1 add concurrent benefit type electronic notice of action/change required to be filed with dwc per...

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Add Concurrent Add Concurrent Benefit TypeBenefit Type

Electronic Notice of Electronic Notice of Action/ChangeAction/Change

Required to be filed with DWC per Required to be filed with DWC per Rule Rule 69L-56.3045(4), F.A.C.69L-56.3045(4), F.A.C.

SROSROI ABI AB

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SROI AB - Add Concurrent SROI AB - Add Concurrent

Benefit TypeBenefit Type

A SROI A SROI ABAB, EDI DWC-4 , EDI DWC-4 equivalent, is required to equivalent, is required to be filed when: be filed when:

• Adding or Adding or

•Reinstating a Reinstating a concurrent concurrent

BTCBTC..

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Concurrent BTC’sConcurrent BTC’s occur occur when:when:

•Indemnity benefits are Indemnity benefits are currently being paid,currently being paid,

•A A secondsecond Benefit Type Benefit Type Code begins,Code begins,

•The The firstfirst Benefit Type Code Benefit Type Code is still being paid.is still being paid.

SROI AB - Add Concurrent SROI AB - Add Concurrent Benefit TypeBenefit Type

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Example:Example:

If If PT SupplementalPT Supplemental Benefits (021) begin Benefits (021) begin afterafter previous payment of previous payment of ongoing Permanent Total ongoing Permanent Total Benefits (020), Benefits (020),

• SROI ABSROI AB should be sent should be sent and and Receive TA 14 days after Receive TA 14 days after Claim Admin.’s knowledge Claim Admin.’s knowledge of entitlement.)of entitlement.)

SROI AB - Add Concurrent SROI AB - Add Concurrent Benefit TypeBenefit Type

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Pop Quiz: Pop Quiz:

What is What is another another

example of example of “Concurrent” “Concurrent” Benefit Types?Benefit Types?

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ANSWER:ANSWER:

When Salary in Lieu When Salary in Lieu of Compensation of Compensation was paid and the EE was paid and the EE also had concurrent also had concurrent employment.employment.

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Example:Example:

Accident EMPR pays salary Accident EMPR pays salary in lieu of compensation and in lieu of compensation and later learns of concurrent later learns of concurrent employment that raises employment that raises AWW.AWW.

EE must now be EE must now be compensated at 66 2/3% of compensated at 66 2/3% of combined wages (where combined wages (where both 0xx and 240 would be both 0xx and 240 would be reported for same period.)reported for same period.)

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SROI AB - SROI AB - Add Concurrent Add Concurrent Benefit TypeBenefit Type

In this case, DWC’s In this case, DWC’s program allows Start Date program allows Start Date of the current BTC being of the current BTC being added to equal the Start added to equal the Start Date of a previous BTC Date of a previous BTC where:where:

• The previous BTC is 2xx The previous BTC is 2xx andand

• Concurrent Employer Concurrent Employer data is data is provided.provided.

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SROI AB - SROI AB - Add Concurrent Add Concurrent


SROI ABSROI AB follows thefollows the“Event” “Event” BenefitsBenefits segment segment rules.rules.

MTC ABMTC AB is only is only populated in the populated in the BenefitsBenefits segment of the Benefit segment of the Benefit Type Code that Type Code that is is being addedbeing added..

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Caveats andCaveats andTips for Tips for

Successfully Successfully Filing SROI MTC Filing SROI MTC

ABAB

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Caveats and Tips for Filing Caveats and Tips for Filing SROI ABSROI AB

The error we see most The error we see most frequently for SROI AB frequently for SROI AB filings is:filings is:

BTC MUST = 020 OR 021 BTC MUST = 020 OR 021 IF MTC = AB OR IF MTC = AB OR P7 P7

This error indicates that This error indicates that either…either…

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Caveats and Tips for Filing Caveats and Tips for Filing SROI ABSROI AB •SROI AB is not the correct SROI AB is not the correct

MTC, or MTC, or

• An incorrect BTC was An incorrect BTC was reported or left off the AB, reported or left off the AB, or or

•Concurrent Employment Concurrent Employment was not reported. was not reported.

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Caveats and Tips for Filing Caveats and Tips for Filing SROI ABSROI AB

The next most frequently The next most frequently occurring error on SROI AB occurring error on SROI AB filings is: filings is: NO SROI ER OR RB NO SROI ER OR RB PREVIOUSLY ON FILEPREVIOUSLY ON FILE This error is generated when DWC This error is generated when DWC reflects indemnity was suspended reflects indemnity was suspended or denied but not yet resumed or denied but not yet resumed prior to receipt of the AB.prior to receipt of the AB.

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Pop Quiz: Pop Quiz:

What MTC would What MTC would be sent each be sent each

January to January to report the new report the new PT Supp Rate? PT Supp Rate?

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Answer:Answer: SROI CASROI CA

To report the new To report the new Net Weekly Amt Net Weekly Amt

for BTC 021 (PTS).for BTC 021 (PTS).

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Suspensions Suspensions (Full)(Full)

SROI S1-S8SROI S1-S8

Electronic Notice Electronic Notice of Action/Changeof Action/ChangeRequired to be filed with DWC per Required to be filed with DWC per

RuleRule 69L-56.3013, F.A.C.69L-56.3013, F.A.C.

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SROI S1 – S8: Suspensions SROI S1 – S8: Suspensions (Full)(Full)

SROI SROI S1-S8 (Sx),S1-S8 (Sx), EDI EDI DWC-4 equivalent, is DWC-4 equivalent, is required If required If ALLALL payments payments of indemnity benefits have of indemnity benefits have stopped (not just one class stopped (not just one class of benefits).of benefits).

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The following DN’s The following DN’s relate to SROI Sx filings:relate to SROI Sx filings:

• Suspension Effective DateSuspension Effective Date (required),(required),

• Suspension NarrativeSuspension Narrative (IA),(IA), andand• Number of Suspension Number of Suspension Narratives.Narratives.

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““SUSPENSION EFFECTIVE SUSPENSION EFFECTIVE DATE” DATE”

For MTC’s S1-S8 For MTC’s S1-S8 (Suspension):(Suspension):

The The last date last date throughthrough which which allall indemnity benefits are indemnity benefits are duedue..

Note:Note: This date is not always the This date is not always the last day through which benefits last day through which benefits were paid if there was an were paid if there was an overpayment.overpayment.

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SUSPENSION NARRATIVE SUSPENSION NARRATIVE SEGMENTSEGMENT

Per IAIABC Variable Segment Per IAIABC Variable Segment Rules:Rules:

Maximum of 3 “Suspension Maximum of 3 “Suspension Narrative” segments may be Narrative” segments may be sent, and sent, and

Must equal the Must equal the ““Number of Number of SuspensionSuspension Narratives” sent Narratives” sent..

Note:Note: This is an “If This is an “If Available/Applicable” field for Available/Applicable” field for FL, but not required.FL, but not required.

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Pop Quiz: Pop Quiz:

Are Suspensions an Are Suspensions an

““Event”Event” Benefit Benefit Segment, or Segment, or

““Sweep”Sweep” Benefit Benefit Segment?Segment?

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Answer: Answer:

““Event”Event” Benefit Benefit Segment Segment

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Therefore,Therefore, the the MTC MTC (Sx)(Sx) is required to be is required to be included in the included in the BenefitsBenefits segment, as well as all segment, as well as all other required benefit other required benefit segment data.segment data.

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Successfully Successfully Filing SROI S1 – Filing SROI S1 –

S8S8

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Caveats and Tips for Caveats and Tips for Filing SxFiling Sx

If a DWC-4 was previously If a DWC-4 was previously filed and it reported filed and it reported suspension of one type of suspension of one type of indemnity, indemnity, BUT NOTBUT NOT ALL ALL benefits were truly benefits were truly suspended:suspended:

• You will have to You will have to reinstate benefits (file RB) reinstate benefits (file RB) prior to sending the next prior to sending the next event.event.

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Caveats and Tips for Filing Caveats and Tips for Filing SxSx

If you filed an incorrect If you filed an incorrect Suspension Code (Sx) Suspension Code (Sx) MTC:MTC:

• Send correct Sx code; Send correct Sx code; ANDAND• Suspension Effective Suspension Effective Date must be the Date must be the same same asas the previous the previous Suspension Eff. Date. Suspension Eff. Date.

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One of the most One of the most frequently occurring errors frequently occurring errors for Sx filings is: for Sx filings is:

SUSP EFFECT DATE MUST <= SUSP EFFECT DATE MUST <= LATEST BEN THROUGH DATELATEST BEN THROUGH DATE

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• This particular This particular effective date is effective date is notnot when you took the when you took the ‘action’ to suspend;‘action’ to suspend;

• It is the date through It is the date through which all benefits were which all benefits were duedue..

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• Therefore, the effective Therefore, the effective date of the suspension date of the suspension should not be later than should not be later than the date through which the date through which benefits were due.benefits were due.Exception:Exception: Suspension Suspension Effective Date may be a Effective Date may be a future date if IB’s are paid in future date if IB’s are paid in a lump sum and are currently a lump sum and are currently being suspended (i.e., Sx being suspended (i.e., Sx MTC in Event segment.)MTC in Event segment.)

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Also, do not report SROIAlso, do not report SROI S1S1 (RTW) prematurely before (RTW) prematurely before the last indemnity payment the last indemnity payment has been reported on the has been reported on the transaction. transaction.

If the “Benefit Period If the “Benefit Period Through Date” on the next Through Date” on the next transaction is later than the transaction is later than the Through Date reported on Through Date reported on the S1, the transaction will the S1, the transaction will reject.reject. ((Thru Date must Thru Date must

not be > prev Thru Date.)not be > prev Thru Date.)

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Future Future Suspension Suspension Effective Dates are allowed:Effective Dates are allowed:

• But must not be more than But must not be more than 2 weeks2 weeks after DWC Rec’d after DWC Rec’d transmission.transmission.

Exception:Exception: IB’s (030 or 530) IB’s (030 or 530) is currently being suspended is currently being suspended (where MTC Sx is in the 030/530 (where MTC Sx is in the 030/530 Benefits segment)Benefits segment)

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Caveats and Tips for Filing SxCaveats and Tips for Filing Sx

Do Do notnot send SROI S1 solely send SROI S1 solely to report to report RTWRTW information. information.

• Suspension codes should Suspension codes should only be sent to report the only be sent to report the cessation of cessation of ALLALL indemnity benefits.indemnity benefits.

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For Example:For Example:

• If EE RTW light duty & there If EE RTW light duty & there is a possibility TP (070) will is a possibility TP (070) will be paid in the near future, be paid in the near future, S1S1 should should notnot be filed. be filed.

• Instead, RTW data should Instead, RTW data should be reported via MTC be reported via MTC 0202 if the if the requirement to report RTW requirement to report RTW (2 (2 weeks after knowledge)weeks after knowledge) falls falls due prior to changing due prior to changing benefits, or CB.benefits, or CB.

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Caveats and Tips for Caveats and Tips for Filing SxFiling Sx

Other typical errors we Other typical errors we are seeing for Sx filings are seeing for Sx filings are:are:

NET WKLY AMT EFF DT CANT BE NET WKLY AMT EFF DT CANT BE CHANGED WITH THIS MTC CHANGED WITH THIS MTC

and and

GROSS AMT MUST CHANGE VIA GROSS AMT MUST CHANGE VIA MTC CB CA 02 AP OR RB MTC CB CA 02 AP OR RB

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• A new Net weekly rate A new Net weekly rate (with a (with a new new Effective Date) Effective Date) cannot be ‘introduced’ cannot be ‘introduced’

via SROI Sx.via SROI Sx.

• Changes or corrections Changes or corrections to the AWW/CR that affect to the AWW/CR that affect the Gross/Net weekly the Gross/Net weekly Amounts must first be Amounts must first be reported via MTC CA. reported via MTC CA.

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We are also seeing a lot We are also seeing a lot of errors for:of errors for:

DUPLICATE SUSPENSION DUPLICATE SUSPENSION WITH SAME EFF DATE WITH SAME EFF DATE

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This error usually occurs This error usually occurs when benefits are when benefits are erroneously reinstated, or erroneously reinstated, or reinstated to correct a past reinstated to correct a past benefit picturebenefit picture, e.g. RB sent , e.g. RB sent when benefits are not when benefits are not actually being reinstated; actually being reinstated; then another “same” Sx is then another “same” Sx is sent to try to re-suspend sent to try to re-suspend the claim. the claim.

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• If trying to change If trying to change Benefit segment data Benefit segment data for past benefits, a for past benefits, a reinstatement should reinstatement should not be sent. not be sent.

• RB should only be RB should only be sent if benefits are sent if benefits are being reinstated. being reinstated.

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• In many situations, In many situations, MTC 02 can be used to MTC 02 can be used to change / correct change / correct Benefit segment Benefit segment information, unless information, unless introducing a new BTC. introducing a new BTC.

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SSxx


• Do not file a “fake” Sx Do not file a “fake” Sx to get around theto get around the DUPLICATE SUSPENSION DUPLICATE SUSPENSION WITH SAME EFF DATE WITH SAME EFF DATE error.error.

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• Instead of filing an RB Instead of filing an RB and then subsequently and then subsequently sending another Sx, sending another Sx, if if an RB is sent in error,an RB is sent in error, email the EDI team email the EDI team asking to remove the asking to remove the RB. RB.

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Another frequent error, Another frequent error, primarily in relation to SROI primarily in relation to SROI S7 S7 (Benefits Exhausted) (Benefits Exhausted) filings filings is:is:

CAN NOT ACCEPT SUSP CAN NOT ACCEPT SUSP AFTER SUSP W-OUT ER, RB AFTER SUSP W-OUT ER, RB

OR EPOR EP

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• If you filed a Sx and If you filed a Sx and afterwards sent afterwards sent another Sx another Sx with a different Suspension with a different Suspension Effective DateEffective Date, you won’t , you won’t be able to report the be able to report the ‘second’ suspension until ‘second’ suspension until after you file an RB, ER or after you file an RB, ER or EP to resume benefits after EP to resume benefits after the ‘first’ suspension. the ‘first’ suspension.

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If a Suspension (Sx) was If a Suspension (Sx) was filed in errorfiled in error but accepted, but accepted, and you subsequently and you subsequently receive a rejection when receive a rejection when trying to report a CA, CB, trying to report a CA, CB, etc., etc.,

• Do not file an RB to get Do not file an RB to get around the edit that is around the edit that is expecting an RB after expecting an RB after Sx...Sx...

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… … Instead, contact the Instead, contact the EDI team for special EDI team for special processing assistance. processing assistance.

• We may be able to We may be able to manually remove the manually remove the suspension status from suspension status from our file and re-process our file and re-process the CA, CB, etc.the CA, CB, etc.

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Questions?Questions?

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Partial SuspensionPartial Suspension SROI P7SROI P7

Electronic Notice Electronic Notice of Action/Changeof Action/Change

Required to be filed with DWC per Required to be filed with DWC per RuleRule 69L-56.3045(5)(j), F.A.C.69L-56.3045(5)(j), F.A.C.

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SROI P7 - Partial SROI P7 - Partial SuspensionSuspension

P7P7 (Benefits Exhausted) is (Benefits Exhausted) is only used in relation to only used in relation to “concurrent” BTC’s.“concurrent” BTC’s.

Occurs when one of theOccurs when one of the “concurrent” benefits is “concurrent” benefits is suspended, but the other suspended, but the other benefit continues.benefit continues.

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SROI SROI P7P7 is required if is required if Permanent Total Permanent Total Supplemental (021) Supplemental (021) benefits are suspended, benefits are suspended, but Permanent Total (020) but Permanent Total (020) benefits are continuing.benefits are continuing.

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P7, Partial Suspension P7, Partial Suspension is considered an is considered an “Event”;“Event”;

• Therefore, Therefore, MTC MTC P7P7 is is reported in the reported in the Benefits Benefits segment for the segment for the “concurrent” benefit “concurrent” benefit type that is being type that is being stoppedstopped..

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Any Any remaining Benefit remaining Benefit Type Codes are sent as Type Codes are sent as “Sweep” “Sweep” BenefitsBenefits segments.segments.

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Successfully Successfully Filing SROI P7Filing SROI P7

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Caveats and Tips for Filing Caveats and Tips for Filing SROI P7SROI P7

We don’t see many errors We don’t see many errors for this SROI (probably for this SROI (probably because it is not filed that because it is not filed that often), but the following often), but the following occurs the most frequent: occurs the most frequent:

BTC MUST = 020 OR 021 BTC MUST = 020 OR 021 IF MTC = AB OR P7 IF MTC = AB OR P7

If you receive this error, If you receive this error, eithereither … …

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• … … P7 was not P7 was not appropriate and you need appropriate and you need to send another MTC, orto send another MTC, or

• An incorrect BTC was An incorrect BTC was sent, orsent, or

• BTC 020, 021 was left off BTC 020, 021 was left off the P7.the P7.

Note: This edit is not run if Note: This edit is not run if Number of Concurrent Employers Number of Concurrent Employers is > 0 or on file, and BTC 2xx is is > 0 or on file, and BTC 2xx is present.present.

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Below is a sequencing error Below is a sequencing error occurring with P7 filings:occurring with P7 filings:

NO SROI ER OR RB NO SROI ER OR RB PREVIOUSLY ON FILEPREVIOUSLY ON FILE

• This error is generated This error is generated when a suspension notice when a suspension notice was previously filed, but…was previously filed, but…

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• … … benefits have not yet benefits have not yet been reported as having been reported as having been resumed.been resumed.

• Therefore, a SROI Therefore, a SROI RB (or RB (or ER)ER) will need to be filed will need to be filed before the P7 can be before the P7 can be accepted.accepted.

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Reinstatement of Reinstatement of Benefits Benefits

By Claim By Claim AdministratorAdministrator

SROI RBSROI RBRequired to be filed with DWC per Required to be filed with DWC per

RuleRule 69L-69L-56.3045(6)(a), 69L-69L-56.3045(6)(a), F.A.C.F.A.C.

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SROI RB - Reinstatement of SROI RB - Reinstatement of Benefits by Claim Benefits by Claim

AdministratorAdministrator SROI SROI RBRB, EDI DWC-4 , EDI DWC-4 equivalent is required if equivalent is required if indemnity payments indemnity payments previously paid by the Claim previously paid by the Claim AdministratorAdministrator are being are being resumed by the resumed by the Claim Administrator Claim Administrator..

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SROI RB - Reinstatement of SROI RB - Reinstatement of Benefits by Claim Benefits by Claim

AdministratorAdministrator

The Benefit Type (BTC) The Benefit Type (BTC) being reinstated being reinstated may or may or may notmay not have been have been previously paid.previously paid.

SROI RB – Reinstatement of SROI RB – Reinstatement of Benefits by Claim Benefits by Claim

AdministratorAdministrator A A prior SROI terminating prior SROI terminating all indemnity benefitsall indemnity benefits must must have been filed via either:have been filed via either:

• SROI SROI S1-S8S1-S8 (Full (Full Suspension), or …Suspension), or …

SROI RB – Reinstatement of SROI RB – Reinstatement of Benefits by Claim AdministratorBenefits by Claim Administrator

• SROI MTC SROI MTC 0404 (Full (Full Denial),Denial),

oror• SROI MTC SROI MTC PDPD with Partial with Partial

Denial Codes Denial Codes A or E.A or E.

• SROI 04 & PD SROI 04 & PD (A or E code)(A or E code) act act like a suspension where all like a suspension where all indemnity benefits are being indemnity benefits are being terminated at the time of terminated at the time of denial.denial.

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SROI RB – Reinstatement of SROI RB – Reinstatement of Benefits by Claim AdministratorBenefits by Claim Administrator

For all MTC’s that initiate or For all MTC’s that initiate or reinstatereinstate a Benefit Type Code a Benefit Type Code (AB, IP, (AB, IP, RBRB, EP, ER, CB): , EP, ER, CB):

• The “The “Benefit Period Start Benefit Period Start DateDate” is the ” is the first date of the first date of the uninterrupted perioduninterrupted period of of benefit payments that benefit payments that corresponds to the Benefit corresponds to the Benefit Type Code being paid.Type Code being paid.

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Successfully Successfully Filing SROI RBFiling SROI RB

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Caveats and Tips for Filing Caveats and Tips for Filing RBRB

The most frequent error The most frequent error occurring for occurring for SROI RBSROI RB filings is:filings is:

NO CORRESPONDING NO CORRESPONDING SROI S1-8, 04, OR PD SROI S1-8, 04, OR PD

ON FILEON FILE

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• Indemnity benefits Indemnity benefits must have been must have been previously ‘stopped’ via previously ‘stopped’ via suspension or denialsuspension or denial notice / transaction notice / transaction before a before a reinstatement can be reinstatement can be

accepted.accepted.

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This next error is for legacy This next error is for legacy cases. If an RB is filed, without cases. If an RB is filed, without a previous suspension, denial a previous suspension, denial or FNor FN on file, this message will on file, this message will be returned. be returned.

NOT APPLICABLE; DWC NOT APPLICABLE; DWC DOESN'T SHOW BENEFITS DOESN'T SHOW BENEFITS

ENDEDENDED Note: For legacy cases, an FN served to Note: For legacy cases, an FN served to suspend benefits.suspend benefits.

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Caveats and Tips for Caveats and Tips for Filing RBFiling RB

We are also seeing a We are also seeing a lot of errors for:lot of errors for:

MTC RB ER SENT AFTER MTC RB ER SENT AFTER PREV SETTLEMENT ON PREV SETTLEMENT ON

FILE FILE

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• If you truly need to If you truly need to resume indemnity resume indemnity benefits, but you benefits, but you previously filed a PY with previously filed a PY with the wrong Lump Sum the wrong Lump Sum Payment / Settlement Payment / Settlement Code (SF or SP), you will Code (SF or SP), you will need to file an need to file an 0202 to to correct this code and re-correct this code and re-send the RB.send the RB.

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Another frequently Another frequently occurring error on the RB occurring error on the RB is:is:

MTC RB SWEEP SEG THRU MTC RB SWEEP SEG THRU DATE MUST = PREV THRU DATE MUST = PREV THRU

DATEDATE

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• Except for the BTC you Except for the BTC you are resuming, all other are resuming, all other ‘sweep’ BTC Through ‘sweep’ BTC Through Dates on the RB should be Dates on the RB should be the same as previously the same as previously reported (except for BTC reported (except for BTC 2xx or if benefits were 2xx or if benefits were reclassified.)reclassified.)

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Reinstatement of Reinstatement of Employer PaidEmployer Paid BenefitsBenefits

SROI ERSROI ERElectronic Notice of Electronic Notice of

Action/ChangeAction/Change

Required to be filed with DWC per RuleRequired to be filed with DWC per Rule 69L-56.3045(6)(b), F.A.C.69L-56.3045(6)(b), F.A.C.

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SROI ER – Reinstatement of SROI ER – Reinstatement of Employer Paid Benefits Employer Paid Benefits

SROI SROI ERER, EDI DWC-4 , EDI DWC-4 equivalent, is required if equivalent, is required if the employerthe employer is resuming is resuming payment of salarypayment of salary in lieu of in lieu of compensation following the compensation following the suspension of all prior suspension of all prior employer paidemployer paid indemnity indemnity benefits.benefits.

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Successfully Successfully Filing SROI ERFiling SROI ER

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Caveats and Tips for Filing Caveats and Tips for Filing ERER

We don’t see that many We don’t see that many errors for ER (not many are errors for ER (not many are sent), but most ER’s reject sent), but most ER’s reject for:for:

NO EP & SROI S1-8, 04, PD NO EP & SROI S1-8, 04, PD OR FN ON FILE OR FN ON FILE

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Caveats and Tips for Filing Caveats and Tips for Filing ERER

• A SROI EP or BTC 2xx A SROI EP or BTC 2xx (full salary information) (full salary information) must have must have been accepted, andbeen accepted, and

• Every SROI Every SROI ERER must be must be preceded by a preceded by a corresponding S1-8, or corresponding S1-8, or SROI 04, or PD (and SROI 04, or PD (and FN for legacy claims.)FN for legacy claims.)

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SROI PY –SROI PY –

Lump Sum Lump Sum Payments/SettlemePayments/Settleme

ntsnts

Electronic Notice of Electronic Notice of Action/ChangeAction/Change

EDI DWC-4 EquivalentEDI DWC-4 Equivalent Required to Required to be filed with DWC per Rulebe filed with DWC per Rule 69L- 69L-

56.304, F.A.C.56.304, F.A.C.

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SROI PY – Lump Sum SROI PY – Lump Sum Payment/Settlement Payment/Settlement

SROI SROI PYPY, EDI DWC-4 , EDI DWC-4 equivalent, is required to equivalent, is required to be filed when an indemnity be filed when an indemnity check is issued for a check is issued for a lump lump sum payment or settlementsum payment or settlement, , either as the initial payment either as the initial payment or subsequent to the initial or subsequent to the initial payment. payment.

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SROI PY – Lump Sum SROI PY – Lump Sum Payment/SettlementPayment/Settlement

SROI PY requires aSROI PY requires a “Lump “Lump Sum Payment/Settlement Sum Payment/Settlement Code”.Code”.

• Exception:Exception: May be sent as May be sent as spaces when paying IB (030) spaces when paying IB (030) in a lump sum.in a lump sum.

• This code describes the This code describes the type of lump sum payment type of lump sum payment or settlement made. or settlement made.

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SFSF

ASASSPSP AA

WW

ADAD

Lump Sum Payment/Settlement CodesLump Sum Payment/Settlement Codes

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A settlement agreed A settlement agreed upon by all parties to end upon by all parties to end past, present, and future past, present, and future liability of all benefits. liability of all benefits.

SFSF


• No future indemnity or No future indemnity or medical benefits are due.medical benefits are due.

Settlement Full Settlement Full (washout)(washout)

• BTC 500 or 524BTC 500 or 524 is is required.required.

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Settlement PartialSettlement Partial

• Settle all medical, but not Settle all medical, but not indemnity (reported as BTC indemnity (reported as BTC 501)…501)…

SPSP


A settlement agreed upon A settlement agreed upon by all parties to:by all parties to:

• Settle all indemnity benefit Settle all indemnity benefit type codes, but not medical type codes, but not medical (reported as BTC 500 or 524 (reported as BTC 500 or 524 for FL)for FL) ; ; oror

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Settlement PartialSettlement PartialSPSP


A settlement agreed upon A settlement agreed upon by all parties to:by all parties to:

• Settle a specific indemnity Settle a specific indemnity benefit type code(s), other benefit type code(s), other than BTC 500 or 501 (reported than BTC 500 or 501 (reported as a specific BTC 5xx code).as a specific BTC 5xx code).

This new use of SP is not This new use of SP is not accepted in FL.accepted in FL.

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A lump sum payment A lump sum payment agreed upon by the parties agreed upon by the parties of one or more benefit of one or more benefit types for a disputed period types for a disputed period of disability. of disability.

ASAS


Agreement StipulatedAgreement Stipulated

• Does not limit future liability.Does not limit future liability.

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An adjudicated lump sum An adjudicated lump sum payment of one or more payment of one or more benefit types for a disputed benefit types for a disputed period of disability. period of disability.

AWAW


AwardAward

• Does not limit future Does not limit future liability.liability.

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ADAD


A lump sum payment of A lump sum payment of benefits in advance of benefits in advance of when it is due. when it is due.

• May be recouped as a May be recouped as a weekly credit against weekly credit against future benefits not to future benefits not to exceed 20%.exceed 20%.

AdvanceAdvance

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If a rate and time period If a rate and time period are are specified,specified, Benefit Type Benefit Type Code Code 0xx 0xx (vs 5xx) series is (vs 5xx) series is used for:used for:

ASAS AWAWAwardAward

ADADAdvanceAdvanceAgreement Agreement

StipulatedStipulated

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• Note: If Note: If BTC 0xxBTC 0xx was was sent for benefits that sent for benefits that were paid in a lump sum, were paid in a lump sum, DWC’s program will apply DWC’s program will apply edits to check accuracy of edits to check accuracy of the 0xx payment $. the 0xx payment $.

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If a rate If a rate and time and time period are period are notnot specifiedspecified, , Benefit Benefit Type Code Type Code 5xx 5xx series series is used is used for:for:

ADADAdvanceAdvanceAWAWAwardAward

SFSF Settlement Settlement Full Full (BTC 500 or (BTC 500 or 524 only)524 only)Settlement Settlement PartialPartial

SPSP

AASS

Agreement Agreement Stip.Stip.


(BTC 500, 524 or 501 (BTC 500, 524 or 501 only)only)

92

Population Rules Population Rules for Lump Sum for Lump Sum

Payments/SettlePayments/Settlementsments

93

SROI PY - Population SROI PY - Population Rules:Rules:

For FL, a For FL, a PaymentsPayments segmentsegment must be must be included on the included on the SROI PY in addition to SROI PY in addition to the Benefits segment.the Benefits segment.

• Exception: Reduced Exception: Reduced Benefit Amount Code = Benefit Amount Code =

S or N.S or N.

94

““Payment Reason Payment Reason Code”Code” must equal a must equal a Benefit Type Code on Benefit Type Code on the transaction. the transaction.


95

““Payment Issue Date”Payment Issue Date” is required unless is required unless Reduced Benefit Amount Reduced Benefit Amount Code = S or N.Code = S or N.

FL uses Payment Issue FL uses Payment Issue Date sent in Date sent in PaymentsPayments segment to load to ‘date segment to load to ‘date payment mailed’ payment mailed’ (vs. (vs. Benefit Payment Issue Date.)Benefit Payment Issue Date.)


96

Example: Payment Example: Payment Reason CodeReason Codeequals Benefit Type Code equals Benefit Type Code 500. 500.


97

BTC BTC 0xx0xx reporting reporting indemnity paid in a indemnity paid in a lump sum represents an lump sum represents an “Event”“Event” BenefitsBenefits segment.segment.

BTC BTC 5xx5xx represents a represents a “Sweep”“Sweep” Benefits Benefits segment.segment.


98

SROI PY - Population SROI PY - Population Rules:Rules: If more than one check is If more than one check is

issued for a lump sum issued for a lump sum payment/settlement, only payment/settlement, only the check(s) that relates to the check(s) that relates to indemnityindemnity Benefit Type Benefit Type Codes should be populated Codes should be populated in the in the Payments Payments segment segment with with (Payment Issue Date)(Payment Issue Date) and repeated in the and repeated in the Benefits Benefits segment.segment.

99

SROI PY - Population SROI PY - Population Rules: Rules: • For For Example:Example: If a If a

settlement resulted in settlement resulted in the payment of a check the payment of a check to the EE and Dr. Smith, to the EE and Dr. Smith, only the check to the EE only the check to the EE would be reported in the would be reported in the Payments segment. Payments segment.

•The other check to Dr. The other check to Dr. Smith represents an OBT Smith represents an OBT Code. Code.

100


If multiple checks for If multiple checks for different Payees are cut different Payees are cut for the same for the same indemnityindemnity type, multiple type, multiple Payments Payments segments (reflecting segments (reflecting different Payees) should different Payees) should be sent with the same be sent with the same Payment Reason Code.Payment Reason Code.

101

SROI PY – Population SROI PY – Population Rules: Rules: For Example:For Example: If you issue If you issue

one settlement check to the one settlement check to the EE and cut another check to EE and cut another check to the court for child support, the court for child support, where both checks are where both checks are coded the same 5xx coded the same 5xx Payment Reason Code, both Payment Reason Code, both amounts should be reported amounts should be reported in separate Payments in separate Payments segment, because of segment, because of different Payees and different Payees and amounts.amounts.

102

Standard processing rules for Standard processing rules for reporting reporting Lump Sum Lump Sum Payments/SettlementsPayments/Settlements are are described in Section 4 of the described in Section 4 of the Release 3 Implementation Release 3 Implementation Guide. Guide.

103

Also, Variable Segment Also, Variable Segment Population Rules for Lump Population Rules for Lump Sum Payments / Settlements Sum Payments / Settlements are included in this sectionare included in this section

104

This section also addresses This section also addresses Population Rules for the Population Rules for the PaymentsPayments Section. Section.

105

“ “Mini” SCENARIO: Mini” SCENARIO: 00/PY 00/PY

Initial Payment as Full Initial Payment as Full SettlementSettlement

EDI DWC-1 Equivalent Required EDI DWC-1 Equivalent Required to be filed with DWC per Rule to be filed with DWC per Rule 69L-56.301(1)(a)1., 69L-56.301(1)(a)1.,

F.A.C.F.A.C.

106

Lump Sum Lump Sum Payments/Settlement Payments/Settlement Example: Example: Settlement FullSettlement Full

Benefit Type Code 500 Benefit Type Code 500 Equals Payment Reason CodeEquals Payment Reason Code

107

Benefit Type Amount Paid Benefit Type Amount Paid Equals Payment AmountEquals Payment AmountPayment was issued February Payment was issued February 21, 2008.21, 2008.

Lump Sum Lump Sum Payments/Settlement Payments/Settlement

108

Lump Sum Lump Sum Payments/Settlement RulesPayments/Settlement Rules If indemnity benefits will If indemnity benefits will be paid after the PY lump be paid after the PY lump sum paymentsum payment, the next , the next applicable transaction applicable transaction should be filed (e.g., should be filed (e.g., IPIP after 00/PY, after 00/PY, APAP after after AU/PY, or AU/PY, or RBRB) ) to report to report the type of benefits that the type of benefits that will be paid on an will be paid on an ongoing basis by the ongoing basis by the Claim Administrator.Claim Administrator.

109

• This is to ensure there This is to ensure there is not a sequencing is not a sequencing failure on future failure on future transactions transactions (e.g., for not (e.g., for not having previously reported a having previously reported a particular BTC.)particular BTC.)


110

• The IP, AP, RB after PY The IP, AP, RB after PY can introduce an entirely can introduce an entirely new BTC not previously new BTC not previously reported on the PY (no reported on the PY (no SROI CB necessary.) SROI CB necessary.)


111

If the initial payment is a If the initial payment is a lump sum amount for lump sum amount for IB OnlyIB Only (030), (030), 00/PY00/PY should be filed should be filed (vs. 00/IP).(vs. 00/IP).

• As mentioned earlier, As mentioned earlier, Lump Sum Lump Sum Payment/Settlement Code is Payment/Settlement Code is not not required to be reported required to be reported here because IB’s are not here because IB’s are not always an Advance payment always an Advance payment (might be for IB owed for a (might be for IB owed for a past time period.)past time period.)


112

In light of the DCA In light of the DCA opinion (Seminole County opinion (Seminole County v. Baumgardner), v. Baumgardner), if IB’s were paid if IB’s were paid in a lump in a lump sum at the sum at the reduced rate because the reduced rate because the EE initially RTW earning EE initially RTW earning full pre-injury wages, …full pre-injury wages, …


113

… … the Claim Admin. the Claim Admin. should monitor the EE’s should monitor the EE’s post-MMI earnings to post-MMI earnings to determine if IB’s need to determine if IB’s need to be adjusted for a given be adjusted for a given week during which the week during which the EE did not earn 100% of EE did not earn 100% of pre-injury wages pre-injury wages (whether causally related (whether causally related to the injury or not.) to the injury or not.)

• M&A may audit for M&A may audit for this.this.


114


Successfully Successfully Filing SROI PYFiling SROI PY

115

Caveats and Tips for Filing Caveats and Tips for Filing PYPY

Most PY’s are failing Most PY’s are failing edits for:edits for:

AWARD/ORDER DATE AWARD/ORDER DATE MISSING MISSING

This date is required This date is required unless:unless:

• You are reporting an You are reporting an advance < = $2,000 oradvance < = $2,000 or

• IB’s were paid in one IB’s were paid in one lump sum.lump sum.

116


Award/Order Date Award/Order Date corresponds to the date corresponds to the date the JCC or mediator signed the JCC or mediator signed the order/agreement.the order/agreement.

• DWC will also accept the DWC will also accept the date the parties signed a date the parties signed a (settlement) release… (settlement) release…

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• … … As a result, yAs a result, you do not ou do not have to wait for JCC to sign have to wait for JCC to sign order approving the order approving the attorney fee to file the PY. attorney fee to file the PY.

• This should help to avoid This should help to avoid late filing penalties for late filing penalties for 00/PY where the settlement 00/PY where the settlement check was mailed more check was mailed more than 14 days before the JCC than 14 days before the JCC order.order.

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Other errorsOther errors frequently frequently occurring are:occurring are:

PAYMENT REASON CODE PAYMENT REASON CODE MUST = 500 OR 524 andMUST = 500 OR 524 and

IF LS SETT CDE = SF, BEN IF LS SETT CDE = SF, BEN SEG W/500 OR 524 SEG W/500 OR 524

REQUIREDREQUIRED

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• FL only accepts FL only accepts Payment Reason Codes Payment Reason Codes 500 or 524 if reporting a 500 or 524 if reporting a Final Settlement , i.e., Final Settlement , i.e., Lump Sum Payment Lump Sum Payment Code “SF”.Code “SF”.

•Exception: RBAC is ‘S’ Exception: RBAC is ‘S’ or ‘N’.or ‘N’.

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Another frequent error Another frequent error is:is:

LUMP SUM LUMP SUM PAYMENT/SETTLEMENT PAYMENT/SETTLEMENT

CODE MISSINGCODE MISSING

• Lump Sum Lump Sum Payment/Settlement Code Payment/Settlement Code is is requiredrequired unless the lump sum unless the lump sum payment is for BTC 030 (IB).payment is for BTC 030 (IB).

121


Other commons errors:Other commons errors:

PAYMENT REASON CODE MUST = PAYMENT REASON CODE MUST = BEN TYPE CODE andBEN TYPE CODE and

IF PYMT SEG, BTC IN BEN SEG MUST IF PYMT SEG, BTC IN BEN SEG MUST = PYMT REAS CODE = PYMT REAS CODE

• There must be an identical There must be an identical BTC in the Benefits Segment BTC in the Benefits Segment that matches the Payment that matches the Payment Reason Code reported.Reason Code reported.

122


123

SROI SROI MTC “PY”MTC “PY”(Advance)(Advance)

SCENARIOSCENARIOSee Rule 69L-56.304(4), See Rule 69L-56.304(4),

F.A.C.F.A.C.

124

While receiving TT While receiving TT benefits, the EE requested benefits, the EE requested the Claim Admin. provide a the Claim Admin. provide a $1,000 advance against $1,000 advance against future TT benefits. future TT benefits.

Lump Sum Lump Sum Payments/SettlementPayments/Settlement

Advance of Advance of TT benefitsTT benefits

125

Benefit Type Code Benefit Type Code Equals Payment Reason CodeEquals Payment Reason Code

Lump Sum Lump Sum Payments/SettlementPayments/SettlementAdvance Advance TT benefitsTT benefits

126

Benefit Type Amount Paid Benefit Type Amount Paid IncludesIncludes Advance Payment Advance Payment Amount.Amount.


127

The Payment Covers Period The Payment Covers Period From/Thru relates to the From/Thru relates to the Advance payment.Advance payment.


128


129

SROI SROI SCENARIOSCENARIOMTC “PY” MTC “PY”

(subsequent to Initial (subsequent to Initial Payment)Payment)

See Rule 69L-56.304(4), See Rule 69L-56.304(4), F.A.C.F.A.C.

130

Lump Sum Payment/Settlement Lump Sum Payment/Settlement (not the Initial Payment) (not the Initial Payment)

If subsequent to the initial If subsequent to the initial payment, an award/order is payment, an award/order is signed for a lump sum signed for a lump sum payment/settlement of payment/settlement of indemnity benefits (i.e., award, indemnity benefits (i.e., award, advance, stipulated agreement, advance, stipulated agreement, or final settlement), an or final settlement), an Electronic Notice of Action or Electronic Notice of Action or Change is represented by Change is represented by sending:sending:

SROI PYSROI PY

131

SROI MTC “PY” Scenario SROI MTC “PY” Scenario NarrativeNarrative

Previously submitted Reports:Previously submitted Reports:1.1.00 FROI with IP SROI00 FROI with IP SROI2.2.CB changing from TTD to CB changing from TTD to IBIB

Employee hired an attorney Employee hired an attorney because he disagreed with because he disagreed with doctor’s impairment rating of doctor’s impairment rating of 10%. 10%.

132

SROI MTC “PY” Scenario SROI MTC “PY” Scenario NarrativeNarrative

Attorney petitioned for a Attorney petitioned for a different treating physician. different treating physician.

The new doctor assigned an The new doctor assigned an 18% impairment rating.18% impairment rating.

Claim administrator Claim administrator requested an IME which requested an IME which rendered a 14% impairment rendered a 14% impairment ratingrating..

133

Parties negotiated a full and final Parties negotiated a full and final settlement of $10,000 to pay a 15% settlement of $10,000 to pay a 15% whole body rating.whole body rating.

On 12/19/07, claim administrator On 12/19/07, claim administrator issued a check payable to the issued a check payable to the attorney and the employee. attorney and the employee.

On 1/2/08, JCC enters order On 1/2/08, JCC enters order approving attorney fees, and claim approving attorney fees, and claim administrator sends PY transaction administrator sends PY transaction to DWC.to DWC.

““PY” Scenario PY” Scenario NarrativeNarrative

134

SROI MTC “PY” SROI MTC “PY” ScenarioScenario

(only pertinent DE’s listed)(only pertinent DE’s listed)On 1/2/08, the Claim On 1/2/08, the Claim Administrator sends a PY Administrator sends a PY Payment report to Payment report to DWCDWC..

135


(only pertinent DE’s listed)(only pertinent DE’s listed)

136

Parties reached a full settlement.Parties reached a full settlement.

Agreement signed 1-2-08.Agreement signed 1-2-08.



137

Award/Order Date is Award/Order Date is requiredrequired uunless the nless the Lump Sum Lump Sum Payment/Settlement Payment/Settlement code = AD (Advance code = AD (Advance < $2,000), or < $2,000), or BTC = 030 BTC = 030 (IB).(IB).

Lump Sum Payment/Settlement Lump Sum Payment/Settlement RulesRules

138



139

BTC “500” BTC “500” BenefitsBenefits SegmentSegment


140



0

141



142

Payments Payments SegmentSegment


143


144

Lump Sum PaymentLump Sum Payment followed by a followed by a Later SettlementLater Settlement for the same for the same


(PY after PY)(PY after PY)

145

Lump Sum Payments followed by Lump Sum Payments followed by a Settlement of same Benefit a Settlement of same Benefit Type CodeType Code

When an Award or When an Award or Stipulated Agreement was Stipulated Agreement was previously reported with previously reported with Benefit Type Code 5XX Benefit Type Code 5XX AND now a Full or Partial AND now a Full or Partial Settlement of the Settlement of the same 5XXsame 5XX Benefit Type is being Benefit Type is being reported ... reported ...

146

...the ...the Benefit Type Amount Benefit Type Amount PaidPaid will include the Award will include the Award or Stipulated Agreement or Stipulated Agreement amount as well as the amount as well as the Settlement amount.Settlement amount.

•The The Payment AmountPayment Amount will will only be the amount of the only be the amount of the most recentmost recent Settlement Settlement Amount.Amount.

Lump Sum Payments followed by Lump Sum Payments followed by a Settlement of same Benefit a Settlement of same Benefit Type CodeType Code

147

Lump Sum Lump Sum Payments/SettlePayments/Settlements Covering ments Covering

More More Than 1 DOIThan 1 DOI

148

Lump Sum Payment/Settlement Lump Sum Payment/Settlement LimitationsLimitations

Settlements covering more Settlements covering more than one Date of Injury: than one Date of Injury:

A Full Settlement may A Full Settlement may involve more than one involve more than one date of injury, but the date of injury, but the settlement amount will settlement amount will only be reported on one only be reported on one PY transaction. PY transaction.

149

Lump Sum Payment/Settlement Lump Sum Payment/Settlement LimitationsLimitationsSettlements covering more Settlements covering more

than one Date of Injury:than one Date of Injury:

To report the settlement To report the settlement of the of the otherother dates of dates of injury, a PY MTC should injury, a PY MTC should be sent for each claim be sent for each claim with the with the Reduced Reduced Benefit Amount Code Benefit Amount Code “S”.“S”.

Note:Note: FROI 00 will have to FROI 00 will have to accompany the PY if not accompany the PY if not previously sent.previously sent.

150

Lump Sum Payment/Settlement Lump Sum Payment/Settlement LimitationsLimitationsSettlements covering more Settlements covering more

than one Date of Injury: than one Date of Injury: Reduced Benefit Amount Reduced Benefit Amount

Code Code “S”“S” Lump Sum P/S CodeLump Sum P/S Code “SF”“SF” and and Award/Order DateAward/Order Date

151

Lump Sum Payment/Settlement Lump Sum Payment/Settlement LimitationsLimitationsThe PY with a Reduced Benefit The PY with a Reduced Benefit Amount Code “S” will Amount Code “S” will notnot contain a contain a BenefitsBenefits segment segment unless indemnity benefits unless indemnity benefits were paid on the case prior to were paid on the case prior to the settlement.the settlement.

152

For DOI’s where the For DOI’s where the statute of limitations has statute of limitations has expired but the DOI is expired but the DOI is still referenced in the still referenced in the settlement order, a 00/PY settlement order, a 00/PY to DWC will to DWC will notnot be be required for DOI’s more required for DOI’s more than 5 years prior to the than 5 years prior to the Award/Order Date.Award/Order Date.

153

POP POP QUIZ:QUIZ:How do you report How do you report

a settlement a settlement involving $0 involving $0 payout (e.g., payout (e.g., waiver of third waiver of third party lien)?party lien)?

154

Answer:Answer:

SROI PY with SROI PY with Reduced Benefit Reduced Benefit Amount Code “N” Amount Code “N” (No Money (No Money Settlement).Settlement).

155

Questions Questions about PY?about PY?

156

We have already We have already discussed A/C/R discussed A/C/R

segments, segments, so we will now so we will now address address

Recoveries Recoveries Segments.Segments.

157

Recoveries SegmentRecoveries Segment RecoveriesRecoveries segments segments are comprised of:are comprised of:

• Recovery CodeRecovery Code,, and and

• Recovery AmountRecovery Amount..

158

RECOVERY CODESRECOVERY CODES Recovery CodeRecovery Code identifies the type of identifies the type of recovery being made.recovery being made.

• A Recovery Code A Recovery Code is is required if a required if a Recovery Amount is Recovery Amount is sent. sent.

159

RECOVERY CODESRECOVERY CODES

Note:Note: For non-legacy For non-legacy claims, Recovery Code claims, Recovery Code 850 850 (Second Injury Fund)(Second Injury Fund) must must be sent instead of be sent instead of Recovery Code 800 (Special Recovery Code 800 (Special Fund Recovery).Fund Recovery).

160

Recovery AmountRecovery Amount is the is the sum of monies received to sum of monies received to date by the insurer for the date by the insurer for the corresponding recovery corresponding recovery code.code.

RECOVERY AMOUNTRECOVERY AMOUNT

• A Recovery Amount is A Recovery Amount is required if a Recovery required if a Recovery Code is sent.Code is sent.

161

Recoveries should Recoveries should notnot be backed out of their be backed out of their respective Benefit respective Benefit Type Amount Paid or Type Amount Paid or Other Benefit Type Other Benefit Type Amounts. Amounts.

• Exception:Exception: Recovery Recovery Codes 830, 880 & 890 – Codes 830, 880 & 890 – see next slide.see next slide.

RECOVERY RECOVERY AMOUNTAMOUNT

162

RECOVERY AMOUNTRECOVERY AMOUNTTo ensure the claim reflects To ensure the claim reflects

costs actually incurred, only costs actually incurred, only the following recoveries the following recoveries should be deductedshould be deducted from the from the applicable Benefit Type applicable Benefit Type Amount Paid or Other Benefit Amount Paid or Other Benefit Type Amount Paid:Type Amount Paid:

• 830 830 (Overpayment (Overpayment Recovery)Recovery)……

163

RECOVERY AMOUNTRECOVERY AMOUNT……

• 880 880 (Voided Indemnity (Voided Indemnity Benefits Benefits

Check Recovery, orCheck Recovery, or

• 890 890 (Voided Other (Voided Other Benefit Benefit Check Check Recovery).Recovery).

164

The presence of this The presence of this recovery data will excuse recovery data will excuse edits that would edits that would otherwise invoke if a otherwise invoke if a Benefit Type Amount Benefit Type Amount Paid is sent as ‘less than Paid is sent as ‘less than previous’. previous’.

RECOVERIES RECOVERIES Segment RulesSegment Rules

165

Unlike A/C/R Unlike A/C/R segments, a Recovery segments, a Recovery segment should segment should always always be includedbe included on each on each SROI transaction SROI transaction once a Recovery has once a Recovery has been made on the claim been made on the claim (unless the recovery was (unless the recovery was reported in error.) reported in error.)

RECOVERIES RECOVERIES Segment Segment RulesRules

166

RECOVERIES RECOVERIES Segment Segment RulesRulesNumber of Recoveries Number of Recoveries

reported in the Variable reported in the Variable Segment Counters should Segment Counters should match the # of Recovery match the # of Recovery codes sent.codes sent.

167

RECOVERIES RECOVERIES Segment Segment RulesRulesExample: Example: Recovery Code 850Recovery Code 850 -- Second Second Injury FundInjury FundRecovery AmountRecovery Amount - - $1600.00$1600.00

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1 add concurrent benefit type electronic notice of action/change required to be filed with dwc per...

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