Workers’ Compensation Claims

69L-3, F.A.C.

Forms Overview

Fred Becknell - Insurance Administrator

E-mail: becknellf@dfs.state.fl.us

850-413-1763

69L-3 WC Claims Forms Overview

First major rewrite of the rule since November 1994.

Each section containing forms updated.

Removal of outdated forms.

Revision of forms / new look.

Drafts of Rule 69L-3 and the incorporated forms are currently available on the

Division’s Website.

www.fldfs.com/wc/

Updated drafts will be made available on the website. Sign up for the DWC e-Alert

program for the quickest notification of rule making & other DWC activities.

New Definition 69L-3.002(3)

“Claims-handling Entity” means any insurer, third-party administrator, servicing company, 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.

Required Fields on all Forms 69L-3.003(3)

Employee’s name (First, middle, last)

Employee’s social security number *

Month, day and year of the accident

(mm-dd-yy or mm-dd-ccyy)

* Or Division assigned number

Required Fields on all Forms 69L-3.003

Insurer Code # & Insurer Name

Service Co/TPA Code # *

Claims-handling Entity File #

Claims-handling Entity’s Name, Address & Telephone

* If applicable

Required Fields on all Forms 69L-3.003(5)

“Sent to Division Date” or

The revised “Sent to Division Date” as applicable for forms returned to the claims-handling entity for correction.

The document will be considered complete & in compliance with the rule when the corrected document is resent to the Division.

Injured Worker Informational Brochure 69L-3.0035

DFS-F2-DWC-60 (English version) & DFS-F2-DWC-61 (Spanish version) are now incorporated.

The applicable brochure is to be sent within 3 business days after notification of the injury or illness, pursuant to Section 440.185(4), F.S.

Injured Worker Informational Brochure 69L-3.0035

DFS-F2-DWC-60 “Important Workers’ Compensation Information For Florida’s Workers”

DFS-F2-DWC-61 “Informacion Importante De Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida”

Injured Worker Informational Brochure 69L-3.0035

With the promulgation of the rule, the DFS-F2-DWC-60 and DFS-F2-DWC-61 must be provided verbatim.

Alternative formats will no longer be permissible.

Employer Informational Brochure 69L-3.006

DFS-F2-DWC-65 (English version) &

DFS-F2-DWC-66 (Spanish version) are now incorporated.

The applicable brochure is to be mailed to the employer annually, pursuant to Section 440.185(4), F.S.

Employer Informational Brochure 69L-3.006

With the promulgation of the rule, the DFS-F2-DWC-65 and DFS-F2-DWC-66 must be provided verbatim.

Alternative formats will no longer be permissible.

Overview of Proposed Changes to Forms

Form numbers are preceded with “DFS-F2” per Departmental

guidelines. For example: DWC-1 = DFS-F2-DWC-1.

The Social Security Number field on all forms will be relocated to make it easier to redact pursuant to

Statute 119, F.S.

Overview of Proposed Changes to Forms

The 2002 North American Industrial Classification System (NAICS) Code is replacing the obsolete Standard Industrial Classification (SIC) Code.

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DFS-F2-DWC-1 / 69L-3.0046First Report of Injury or Illness

Major changes

1. Reporting of delayed disability cases2. Reporting of penalties & paid to the

employee3. Filing requirements detailed4. Reporting of “Indemnity Only Denied

Cases”5. Reporting of the insurer’s name

Claims-Handling Entity Information

Pursuant to 69L-3.0045(1)(d) – the claims-handling entity shall complete the “Claims-handling Entity Information” section on Form DFS-F2-DWC-1

Insurer Code #Service Co/TPA Code #Employee’s Class CodeEmployer’s NAICS CodeClaims-Handling Entity File #Insurer NameClaims-Handling Entity Name, Address & Telephone

Reporting of Delayed Disability Cases 69L-3.0045(1)(d)5.c.1

The claims-handling entity is to report:

the “Employee’s 8th Day of Disability” and the

“Claims-handling entity’s Knowledge of the 8th Day of Disability”.

New fields on the DFS-F2-DWC-1

Employee’s 8th Day of Disability

Entity’s Knowledge of 8th Day of Disability

Reporting of Delayed Disability Cases 69L-3.0045(1)(d)5.c.1

The alternative electronic format for reporting delayed disability cases electronically (EDI) will be presented by Linda Yon in the next presentation.

Reporting of Penalties & Interest 69L-3.0045(1)(f)

If the initial payment of compensation was not timely paid in accordance with Section 440.20, F.S., the claims-handling entity is to report the

“Penalty Amount Paid in 1st Payment” and the

“Interest Amount Paid in 1st Payment”.

New fields on the DFS-F2-DWC-1

“Penalty Amount Paid in 1st Payment”

“Interest Amount Paid in 1st Payment”

Reporting of Lost Time Cases 69L-3.0045(2)(a)

When disability is immediate and continuous for 8 or more days, the claims-handling entity shall send a completed Form DFS-F2-DWC-1 within 14 days after the claims-handling entity’s knowledge of the injury or illness for the following

Reporting of Lost Time Cases 69L-3.0045(2)(a)

1. Initial lost time cases

2. Full salary cases (employer paid for 8 or more days)

3. Death cases with/without dependents

4. Volunteers

Timely Reporting of Lost Time Cases By EDI 69L-24.0231(1)(a)

an electronic equivalent of a First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division on or before the 21st day after the carrier’s knowledge of the injury and is assigned an acknowledgement code of Transaction Accepted (TA).

3. Lost Time Case

“1st Day of Disability”, “Full Salary in lieu of comp? “Full Salary End Date” “Date First Payment Mailed” “AWW” / “Comp Rate” and the “Disability Type”

Reporting of Delayed Disability Cases 69L-3.0045(2)(b)

When disability is not immediate and continuous but result in 8 or more days of disability, the claims-handling entity shall send a completed Form DFS-F2-DWC-1 within 6 days after the claims-handling entity’s knowledge of the eighth day of disability.

Timely Reporting of Delayed Disability Cases By EDI - 69L-24.0231(1)(a)

the electronic equivalent of a First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division on or before the 13th day after the carrier’s knowledge of the 8th day of disability and is assigned an acknowledgement code of Transaction Accepted (TA).

2. Medical Only Which Became Lost Time Case (Complete all Information in #3)

“1st Day of Disability”, “Full Salary in lieu of comp? “Full Salary End Date” “Date First Payment Mailed” “AWW” / “Comp Rate” and the “Disability Type”

“Indemnity Only Denied Cases” 69L-3.0045(2)(g)

For cases where the claims-handling entity denied only indemnity benefits and medical benefits are being provided:

Box 1(b) “Indemnity Only Denied Case” is to be marked & Forms DFS-F2-DWC-1 and DFS-F2-DWC-12 are to be filed with the Division at the same time.

1(b) Indemnity Only Denied Case – DWC-12, Notice of Denial Attached

Attach a DFS-F2-DWC-12 – pursuant to:

69L-3.0045(1)(d) 5.b & 69L-3.012(3)

Summary of Key Elements

The status of the case by marking the appropriate box on each DFS-F2-DWC-1 filed with the Division;

Box 1(a) “Denied Case”

Box 1(b) “Indemnity Only Denied Case”

Box 2 “Medical Only which became Lost Time Case”

Box 3 “Lost Time Case”

Key Elements - Continued

For lost time cases include the following data as applicable:

“1st Day of Disability”

“Full Salary in lieu of comp?

“Full Salary End Date”

“Date First Payment Mailed”

“AWW” / “Comp Rate” and the

“Disability Type”

Key Elements - Continued

The claims-handling entity shall complete the “Claims-handling Entity Information” section

“Insurer Name”

“Insurer Code #”

“Claims-handling Entity Name, Address &

Telephone”

“Service Co/TPA Code #”

“Claims-handling Entity File #”

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S-F

2-D

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DFS-F2-DWC-4 / 69L-3.0091Notice of Action/Change

File with the Division within 14 days of the claims-handling entity’s knowledge of the action or change which it is reporting for lost time cases.

Copies of the Form are to be mailed to the employee and employer at the same time.

DFS-F2-DWC-4 / 69L-3.0091Notice of Action / Change

Clarification of when the DFS-F2-DWC-4 is required to be filed with the Division and the applicable fields that are to be completed for each required filing.

Complete the applicable fields and only use the “Remarks Section” to supplement the information reported.

DFS-F2-DWC-4 / 69L-3.0091Incomplete Forms

The filing of the form with only the “Remarks Section” completed will not constitute filing of the required information if the applicable field(s) are left blank.

DFS-F2-DWC-4 / 69L-3.0091(8) New Required Filing

Report a revised “Start Date” and the new “Weekly Rate”, when the payment of Impairment Income Benefits is changed due to the employee’s return to work or stopped earning at least the average weekly wage.

DFS-F2-DWC-4 / 69L-3.0091Deleted Fields

Initial Indemnity Started: “Effective Date” & “Disability Type”

PI Benefits: “Date Paid”

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2-D

WC

-12

DFS-F2-DWC-12 / 69L-3.012Notice of Denial

Copies of the Form are to be mailed to the employee, employer and any additional party requesting payment or authorization.

Removal of the “Lost Time Case” and “Medical Only Case” Boxes.

DFS-F2-DWC-12 / 69L-3.012(3)Denial of Indemnity Only

If the claims-handling entity initially denies only the indemnity benefits of a claim, it shall send Form DFS-F2-DWC-12 to the Division within 14 days after notification of the injury, illness or death with a completed DFS-F2-DWC-1

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2-D

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DFS-F2-DWC-13 / 69L-3.016Claims Cost Report

Initial Report – file within 30 days after the 6th month anniversary of the date of accident – no early filings accepted – unless filing as the final report.

Annual Reports – file within 30 days after the annual anniversary of the date of accident – no early filings accepted – unless filing as the final report.

DFS-F2-DWC-13 / 69L-3.016Claims Cost Report

All filings are to report the cumulative amounts of all applicable categories on the form.

For acquired / take over claims – the insurer shall provide cumulative totals by specific claim cost type for all applicable data elements on each transferred case to the new claims-handling entity.

69L-3.025 Forms No Longer Required

The DFS-F2-DWC-48 “Monthly Risk Class/SIC Code Report”

and the

DFS-F2-DWC-51 “Aggregate Defense Attorney Fee Report”

69L-3.025 Forms

90 days after the promulgation of the rule, only forms dated August 2004 will be accepted.