Fla. Admin. Code Ann. R. 69L-3.002 - Definitions

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.

Notes

Fla. Admin. Code Ann. R. 69L-3.002

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, Amended by Florida Register Volume 40, Number 117, June 17, 2014 effective 6/30/2014.

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.