Fla. Admin. Code Ann. R. 69L-56.301 - Electronic First Report of Injury or Illness

On or before the compliance date established in the insurer's Primary Implementation Schedule set forth in paragraph 69L-56.300(3)(a), F.A.C., the insurer shall file the electronic form equivalent for claims information otherwise reported on Form DFS-F2-DWC-1 adopted in Rules 69L-56.4011 and 69L-3.025, F.A.C. Pursuant to Section 440.593(1) F.S., the Division may establish different deadlines for filing required reports electronically than are otherwise required when reporting information by other means. Accordingly, notwithstanding the deadlines for filing the injury report by other means as set forth in Section 440.185(2), F.S., the insurer or its claim administrator shall send to the Division the electronic form equivalent of the First Report of Injury or Illness for the following cases, and by the following filing time periods:

(1) Initial Payment for "Lost Time Case" or "Medical Only to Lost Time Case."

(FROI MTC 00 with SROI MTC IP, EP, CD, VE, or PY as found in the IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2009 Edition):

(a) Where the initial payment of indemnity benefits, excluding Temporary Partial benefits, Impairment Income benefits, and Lump Sum Payment/Settlement, is made by the claim administrator, or where the employer is paying salary in lieu of compensation, or for a compensable death with no known dependents, or a compensable volunteer:

1. If disability is immediate and continuous for 8 or more calendar days after the workers' compensation injury, an Electronic First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before 21 days after the claim administrator's knowledge of the injury. The claim administrator shall report Claim Type "I" (Lost Time/Indemnity).

2. If the first 7 days of disability are nonconsecutive or delayed, an Electronic First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before 13 days after the claim administrator's knowledge of the employee's 8th day of disability. The claim administrator shall report the "Initial Date of Lost Time" (i.e., the employee's 8th day of disability) and the "Date Claim Administrator Had Knowledge of Lost Time." The claim administrator shall also report Claim Type "L" (Became Lost Time/Indemnity).

3. The Electronic First Report of Injury or Illness shall be represented by sending the FROI and SROI records as follows:

a. Initial Payment by Claim Administrator: FROI MTC 00 (Original) with SROI MTC IP (Initial Payment);

b. Employer Paid Salary in Lieu of Compensation: FROI MTC 00 (Original) with SROI MTC EP (Employer Paid);

c. Compensable Death, No Dependents/Payees: FROI MTC 00 (Original) with SROI MTC CD (Compensable Death);

d. Compensable Volunteer: FROI with MTC 00 (Original) with SROI MTC VE (Volunteer);

(b) Where the initial payment of indemnity benefits is for Temporary Partial benefits, Impairment Income benefits, or results from a Lump Sum Payment/Settlement, an Electronic First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before 14 days after the date the initial payment of benefits was mailed to the employee or to the employee's legal representative.

1. The Electronic First Report of Injury or Illness shall be represented by sending the FROI and SROI records as follows:

a. Initial Payment of Temporary Partial Benefits (TP): FROI MTC 00 (Original) with SROI MTC IP (Initial Payment) and Benefit Type Code "070" (Temporary Partial);

b. Initial Payment of Impairment Income Benefits (IB): FROI MTC 00 (Original) with SROI MTC IP (Initial Payment) and Benefit Type Code "030" (Permanent Partial Scheduled);

c. Initial Payment of Lump Sum Payment/Settlement: FROI MTC 00 (Original) with SROI MTC PY (Payment Report) and Benefit Type Code that applies to the specific benefit(s) covered by the lump sum payment/settlement.

(2) "Denied Case":

(FROI MTC 04, or SROI MTC PD with applicable FROI MTC as found in the IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2009 Edition).

(a) Full/Total Denial - If, by the 14th day after the claim administrator's knowledge of the injury, the employee sustains disability as defined in Section 440.02, F.S., and the claim administrator's initial disposition is to deny the case in its entirety (i.e., both medical and indemnity benefits are denied), an Electronic First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before 21 days after the claim administrator's knowledge of the injury. The claim administrator shall report Claim Type Code "L" (to represent the full denial of a "Medical Only to Lost Time Case") or Claim Type Code "I" (to represent the full denial of a "Lost Time/Indemnity Case").

1. The Electronic First Report of Injury or Illness reporting a "Full/Total Denial" shall be represented by sending FROI MTC 04 (Denial).

2. The electronic form equivalent of Form DFS-F2-DWC-12 adopted in Rules 69L-56.4012 and 69L-3.025, F.A.C., required in Rule 69L-56.3012, F.A.C., to be filed with the Division to explain the reason(s) for the denial, shall be accomplished by reporting the applicable Full Denial Reason Code(s), Full Denial Effective Date, and Denial Reason Narrative on the same FROI MTC 04 (Denial).

(b) Medical Only Case that becomes a Total Denial - If the claim administrator is making the decision to deny the case in its entirety (i.e., both medical and indemnity benefits are denied) after the claim administrator's initial disposition to accept compensability of a "Medical Only Case," an Electronic First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before 14 days after the claim administrator's decision to deny the entire claim. The claim administrator shall report Claim Type Code "M" (to represent a "Medical Only Case" that is being totally denied).

1. The Electronic First Report of Injury or Illness to report the denial of both indemnity and medical benefits on a case initially determined to be a Medical Only case, shall be represented by sending a FROI MTC 04 (Total Denial).

2. The electronic form equivalent of Form DFS-F2-DWC-12 adopted in Rules 69L-56.4012 and 69L-3.025, F.A.C., required in Rule 69L-56.3012, F.A.C., to be filed with the Division to explain the reason(s) for the denial, shall be accomplished by reporting the applicable Full Denial Reason Code(s), Full Denial Reason Effective Date, and Denial Reason Narrative on the same FROI MTC 04 (Denial).

(c) Partial (Indemnity Only) Denial or Medical Only Case that becomes a Partial Denial - If the claim administrator's initial disposition of a claim is the acceptance of compensability but denial of indemnity benefits only, an Electronic First Report of Injury or Illness will be considered timely filed with the Division when it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before 14 days after the claim administrator's decision to deny indemnity benefits.

1. The Electronic First Report of Injury or Illness reporting a Partial (Indemnity Only) Denial shall be represented by sending FROI MTC 00 (Original) with SROI MTC PD (Partial Denial).

2. The electronic form equivalent of the DFS-F2-DWC-12 adopted in Rules 69L-56.4012 and 69L-3.025, F.A.C., required in Rule 69L-56.3012, F.A.C., to be filed with the Division to explain the reason(s) for the denial, shall be accomplished by reporting the applicable Partial Denial Code ("A" or "E") and Denial Reason Narrative on the same SROI MTC PD (Partial Denial).

(3) If the claim administrator receives notification of an injury from the employer via telephone or electronic data interchange where no Form DFS-F2-DWC-1, First Report of Injury or Illness adopted in Rules 69L-56.4011 and 69L-3.025, F.A.C., has been completed and provided to the employee and employer, the claims administrator shall produce and send to the employee and employer within three (3) business days of the claims administrator's knowledge of the injury, either Form DFS-F2-DWC-1 or Form IA-1 adopted in Rules 69L-56.4011 and 69L-3.025, F.A.C. The claim administrator shall not send Form IA-1 to the Division to report the First Report of Injury or Illness.

(4) Any insurer failing to timely file the Electronic First Report of Injury or Illness required under this section is subject to administrative penalties assessable by the Division according to the provisions of Rule 69L-24.006, F.A.C., and as allowed for in Section 440.185(9), F.S. If the initial payment is not timely issued in accordance with the time period prescribed in Section 440.20, F.S., or the Electronic First Report of Injury or Illness is not timely filed with the Division in accordance with this section, the claim administrator shall report the appropriate Late Reason Code(s) when sending the Electronic First Report of Injury or Illness. If the initial payment and Electronic First Report of Injury or Illness were originally reported to another jurisdiction and the claim was subsequently transferred to Florida, the claim administrator shall include Late Reason Code "L4" (late notification, jurisdiction transfer) on the Electronic First Report of Injury or Illness that is being re-filed in Florida.

(5) An Electronic First Report of Injury or Illness for a "Medical Only Case" shall not be sent to the Division unless the claim administrator has received a written or electronic request from the Division, or if the claim began as a Medical Only Case and is being reported to the Division as a Full or Partial Denial of indemnity benefits.

(6) When both FROI and SROI transactions are sent to report the Electronic First Report of Injury or Illness, the claim administrator shall ensure the values sent on the FROI and SROI records for data elements identified in the "FROI to SROI" column of the Match Data Table contained in the FL Claims EDI R3 Edit Matrix are the same value.

(7) An Electronic First Report of Injury or Illness filed in accordance with Rule 69L-56.301, F.A.C., or a paper First Report of Injury or Illness must have been received and accepted by the Division before any subsequent electronic filings will be accepted.

(8) Only 2002 NAICS Codes shall be reported for the Industry Code and must be sent as a minimum of 5 digits. If the insured is a Professional Employment Organization (PEO), the Industry/NAICS Code should represent the nature of the client's/employer's business.

(9) If the employee does not have or wish to provide a Social Security Number, the claim administrator shall contact the Division by following the instructions provided on the Division's website: http://www.myfloridacfo.com/Division/WC/odqc.htm (under Division-Assigned Numbers) and obtain a Division-assigned number. Upon receipt of the employee's Social Security Number, the claim administrator shall file MTC 02 (Change) and provide the employee and employer with Form DFS-F2-DWC-4, pursuant to Rule 69L-3.025, F.A.C.

Notes

Fla. Admin. Code Ann. R. 69L-56.301

Rulemaking Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS.

New 1-7-07, Amended 5-17-09.

New 1-7-07, Amended 5-17-09.