ is missing from the CA.

  42. Caveats and Tips for Successful Filing of CA • If the wrong BTC was previously reported and never actually paid, you will need to file an 02 with the “R” code to reclassify those benefits. • In this case a CA is not needed because you are totally replacing the prior benefit with a new BTC and new Net.

  43. Caveats and Tips for Successful Filing of CA • Another error occurring frequently for SROI CA filings is: BENEFIT TYPE AMOUNT PAID < PREVIOUSLY REPORTED $ < Prev

  44. Caveats and Tips for Successful Filing of CA • A reductionin either the number of BTC’s or the amount paid for a BTC must be ‘explained’ by reporting: • Reduced Benefit Amount Code ‘R’ (Reclassification), or • Recovery Code, or • Adjustment, or • Credit information.

  45. Questions?

  46. Let’s now discuss Adjustments, Credits & Redistributions (A/C/R’s)

  47. The below errors (addressed earlier) also occur when the Gross Weekly Amount (computed by DWC) minus the Adj or Credit Amount sent does not equal the Net Weekly Amount reported: NET < FL CALC GROSS AMT MINUS ADJ/CREDIT AMTS and NET $.05 OVER FL CALC GROSS MINUS ADJ/CREDIT AMTS

  48. Net Weekly Amount • The Net Weekly Amount equals the Gross Weekly Amount minus any applicable adjustments or credits for the corresponding benefit type. • If Net Weekly Amt is different from the Gross Weekly Amount, the applicable Adjustment or Credit information must be sent.

  49. Benefit Adjustment Codes Definition: A code that identifies reductions applied to the Gross Weekly Amount resulting in a new Net Weekly Amount for a specific benefit type. Format: 4 A/N (BNNN) B = Benefit Adjustment Code NNN = Benefit Type Codes

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

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